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[ { "category": "Echo", "chartdate": "2140-02-17 00:00:00.000", "description": "Report", "row_id": 62258, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath. S/P kidney transplant\nHeight: (in) 77\nWeight (lb): 186\nBSA (m2): 2.17 m2\nBP (mm Hg): 167/77\nHR (bpm): 96\nStatus: Inpatient\nDate/Time: at 16:35\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: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Top normal/borderline dilated LV cavity\nsize. Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildly dilated aortic root. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Borderline\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is dilated. The right atrium is moderately dilated. There is\nmild symmetric left ventricular hypertrophy. The left ventricular cavity size\nis top normal/borderline dilated. Overall left ventricular systolic function\nis normal (LVEF>55%). Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nstructurally normal. Mild (1+) mitral regurgitation is seen. There is\nborderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nCompared with the prior study (tape reviewed) of , estimated\npulmonary artery systolic pressure is now lower.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-17 00:00:00.000", "description": "BX-NEEDLE KIDNEY BY NEPHROLOGIST", "row_id": 856765, "text": " 2:12 PM\n BX-NEEDLE KIDNEY BY NEPHROLOGIST; GUIDANCE/LOCALIZATION FOR NEEDLE BIOPSY US (S&I)Clip # \n Reason: ACUTE RENAL FAILURE, ASSESS REJECTION\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man s/p CRT in 04 with acute renal failure.\n REASON FOR THIS EXAMINATION:\n Is there a rejection?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post renal transplant, now with acute renal failure. The\n patient now presents for an ultrasound-guided renal biopsy.\n\n LOCALIZATIONS/GUIDANCE FOR RENAL BIOPSY: Localization and guidance was\n provided for the nephrology service. Two biopsies of the lower pole of the\n transplanted kidney were obtained by the nephrology fellow.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-16 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 856659, "text": " 5:04 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ? rejection vs. decrease flow\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with HIV with elevated CR ? rejection vs. decrease flow of\n vessels\n REASON FOR THIS EXAMINATION:\n ? rejection vs. decrease flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, recent elevation of creatinine. Evaluate for rejection or\n decreased blood flow to the vessels.\n\n TECHNIQUE: Tranplant kidney ultrasound was performed with color and pulse\n wave Doppler. Pulse wave Doppler was used for assessment of arterial flow\n within the tranplanted kidney.\n\n COMPARISON: .\n\n FINDINGS: The transplanted kidney in the right lower quadrant is markedly\n enlarged, measuring 14.2 cm (previously 11.0 cm) with an edematous appearance\n of the cortex with hypodense pyramids. This is markedly changed since the\n prior examination. At the upper pole of the kidney, there are high systolic\n peaks, and virtually no diastolic flow was seen, with resistive indices of\n approximately 0.9 and 0.95. At the interpolar region, diastolic flow is\n somewhat increased, with resistive indices of approximately 0.77. At the\n lower pole, the diastolic flow is again considerably decreased, with resistive\n indices of approximately 0.85. The resistive index of the main renal artery\n is also elevated measuring approximately 0.85.\n\n Comparison to the prior examination, the resistive indices have increased\n significantly, and there has been interval development of marked swelling of\n the kidney.\n\n IMPRESSION: Diffusely increased resistive indices and decreased diastolic\n flow, in conjunction with gross enlargement of the kidney and edematous\n appearance of the cortex. Findings are suggestive acute renal interstitial\n edema rather than of chronic rejection.\n\n Findings were discussed with , PA at 5:45 P.M. .\n\n" }, { "category": "Radiology", "chartdate": "2140-02-17 00:00:00.000", "description": "RENAL TRANSPLANT U.S.", "row_id": 856780, "text": " 3:44 PM\n RENAL TRANSPLANT U.S. Clip # \n Reason: ACUTE RENAL FAILURE, ASSESS FOR REJECTION\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of renal transplant, now with acute renal failure.\n\n COMPARISON: Renal transplant ultrasound of .\n\n RENAL TRANSPLANT ULTRASOUND: Overall, there have been no significant changes\n since the exam of one day ago. Again noted is diffuse enlargement of the\n transplant kidney, measuring up to 15.0 cm in length. There is no evidence of\n focal renal masses, stones, or hydronephrosis. Color Doppler images show\n normal-appearing intraparenchymal arterial waveforms within the upper pole,\n with resistive indices measuring 0.69. The arterial waveforms within the mid\n portion of the kidney are slightly dampened, with resistive indices measuring\n 0.77. Decreased diastolic flow is again seen within the lower pole, with\n persistent increased resistive indices measuring 0.86. The resistive index\n within the main renal artery again measures 0.90.\n\n IMPRESSION: No significant change from the renal ultrasound of one day ago.\n Persistent enlargement of the transplant kidney with elevated resistive\n indices.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 856951, "text": " 5:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess failure\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with HIV, s/p CRT\n\n REASON FOR THIS EXAMINATION:\n assess failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: HIV, status post CRT.\n\n COMPARISON: .\n\n FINDINGS: The heart remains enlarged. Lung volumes remain somewhat low.\n Again noted is slight interval improvement in CHF, which is predominantly\n resolved. There is no pleural effusion or pneumothorax.\n\n IMPRESSION: Cardiomegaly.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 856672, "text": " 5:58 PM\n CHEST (PA & LAT) Clip # \n Reason: ? infiltrates\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with with hIV s/p kidney transplant now with SOB with recent\n fevers\n REASON FOR THIS EXAMINATION:\n ? infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST:\n\n HISTORY: Kidney transplant with shortness of breath and fever in HIV patient.\n\n\n There is cardiomegaly with upper zone redistribution and diffuse bilateral\n predominantly air space opacities consistent with pulmonary edema. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2140-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 856749, "text": " 11:38 AM\n CHEST (PORTABLE AP) Clip # \n Reason: resp distress\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with HIV, s/p CRT\n REASON FOR THIS EXAMINATION:\n resp distress\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of HIV and renal transplant. Respiratory distress.\n\n COMPARISON: .\n\n SEMI UPRIGHT AP CHEST: The heart is again enlarged. Mediastinal contours are\n stable. The diffuse bilateral airspace opacities consistent with pulmonary\n edema has slightly improved since yesterday's exam. However, significant\n pulmonary edema persists. No definite pleural effusions are identified. No\n pneumothorax.\n\n IMPRESSION:\n\n Slight interval improvement in pulmonary edema, though significant edema\n persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 856827, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CHF\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with HIV, s/p CRT\n\n REASON FOR THIS EXAMINATION:\n eval CHF\n ______________________________________________________________________________\n FINAL REPORT\n VIEW: Portable chest .\n\n COMPARISON: .\n\n INDICATIONS: HIV positive. Evaluate for CHF.\n\n FINDINGS:\n\n There is stable cardiac enlargement. There has been slight improvement in the\n degree of vascular engorgement and areas of previously noted perihilar\n haziness have nearly resolved with minimal residual haziness remaining. There\n are no confluent areas of consolidation in either lung.\n\n IMPRESSION:\n\n Resolving pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-22 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 857323, "text": " 12:32 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o infiltrate\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with with hIV s/p kidney transplant now with SOB with recent\n fevers\n REASON FOR THIS EXAMINATION:\n r/o infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n COMPARISON: .\n\n CLINICAL INDICATION: Shortness of breath and fever. HIV positive, kidney\n transplant recipient.\n\n There is enlargement of the cardiac silhouette, which is stable compared to\n the prior study of . There is upper zone vascular\n redistribution. Previously identified changes of pulmonary edema on , have essentially resolved with only minimal haziness remaining in the\n right perihilar region. No confluent areas of consolidation are observed, and\n there are no pleural effusions.\n\n IMPRESSION:\n\n Minimal right perihilar haziness, which is most likely due to resolving\n pulmonary edema given the serial chest radiographic findings dating back to\n . However, an early focus of pneumonia in this area is not\n fully excluded, and followup films may be helpful in this regard.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-02-22 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 857324, "text": " 12:32 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: r/o perforation\n Admitting Diagnosis: STATUS POST KIDNEY TRANSPLANT;ELEVATED CREATININE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with HIV s/p kidney tx with distended abd and diarrhea\n REASON FOR THIS EXAMINATION:\n r/o perforation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of HIV, status post kidney transplant with distended\n abdomen and diarrhea. Evaluate for perforation.\n\n COMPARISON: Prior x-rays from .\n\n SUPINE AND ERECT ABDOMINAL X-RAYS: Multiple air fluid levels are noted within\n the small intestine. Several loops of small bowel are noted, one of which is\n dilated. Additionally, air is seen within the ascending and transverse colon.\n There is positive air within the sigmoid colon and rectum. Stool is seen\n within the descending colon. No free air is identified within the abdomen.\n Soft tissue and osseous structures are normal.\n\n IMPRESSION: Air fluid levels in the small intestine. Air is seen within the\n transverse and descending colon. There is no significant dilatation of small\n bowel loops. These findings are nonspecific, and correlate to provided\n clinical history. No evidence of intestinal perforation.\n\n" }, { "category": "ECG", "chartdate": "2140-02-17 00:00:00.000", "description": "Report", "row_id": 121877, "text": "Sinus rhythm\nProlonged Q-Tc interval - is nonspecific and is otherwise normal ECG but\nclinical correlation is suggested for possible metabolic/drug effect\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2140-02-19 00:00:00.000", "description": "Report", "row_id": 1263559, "text": "SICU NPN:\nS-I will probably leave today.\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-Uneventful night. Resting comfortably with standing dose of Ambien. Hemodynamics stable. K repleted. Stable this AM. HCT stable as well. Denies SOB breath. Breath sounds with faint crackles at right bases. O2 Sats > 95% on 3LNP. Foley with adequate urine outputs. Good PO intake.\n\nA/P: Stable night\n\nCall out to floor\n" }, { "category": "Nursing/other", "chartdate": "2140-02-18 00:00:00.000", "description": "Report", "row_id": 1263557, "text": "SICU NPN:\nS-\"I feel much better, hope I can get out of here tommorow!\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VITAL SIGNS\n\nO-Pt a/o/x/3, very pleasant and cooperative with care. C/o of back pain while on bedrest and alleviated when off. Did sit up and dangled legs and felt better. Given Ambien for sleep with good effect. IVNTG weaned to Labetalol gtt with good affect. Accepting BPs < 170(?180). BPs well controlled on IV Labetalol, started at 2mg/min and currently at 0.3mg/min. Anticipate will be off by AM. HR 70-80s, NSR with no viewed ectopy, SBP 120-140s on Labetolol gtt. Pulses palpable throughout. Palpable thrill to left AV fistula. K 2.6 and repleted with 80meq of PO K. CK continue to be flat and repeat HCT stable at 23 with AM pending. Breath sounds clear througout. O2 weaned from 70% Fio2 FM to 6LNP and tolerating well. F/u ABG with incident. Breathing even and less labored. Pt denying SOB at rest or on exertion. Foley draining adequate amounts of clear to cloudy urine post diuresis, around 100cc/hr. Abd remain softly distended with (+) bowel sounds. Given light snack at HS and taking POs well. Did pass small loose stool times one. BCxs from with GPCs in aerobic bottle, did recieve Vancomycin IV time one, AM Vanco level pending. Zosyn dc'd and continue PO Levofloxacin. Urine sent for viral cultures, stool cultures x three needed, in addition sputum induction this AM for viral, influenza, AFB, etc. Pt placed on droplet precautions till further info available.\n\nA/P: s/p past renal transplant now presents with low grade temps, elevated creatine, hypertension, and mild respiratory distress. Since in unit diuresed and BP controlled and doing better\n\nContinue to monitor BPs\nFollow Creat and lyters\nContinue to monitor\n" }, { "category": "Nursing/other", "chartdate": "2140-02-18 00:00:00.000", "description": "Report", "row_id": 1263558, "text": "nursing note\nNeuro: A+O x3, asking approp questions re:care and rejection.\nCV:SR, no ectopy. SBP remains 150-180, prn lopressor given with effect and atenolol changed to po lopressor per nephrology recs. hep sq started, p-boots on. 2u PRB given with post HCT 29.1. Requiring high amounts KCL PO, last K 3.1\nRESP:LS clear with crackles halfway up. tol 3l nc, remains dyspneic with exertion, subj comfortable. sputum's sent per RT.\nGI:tol renal diet, fair appetite. Liquid BM on bedpan- sent for cultures.\nENDO:insulin gtt started and titrated to keep glu <120.\nGU:foley patent clear yellow urine- lasix post blood. second 100mg lasix held per ICU team. ? dose later this eve. + rejection via biopsy, ATG hung with po pre (methylpred earlier today). CR down to 3.6\nSKIN:intact.\nSOCIAL:roommate in to visit.\n\nPLAN: ATG therapy, monitor labs and K. stool cx if BM later (need x3). insulin gtt. ? start PO bicarb. BP <180. ? lasix later this eve, transfer to floor.\n" }, { "category": "Nursing/other", "chartdate": "2140-02-17 00:00:00.000", "description": "Report", "row_id": 1263556, "text": "nursing note\nAdmitted from 10 secondary to SOB, Increased RR and worsening ABG. Aline placed, ABG's improving, Kidney tx done. Bandaid to RLQ intact, no bleeding. Place nitro to keep SBP <160 with question on increased pulm HTN. CPK's neg. loprssore added to keep SBP <160. MD aware of inability to keep SBP <160. SR, no ecotpy. p-boots on. bedrest maintained flat post biopsy. LS clear, ?CHF per CXR. lasix 80 mg given- response pending. FIo2 weaned.\n\nPLAN:await biopsy results, labs pending. wean fio2 as tol, follow ABG. collect PCP . nitro to keep SBP <160 with PRN lopressor.\n" } ]

[ { "category": "ECG", "chartdate": "2141-02-20 00:00:00.000", "description": "Report", "row_id": 280129, "text": "Sinus bradycardia. Since the previous tracing of the rate has slowed\nand the QTc interval has lengthened. Previously described abnormalities\npersist.\n\n" }, { "category": "ECG", "chartdate": "2141-02-18 00:00:00.000", "description": "Report", "row_id": 280130, "text": "Sinus rhythm. Prior inferior myocardial infarction. Non-specific ST-T wave\nabnormalities. Compared to the previous tracing of ventricular ectopy is\nabsent and the rate has increased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2141-02-20 00:00:00.000", "description": "Report", "row_id": 1263280, "text": "Nursing Progress Note\nCCU\n7 pm - 7 am\nPatient without complaints. Feet warm, although toes remain equally cool on both feet. Distal pulses + DP's bilat ... with PT dopplerable. Left groin with small soft hematoma. Heparin increased to 1150 u/hr for a ptt of 48.\nCV HR 50-60's...rare to occasional unifocal pvc's//k 3.9..SBP 100-120's/50's..Denies chest pain or sob. Lungs clear to diminished at the bases. On 4l nasal prongs with 02 sats >96%\nUrine output brisk without diuresis. Please carevue for intake/output.\n1600 cc positive for length of stay.\nAM labs\nTo the cath lab for high risk aorto/iliac intervention\n" }, { "category": "Nursing/other", "chartdate": "2141-02-19 00:00:00.000", "description": "Report", "row_id": 1263278, "text": "NURSING ADMISSION NOTE\n0330-0700\nPULSELESS RIGHT FOOT\nVERY PLEASANT 66 YR OLD FEMALE WHO EXPERIENCED SUDDEN ABD PAIN/NAUSEA WITH VOMITING ..( ANGINAL EQUIVALENT ) BUT SOON DEVELOPED A COLD PAINFUL RIGHT FOOT THAT SHE COULD NOT MOVE. IN THE EW SHE WAS FOUND TO HAVE A MOTTLED, COLD WHITE FOOT. TO THE CATH LAB. CATHED VIA LEFT GROIN APPROACH ..FINDINGS SIGNIFACANT FOR ABD AORTA DISTALLY WITH 70% ULCERATIONS AT THE BIFURCATION. RIGHT RENAL ARTERY WITH 90% LESION. RIGHT ANT TIBIAL MID VESSEL WITH THE PT .. LASER THROMBECTOMY/PTCA TO BOTH OCCLUSIONS. TO THE CCU POST PROCEDURE.\n\nCV HR 70'S SINUS WITH FREQUENT PVCS...SBP 140-150'S/60'S..GOAL FOR SBP< 140. IV NTG AT .24 MCGS/KG..INTEGRELIN AT 1 MCG..HEPARIN AT 350 U/HR. SIGNIFICANT ARTERIAL OOZING FROM CATH SITE. DR AND DR IN TO EVALUATE. GEL FOAM WITH A PRESSURE DSG TO SITE ...SATURATED PRESSURE DSG WITHIN ~~ 30 MINUTES. DR AWARE. HEPARIN OFF AT 0415. DR ADVANCING SHEATH TO HUB TO STOP OOZINGINTEGRELIN CONTINUES. PRESSURE DSG REAPPLIED AGAIN WITH DR . FEET WARM ( TOES COOL EQUALLY ) DP 3+/PT 2+ SOCKS APPLIED PER PATIENTS REQUEST. TYPE AND SCREEN SENT.\n\nRESP ON 3L NP..LUNGS DIMINISHED AT THE BASES\n\nGI/GU URINE OUTPUT 40-60 CC Q1 HOUR.\n\nCOMFORT GIVEN 2 MG IV MS04 FOR BACK PAIN\n\nPLAN FOR ACT AT 0700..DR WITH D/C ARTERIAL SHEATH WHEN ACT <180\nINTEGRELIN FOR 18 HOURS\nFOUR HOURS AFTER SHEATH REMOVAL HEPARIN TO BE RESTARTED WITHOUT BOLUS\nRE-LOOK ON MON/TUES FOR AORTO-ILIAC STENTING AND RELLOK TO RLE\nMUCOMYST\nPOST HYDRATION FLUIDS 1/2 NS AT 80 CC/HR FOR 2 LITERS\n" }, { "category": "Nursing/other", "chartdate": "2141-02-19 00:00:00.000", "description": "Report", "row_id": 1263279, "text": "CCU NSG NOTE: ALT IN CV/R LEG ISCHEMIA\nS: \"It feels sore, but so much better\".\nO: For complete VS see CCU flow sheet.\nID: Pt afebrile.\nCV: Pt conts to have palpable and dopplerable pulses in feet with no further loss of sensation or movement. Both feet have cool toes, but C,M S remain nl. L femoral sheath came out at 0900. Groin area is eccymotic, with no ooze or hematoma. Pt remained flat for 6 hrs and then was OOB to chair. Later she took a walk with no change in pulses or groin site. R leg remains sore in calf area. She continues on integrellin at 1 mic/kilo until 2100, and heparin was restarted at 1000u/hr at 1330. IV nitro was shut off at 0730 for bp in 90s. She is receiving her second liter of 1/2NS at 100cc/hr. Plan is to go back to cath lab tomorrow for stenting of ulcerated areas in lower aorta, with stents into either iliac. pt spoke to Dr about this, but concent not yet signed. She was K+ replaced with 40 meq at noon. REpeat K at 1600 was 3.0. She has received another 40meq PO.\nRESP: BS decreased on R, clear otherwise. She is sating 96-99% on RA.\nGI: Pt eating and drinking without problem. She has no c/o of nausea. No BM.\nRENAL: Foley draining clear urine. Slightly pink after heparin re-started. U/O only 10-80cc/hr. She is ~1600cc pos for the day. However BUN/creat have returned to baseline. As she had vomiting and diarrhea she may have been dry.\nMS: PT A & O X 3 with no deficits. She is in good spirits and motivated to keep moving. Family in to visit.\nA: Stable post debree removal and PTCA to R lower leg vessels\nP: NPO after M/N. Check PTT 8-9pm. Monitor groin for ooze. Shut off integrellin at 2100. Monitor pulses.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2102-06-04 00:00:00.000", "description": "Report", "row_id": 1659173, "text": "Resp care: Pt continues intubated #7 oett secured @ 23 @ lip and on ventilatory support with psv, no vent changes overnoc maintaining Vt 300's with Ve 7 L, sp02 100%; bs clear, sxn no secretions, rsbi 115, will weean when awake.\n" }, { "category": "Radiology", "chartdate": "2102-06-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1015695, "text": " 12:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for evidence of pna / effusion\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n please eval for evidence of pna / effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Query effusion, pneumonia in 22-year-old with altered mental\n status.\n\n COMPARISON: None available.\n\n CHEST, SINGLE VIEW: An ET tube tip terminates 4.4 cm above the carina. An NG\n tube and sidehole projects below the diaphragm in the left upper quadrant.\n Heart size and cardiomediastinal contours are normal. There is no focal\n airspace opacification. Pulmonary vasculature is normal. No gross osseous\n abnormalities.\n\n IMPRESSION: No acute intrathoracic process. ETT and NGT in appropriate\n position.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-06-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1015696, "text": " 12:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for evidence of bleed / fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 22 year old woman with altered mental status\n REASON FOR THIS EXAMINATION:\n please eval for evidence of bleed / fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DSsd SAT 1:26 PM\n slightly limited by motion artifact, but no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 22-year-old female with altered mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Evaluation is slightly limited by patient motion artifact. There\n is no evidence of hemorrhage, edema, mass, mass effect or infarction.\n Ventricles and sulci are normal in size and configuration. There is no\n fracture. Inspissated secretions in the posterior nasopharynx likely reflect\n the patient's intubated status.\n\n IMPRESSION: No acute intracranial process.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 1659170, "text": "Respiratory Therapy\n\nPt received from ER orally intubated on full mechanical support; weaned to +12PSV/+5PEEP w/ Vt ~300s RR high teens, maintaining Ve ~7L/M. SpO2 90s. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 1659171, "text": "MICU admit note\n\nPt is a 22y/o female transferred from OSH for TCA OD. Pt has a long term history of heroin abuse. Per father's report, pt had been involved with a methadone clinic but had recently been \"kicked out.\" He did not think she had been actively using recently. PEr OSH records, pt reported taking 14 doxepins. She was brought to EW where she had increased lethargy and decreased mental status. She was transferred to where she was intubated for airway protection. Pt received head CT which was unremarkable for intracranial process. PT transferred to MICU for intensive monitoring\n\nPlease see carevue for all objective data.\n\nNeuro: Pt sedated on propofol drip. Neuro check upon arrival (propofol gtt off ) she became aggitated with turning. She did not open eyes or follow commands. PERRL, sluggish.\n\nResp: Received pt on ACx12/500/40/5 with ABG: 7.40/41/402/26. Vent changed to PSV 12/5. LS CTA.\n\nCV: Hemodynamically stable. No arrythmias noted. NSR with no ectopy.\nBicarb gtt hanging initially but d/ced per Dr. . Serial EKGs x4. Next one needed in am.\n\nGI/GU: NPO. OGT in place. Positive placement per auscultation. Adequate u/o via foley. Pt is net negative since arrival to MICU.\n\nSocial: Father visited. Updated by Dr. . Pt will need SW/psych consult once awake. ? if this was a SI or accidental OD.\n\nDispo: remain in MICU. Full code\n" }, { "category": "Nursing/other", "chartdate": "2102-06-04 00:00:00.000", "description": "Report", "row_id": 1659172, "text": "NURSING PROGRESS NOTE 1900-0700\nREPORT RECEIVED FROM AM SHIFT. ALL ALARMS ON MONITOR AND VENTILATOR ARE FUNCTIONING PROPERLY. PT'S ENVIRONMENT SECURED FOR SAFETY.\n\nNEURO: PT CURRENTLY LIGHTLY SEDATED ON 50MCG/KG/MIN PROPOFOL GTT- HAVE BEEN TURNING OFF FOR NEURO ASSESSMENTS. PT WILL THRASH IN BED BUT DOES NOT OPEN EYES NOR FOLLOW COMMANDS. PERRLA, 3/SLUGGISH. AFEBRILE. NO SEIZURE ACTIVITY NOTED. BILATERAL WRIST RESTRAINTS APPLIED FOR SAFETY AS PT WILL ACTIVELY ATTEMPT TO GRAB AT ETT.\n\nRR: INTUBATED. CONTINUES ON CPAP/PS THROUGH THE EVENING WITH NO UNTOWARD INCIDENT. BBS= ESSENTIALLY CLEAR THROUGHOUT ALL LUNG FIELDS. BILATERAL CHEST EXPANSION NOTED. SP02 > OR = TO 95%.\n\nCV: S1 AND S2 AS PER AUSCULTATION. NSR- ST WITH HR 80-110'S DEPENDENT ON AGITATION. NO SIGNS OF ECTOPY NOTED. SBP > OR = TO 100 WITH NO HYPER OR HYPOTENSIVE CRISIS NOTED. PALPABLE PULSES NOTED TO BILATERAL DORSALIS AND RADIALS. PIV ARE SECURE AND INTACT.\n\nGI: ABD IS SOFT, NON-DISTENDED. BS X 4 QUADRANTS. OGT IS SECURE AND PATENT. PROPER POSITIONING VERIFIED WITH AUSCULTATION OF 30CC/AIR. NPO FOR IMPENDING EXTUBATION. PASSING FLATUS. NO BM THIS SHIFT.\n\nGU: INDWELLING FOLEY CATHETER IS SECURE AND PATENT. PT RECEIVE TOTAL OF 500CC NS BOLUS FOR DECREASED UOP- THERAPEUTIC RESULTS- CURRENTLY AVERAGING > OR = 30CC/HR. URINE NOTED TO BE GREEN TINGED- MOST LIKELY D/T PROPOFOL GTT.\n\nINTEG: NO SIGNS OF BREAKDOWN NOTED TO BACK OR BUTTOCKS.\n\nSOCIAL: NO CONTACT FROM FAMILY THIS SHIFT.\n\nPLAN: EXTUBATION. SUICIDE PRECAUTIONS. WILL NEED A 1:1 SITTER UNTIL CLEARED BY PSYCH. PLEASE SEE FLOW SHEET AS NEEDED FOR ADDITIONAL INFORMATION. THANK YOU!\n" }, { "category": "ECG", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 213974, "text": "Sinus rhythm\nNormal ECG\nSince previous tracing of , sinus tachycardia absent\n\n" }, { "category": "ECG", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 214202, "text": "Sinus tachycardia\nNormal ECG except for rate\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 214203, "text": "Technically difficult study\nSinus tachycardia\nConsider left atrial abnormality\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-06-03 00:00:00.000", "description": "Report", "row_id": 214204, "text": "Sinus tachycardia\nConsider left atrial abnormality\nNormal ECG except for rate\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "ECG", "chartdate": "2160-07-19 00:00:00.000", "description": "Report", "row_id": 244630, "text": "Sinus rhythm\nMarked left axis deviation, intraventricular conduction delay, R wave reversal\nin leads V3-V4\nPossible old anterior infarct\nProlonged Q-Tc interval for rate\nSince previous tracing of , ST-T wave abnormalities in leads l, aVL\nresolved, QT interval increased\n\n" }, { "category": "ECG", "chartdate": "2160-07-18 00:00:00.000", "description": "Report", "row_id": 244631, "text": "Sinus rhythm. Compared to tracing #2 the rate is faster. Lateral T wave\nabnormalities are new. Cannot rule out myocardial ischemia. Clinical\ncorrelation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2160-07-17 00:00:00.000", "description": "Report", "row_id": 244632, "text": "Sinus bradycardia. Compared to tracing #1 no significant diagnostic\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2160-07-17 00:00:00.000", "description": "Report", "row_id": 244633, "text": "Sinus bradycardia. Left axis deviation with left anterior fascicular block.\nPoor R wave progression - cannot rule out old anteroseptal myocardial\ninfarction. Compared to the previous tracing of there are no longer\nvoltage criteria for left ventricular hypertrophy. Lateral T wave abnormalities\nare resolved.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2160-07-19 00:00:00.000", "description": "Report", "row_id": 1401261, "text": "NEURO: \" WILL THEY MAKE ME HAVE THAT TEST IF I DON'T WANT TO? I SIGNED THAT PAPER SO THEY WILL MAKE ME DO THINGS I DON'T WANT TO. THAT DOCTOR IS QUITE PUSHY ABOUT ME HAVING THAT TEST AGAIN AND I DON'T WANT TO. I JUST WANT TO GO HOME.\" ANXIOUS WITH INCREASE IN BP ABOUT BEING MADE TO HAVE PROCEDURES OR TAKE MEDICATIONS. THIS NURSE REPEATEDLY EXPLAINED THAT NO ONE WILL FORCE HER TO DO ANYTHING SHE DOESN'T WANT TO DO WHILE TRYING TO EXPLAIN RATIONALE FOR MEDS AND RX BEING ORDERED.\n\nPULM: RA SATS > 94%. LUNGS CLEAR. NO RESPIRATORY DISTRESS.\n\nCV: FIRST DEGREE AV BLOCK (PR 0.24) WITH BBB (QRS 0.14) AND PROLONGED QTC (0.68-0.73). RHYTHM POINTED OUT TO MD AT 2100. LABETALOL GTT AT 4MG/MIN TO CONTOL SBP ~120. LABETOLOL 20MG PO STARTED AT 2130 WITH EFFECT. LABETALOL GTT WEANED OFF RAPIDLY D/T BP DROPPING TO 103/39. PT C/O DIZZINESS WITH POSITION CHANGES. RECEIVED PT ON POTASSIUM GTT 40 MEQ/LITER NS AT 100CC/HR. REPEAT K+ AT 2100 5.4, POTASSIUM GTT STOPPED. MD INFORMED. RX WITH 2 GMS CA GLUC IV IN 100 NS OVER 1H. REPEAT K+ 3.4 AT 0230. 20 MEQ KCL PO AT 0400 MD. CHEST PAIN OR DISCOMFORT Q2H. DOES C/O BACK ACHE(CHRONIC) BUT REFUSES TYLENOL FOR DISCOMFORT. PALPABLE PEDAL PULSES. 2+ PERIPHERAL EDEMA.\n\nENDO: BLD SUGARS 130-170. NO COVERAGE. SSRI COVERAGE DISCONTINUED ON DAY SHIFT D/T PT REFUSING TO TAKE INSULIN SHOTS.\n\nGI: ABDOMEN SOFT, + BS. NAUSEA, NO VOMITING. C/O MOUTH BEING VERY DRY. ? FROM COMPAZINE GIVEN ON PREVIOUS SHIFT. ENCOURAGED TO DRINK H20.\n\nGU: VOIDING CLEAR AMBER URINE IN SMALL AMTS, 100CC X 2 IN BEDPAN.\n CREATININE UP TO 1.7 FROM 1.4, BUN 34. MD AWARE. OBTAIN URINE LYTES WITH NEXT VOIDING.\n\nSOCIAL: DAUGHTER CALLED IN FOR UPDATE AT 2200. PT INTERACTIVE WITH THIS NURSE.\n\nPLAN: MONITOR BP Q1H. INCREASE ACTIVITY WHILE MONITORING BP. REPEAT EKG THIS AM. MONITOR PR, QRS AND QTC Q2H. PT TO TAKE PO LABETOLOL TO CONTROL BP. ADVOCATE FOR PATIENT. CALL DAUGHTER TO ACT AS LIASON WITH HEALTHCARE TEAM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-07-19 00:00:00.000", "description": "Report", "row_id": 1401262, "text": "ADDENDUM: IN REVIEWING THE CARDIAC RHYTHM INTERVALS THIS NURSE FOUND ERRORS IN CALCULATIONS OF R-R INTERVALS WITH SUBSEQUENT ERRORS IN QTC INTERVALS AS DOCUMENTED UNDER COMMENTS IN RHYTHM COLUMN OF CAREVUE FROM UNTIL 0600 TODAY. QTC 0.48 AT 0600.\n" }, { "category": "Nursing/other", "chartdate": "2160-07-19 00:00:00.000", "description": "Report", "row_id": 1401263, "text": "Nursing Progress Note\n\nS: \"I just want to get out of here.\"\n\nO: Please see flow sheet for objective data. Tele first degree AVB to sinus rhythm PR .24-.20. Labetolol dose increased to 300mg twice daily. SBP remains elevated at times. House staff aware. No further meds to be added at this time. Seen by vacular service per family request. No further studies or intervention at this time.\n\nResp: Lungs CTA. O2 sat 95-98% on room air.\n\nNeuro: Pt is alert and oriented. OOB to chair with minimal assistance several times throughout the day tolerated well. Generalized c/o leg pain. Pt more cooperative with care today. Consenting to take meds as ordered.\n\nGU/GI: Appetite improved today. No c/o n/v. Abd is soft with bowel sounds present. Brown soft stool x's 3. Voiding in small amts. Creat ^ to 1.7. IV NS at 100/hr x's 1 liter.\n\nSocial: Daughter in to speak with pt regarding cooperating with the POC. Pt agreeing to take meds.\n\nA&P: BP remains elevated in spite of increased dose of BB. Cont to monitor BP. No intervention at this time cont to treat medically. Possible transfer to floor in am.\n" }, { "category": "Nursing/other", "chartdate": "2160-07-20 00:00:00.000", "description": "Report", "row_id": 1401264, "text": "CCU Nursing Progress Note 1900-0700\nS: \" 139 is a very good blood pressure for me\"\n\nO: Please see careview for complete VS/additional objective data.\n\n\nMS: AAOx3. Pleasant and cooperative. MAE. PEARL. 3 mm in size. Brisk in response. Pt's daughter brought in pain med () from home for management of LE pain/ aches. Pt received just prior to shift change. No further c/o pain. Upon assessment at 2200, pt ^ anxious. Suggested Ativan 0.5 mg which pt agreed to stating that she felt a little anxious as well. Pt received Ativan w/ minimal resolution of anxiety. Pt dozed in naps overnoc in between bedpan use.\n\nCV: VSS. NSR/SB. HR 74-85. PR 0.17. No ectopy. Received pt with SBP 170s per NIBP despite 100 mg additional po Labetolol to make dose 400 mg and 10 mg IV as well. NIBP R/L arms correlating accordingly. At 00 notified HO of SBP of 180s.MAP>77. Pt was ordered to resume IV Labetolol gtt. Gtt started and remains at 2 mg/min as ordered. SBP 120-130. Cont heparin SC for DVT prophylaxis.\n\nGI/GU: Abd soft. Impoving intake as tolerated. Ate dinner per prior report. No N/V overnoc until Magnesium repletion which the pt spit up following ingestion. Otherwise tolerating all other pills and liquids +BS. Small formed brown stool x2. Guiac negative.\n ? insult to kidneys from CT contrast. Creatine improving. 1.4 last pm (1.7). UO improving overnoc. Pt voiding 100-350cc cyu q 1-2 hours. Incontinent at times d/t urgency. Pt refused recommendation for f/c insertion.\n\nResp: LS cta. Pt SOB/difficulty breathing. RR 15-19. O2 sats 94-96%. Pt remains off all supplemental O2. Pt tolerating lying flat without difficulty.\n\nID: Afebrile. Tmax 97.9 po. No abx at present.\n\nSkin: 2+ bilateral peripheral edema. Elevated UE most of noc. From frequent bedpan use pt has slightly pinked buttocks. Applied barrier cream with good effect.\n\nSocial: Daughter into visit. Very supportive and involved in POC.\n\nAccess: R hand IV infiltrated. New #20g RUE IV placed successfully. R antecub remains intact.\n\nEndo: BS 123. NIDDM, controlled w/ diet modification. No SS d/t pt noncompliance regarding insulin injections.\n\nA/P: 86 yo female w/ h/o DM2, hyperlipidemia and Breast CA with uncontrolled HTN presented w/ chest tightness. SSCP on/off x several wks. EKG indicative of LAD w/ LAFB and LVH. No ischemia noted. CT revealed extensive atherosclerotic ds of thoracic aorta w/ diffuse irregularity and penetrating ulcers of aorta. ? disection. Medically managed at present. Pt switched to po meds for BP mgmt but SBP steadily increasing as day progressed requiring resumption of IV Labetolol. Cont supportive care. Keep family involved in POC.\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-07-18 00:00:00.000", "description": "Report", "row_id": 1401259, "text": "CCU NPN 0430-0700\nS: \"Call me ...\"\nO: see admit note for complete assesment data\nNERUO: A&Ox2-3, MAE, equal strentgh. PERRL 2-3mm and brisk. C/o mid sternal CP \"tightness\" , relieved w/ maalox. Mildly confused, ? r/t sleep deprivation.\n\nCV: arrived from on 100mcg esmolol and .3mcg Nipride. Started labetalol and titrated up to 4mg/min w/ BP 120s/40s. Weaning esmolol currently on 67mcg, nipride off transiently but BP back up to 150s, restarted @ .15mcg/kg/min. HR 80s-90s NSR, no ectopy. All am labs pending. C/o nausea and BP ^ 160s w/ vomiting. BP equal both arms, radial pulses palpable, DP/PT by doplar.\n\nRESP: NAD, LSCTA, SpO2 94-98% on RA. No cough.\n\nGI/GU: abdomen soft, nontender, nondistended. +BS/LBM earlier today in ED. +N/V twice since admit to ccu, awaiting anzemet. Vomiting ~ 50-100cc-> anzemet for nausea. Incontinent urine, BUN/Cr elevated, ? new or CRI.\n\nENDO: BG @ 0600 184->refused insulin coverage\n\nID: afebrile, no abx, wbc pending.\n\nSKIN: 2+ edema all extremieies, 2 PIVs R arm. No breakdown noted.\n\nA: 86yo presenting to ED w/ chest tightness, tnt negative but serial ECG showing mild INF STEs; d dimer 1200s in ED, CT angio r/o PE but showed atherosclerotic lesions w/ penetrating ulcerations in aorta, could not r/o localized dissection. To ccu for BP control monitoring and further eval of dissection. Currently on esmolol, nipride and labetolol w/ BP 120s\nP: cont to wean esmolol and nipride as tolerated for SBP 110s-120s. Compazine if no relief of nausea w/ anzemet. Monitor CP/tightness. ? place foley. F/u labs sent @ 0630.\n" }, { "category": "Nursing/other", "chartdate": "2160-07-18 00:00:00.000", "description": "Report", "row_id": 1401260, "text": "Nursing Note 7a-7p\nS:\"I don't really want to do that...I don't want to take anymore pills.\"\nO: Pt A+Ox3, pleasant but very anxious about being in hospital and taking any new medications. PEARL MAE, c/o bil thigh cramps d/t K+ low, 3.2, repleated. Up to commode x1 with min assist.\nCV- Tele SR 60s-70s, conts on Labetolol gtt currently @ 4mg/min d/t NBPs raising into the 140s. Goal SBP 110-120. Plan is to wean off iv Labetolol while starting on the po version. NBPs 112-145/40's-52, Nipride and Esmolol were d/c'd. D5+40kcl @ 100 x 1L infusing, received kcl 20meqs po. Pt spoke with Dr. regarding aortic ulcerations with no planned interventions @ this time.\nResp- LSC, r/a sats >95%, no sob/doe.\nEndo- FS's 160, 119 pt was refusing insulin injections, SS was d/c'd.\nSkin- Intact, no breaks.\nGI/GU- Abd soft/firm, +bs no stool this shift. Has nausea and vomited x2, given compazine ivp with good effect. Tol liquids and sm amts of solids, appetite poor. OOB-commode for 130cc cyu plus incontinent of lg amt in bed.\nA/P: 86yo female admitted from ER with hypertension and aortic artherosclerosis with penetrating ulcers seen on CT scan. Pt declining intevention at this time. On Labetolol gtt for BP management, plan is to wean off and replace with po form. Monitor lytes, urine op and medicate for N/V.\n" } ]

[ { "category": "ECG", "chartdate": "2198-08-31 00:00:00.000", "description": "Report", "row_id": 122891, "text": "Sinus tachycardia with a single ventricular premature beat. The Q-T interval\nis markedly prolonged for rate with the ventricular premature beat appearing\ndelayed after depolarization. There is ST segment depression in\nleads II, III and aVF with minimal ST segment elevation in lead V1 concerning\nfor an acute myocardial injury. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2198-09-02 00:00:00.000", "description": "Report", "row_id": 122889, "text": "Sinus rhythm with a single ventricular premature complex with improvement of\nthe previously noted abnormalities. Clinical correlation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2198-09-01 00:00:00.000", "description": "Report", "row_id": 122890, "text": "The rate is slower with slight shortening of the Q-T interval and persistence\nof the ST segment and T wave abnormalities.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2198-09-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1249505, "text": " 2:30 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PNA\n Admitting Diagnosis: HYPOKALEMIA;ETOH WITHDRAWAL AEIZURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with etoh w/d s/p seizure\n REASON FOR THIS EXAMINATION:\n eval for PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Seizure, ETOH, question pneumonia.\n\n CHEST, SINGLE AP PORTABLE VIEW.\n\n Slight rotated positioning. There is probable mild cardiomegaly. There is\n prominence of the right mediastinum, which may reflect some unfolding of the\n aorta. There is minimal upper zone redistribution, but no overt CHF. No\n focal infiltrate or consolidation is identified. No effusion. Minimal\n atelectasis at both bases. Mild degenerative changes of the thoracic spine are\n noted.\n\n IMPRESSION:\n 1. No focal infiltrate to suggest aspiration or pneumonia.\n 2. Possible mild cardiomegaly, with upper zone redistribution, but no overt\n CHF.\n 3. Prominence of the right mediastinum, ? due to unfolded aorta. Recommend\n PA and lateral view when the patient is stable to confirm this.\n\n" }, { "category": "Radiology", "chartdate": "2198-08-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1249489, "text": " 8:24 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for ICH/acute proces\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 62F with seizures, likely secondary to ETOH withdrawl, now confusion.\n REASON FOR THIS EXAMINATION:\n assess for ICH/acute proces\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ASpf FRI 11:53 PM\n No acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old female with seizures, likely secondary ethanol\n withdrawal, now with confusion.\n\n COMPARISON: No relevant comparisons available.\n\n TECHNIQUE: MDCT images were acquired through the head without contrast.\n Multiplanar reformations were obtained and reviewed.\n\n FINDINGS:\n\n No acute intracranial hemorrhage, large vascular territory infarct, shift of\n midline structures or mass effect is present. The ventricles and sulci are\n normal in size and configuration. The visible paranasal sinuses and mastoid\n air cells are well aerated.\n Empty sella with very thin pituitary is noted.\n\n IMPRESSION:\n\n No acute intracranial hemorrhage or mass effect. Study slightly limited due to\n rotated position and artifacts. Correlate clinically to decide on the need for\n further workup.\n Empty sella.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2171-04-30 00:00:00.000", "description": "P BABYGRAM (CHEST ONLY) PORT", "row_id": 761386, "text": " 11:42 AM\n BABYGRAM (CHEST ONLY) PORT Clip # \n Reason: r/o abnl cardiac silhouette\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with murmur.\n REASON FOR THIS EXAMINATION:\n r/o abnl cardiac silhouette\n ______________________________________________________________________________\n FINAL REPORT\n CHEST: 11:45 am\n\n CLINICAL HISTORY: This is a 3 day old infant with a murmur. The film is\n first available for interpretation on .\n\n FINDINGS: A single portable view of the chest was obtained. I have no prior\n films available for comparison. This film was obtained with the child bent\n toward his left side.\n\n The heart size and pulmonary vascularity are within range of normal limits\n given the relatively expiratory nature of the film. The lungs are clear.\n Twelve ossified rib pairs are visible and there are no appreciable vertebral\n body abnormalities. It is assumed that this smooth curve of the thoracic\n spine is positional rather than intrinsic. This would need to be correlated\n with physical examination.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-04-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 761226, "text": " 10:17 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: DROP IN HCT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with falling hct, vacuum assisted delivery. high pitched cry, hypotonia\n REASON FOR THIS EXAMINATION:\n r/o intracranial bleeding\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Falling hematocrit following delivery. High pitched cry. Hypotonia.\n Intracranial bleeding suspected.\n\n TECHNIQUE: Non-contrast head CT scans were obtained.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, shift of normally\n midline structures, minor or major vascular territorial infarctions seen.\n There is no abnormality of the visible fontanelles or sutures. There is a\n small amount of scalp soft tissue swelling seen in the right parietal vertex,\n presumably related to the vacuum assisted delivery. The surrounding osseous\n and soft tissue structures are otherwise unremarkable.\n\n CONCLUSION: No intracranial hemorrhage.\n\n COMMENT: The study was reviewed in conjunction with Dr. ,\n Chief of Neuroradiology, , .\n\n" }, { "category": "Echo", "chartdate": "2171-05-01 00:00:00.000", "description": "Report", "row_id": 73012, "text": "PATIENT/TEST INFORMATION:\nIndication: Congenital heart disease.\nBP (mm Hg): 76/46\nStatus: Inpatient\nDate/Time: at 07:54\nTest: Portable TTE(Congenital, complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nPediatric study. Report will be generated by .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-29 00:00:00.000", "description": "Report", "row_id": 1935197, "text": "NPN\n\n\n#1 remains stable on antibiotics, VSS, no S/S sepsis A:\ncont R/O sepsis P: monitor\n#2 Infant stable, 67/46, 48. HR 113-130's, no murmur\naudible. color quite jaundice. A stable P: monitor, in for\nhct, bili in a.m.\n#3 is ad lib po feeding taking 40-50 cc E20, abd benign,\nvdg/stlg qs, no loops or distention. Weight 3.095 down 90\ngrams. A: feeding great P: cont, no change.\n#4 Family in to visit, Mom held and fed , handles infant\nquite confidently, dad changed diaper. Both pleased that he\nis making some progress. A: involved family P: cont support\nand inform\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-29 00:00:00.000", "description": "Report", "row_id": 1935198, "text": "Neonatology Attending Note\nDOL 2\n\nRA. 97+sats in RA. No A&Bs. RR30-60s. Cl and =. No GFR. + murmur. HR 120-130s. Mean BP > 40. +Jaundice. Wt down 90 to 3095g. PO ad lib E20, since 4 pm. Off IVF since 6pm. d/s 94. Nl voiding and stooling. Open crib.\n\nLabs:\nHct 30, 3.4\nBili 8.1/0.3\n\nIssues:\n1. s/p hypotension, now off dopa\n2. anemia - ? maternal -fetal hemorrhage\n3. r/o sepsis - initial bandemia, hypotension\n4. murmur\n5. initial abnormal neurological exam with hypotonia, later high-pitched cry\n\nPlan:\n1. RESP - ok in RA. No active issues.\n2. CV - Murmur may be related to anemia. Will con't to follow. If present prior to discharge will do cardiology eval and consider consult.\n3. HEME - anemia. Source unclear but probably maternal fetal hemorrhage. K-B should be run today. Hemodynamically well compensated. Will start Fe and follow levels. No transfusion at this point.\n4. ID - Cultures have remained negative. However, in light of initial bandemia, hypotension, and slowly normalizing exam will treat for full week. Will need LP.\n5. NEURO - Exam appears to be improving steadily with increase in tone, normal extension and flexion, symmetric movements. Reportedly normal state changes. Will continue to assess. If exam fails to completely normalize or worsens will call neurology to further evaluate. Will get final CT report.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-29 00:00:00.000", "description": "Report", "row_id": 1935199, "text": "Neonatology Attending Note\nEXAM:\n\nAwake, looking around. AFSF. Some decreased molding, decreased swelling. Still w/ superficial bruising. Suck much better w/ good vigorous suck. Lungs CTA. CV RRR, + sys murmur along right border. Abd soft, +BS. GU nl. Neuro: Improved tone, symmetric, awake and active. ? of hypereflexia of LE. Skin: pale/pink and jaundiced.\n\nOverall much better exam. Continues to improve daily. No change to plan as outlined above. Family meeting held at bedside to discuss above.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-29 00:00:00.000", "description": "Report", "row_id": 1935200, "text": "Nursing Progress Note\n\n\n1. Infant continues on Amp and Gent as ordered. Levels\nobtained today trough 1.2 peak 11.3 - shown to NNP\nAmbrisino. Temp stable swaddled in OAC. Infant is active\nwith cares. Infant remains hypertonic. LP unsucessful\ntoday, will try tonight.\n\n2. BP stable today 58/34 (42). Infant is pale pink and\njaundice. Infant has murmur, MD aware. Started on\nIron supps today, on Enfamil with Iron formula.\n\n3. Infant is bottling ad lib amts of E20 with FE. Voiding\nQS, yellow stools Q2-4 hrs (guiac neg). Abd exam benign.\nTolerating feedings, no spits. Started on Iron supps today.\nD-stick 97.\n\n4. Parents in throughout day. Parents updated at bedside\nby , MD and , NNP. Parents performing\nbasic infant cares with min assistance. Parents holding and\nfeeding infant throughout day. Parents loving toward\ninfant. Paternal grandmother in to visit. Demonstrated\nadmin of Iron supps to parents today. Paernts signed consent\nfor Hep B and PKU screen today. D/C teaching started with\nparents, see d/c sheet.\n\n5. Neuro:\nOn exam, infant is hypertonic, unable to extend elbows.\nInfant has high pitched cry. Infant has quiver of jaw.\nInfant is jittery. Infant tends to hold thumbs in toward\npalm of hand. Infant tends to curl toes. Infant has\nuncoordinated suck. Infant is alert and active with cares.\nInfant sleeps well between feedings. Infant has quiet alert\nstate. Infant is bottling QS amts of E20.\n\n**Infant is scheduled for Circ tomorrow at 8am, consent is\nin chart.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935201, "text": "NNP On-call/Procedure Note\nLumbar Puncture\n\nIndication: to complete sepsis evaluation\n\nSigned parental consent in chart.\n\nInfant positioned sitting, prepped and draped in sterile fashion. Analgesia with sucrose solution PO, subcutaneous 1% Lidocine local. #22 g spinal needle introduced into L3-4 interspace, clear fluid obtained. CSF sent for culture, gram stain, cell count/diff, glucose protein. Infant tolerated procedure well, no complications.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935202, "text": "NPNOte;\n\n\n#1.Remains on Amp+ Gent, given as ordered.LP done at\n1.30am,sucrose pacifier given, csf xanthochromic, protein\n78. glucose 41, d'stix 71.\n\n#2.Pale pink with mildly Jaundiced, murmur+, well perfused.\n\n#3.Todays weight=3.075kg, down 25gms, TF=adlib E20, po feeds\nsucked well and tolerated. BS+, no loops,voided and stoolx1,\nsmall amount.D'stix 71.A; feeds tolerated.P; continue adlib\npo.\n\n#4.Parents were in at the beggining of this shift, and then\nno calls thus far this shift.\n\n#5. Neuro; Infant has irritable cry with care, sleeps in\nbetween care, mildly jetteric,quiver jaw noted at times,\nhypertonic, loves pacifier. caput+.A; sleeps well inbetween\ncare.P; continue to monitor.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935203, "text": "Neonatology Attending Note\nEXAM:\n\nResting comfortably in no distress. Jaundiced. AFSF. Lungs CTA, cl and =. CV RRR, +3/6 SEM prominant along RSB, tramsission to left. Abd soft, +BS. Ext pink/jaundiced. Neurology: remains w/ high-pitched cry, but suck, tone, activity and alertness all within normal limits.\n\nCardiac eval:\n1. Hyperoxia > 300\n2. 4 ext BP ok\n3. CXR heart size 50-55% cardiothoracic diameter. Narrow mediastinum, ? thymic shadow present.\n4. EKG final pending.\n\nCalled cardiology. They will assess tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-01 00:00:00.000", "description": "Report", "row_id": 1935208, "text": "Neonatology Attending Note\nDOL 4\n\nRA. RR40-60s. 98-100%. No A&Bs. +murmur. HR 120-160s. BP 66/35, mean 46. Weight 3135, up 60. PO ad lib (160). Nl voiding and stooling. +circ yest. Day of amp/gent. Open crib.\n\nHct 25.5, 5.0\nbili 8.2/0.3\nalt 71, ast 40\n\nPlan:\nresp - no active issues.\ncv - murmur, cardiology to evaluate today\nnutrition - po intakes are good\nanemia - pres due to maternal fetal hemorrhage, Fe to 4 mg/k/day\nbili stable\nneuro - continued reports of irritability, however, exams with continued improvement and he can be contained. W/ hypotonia, early hypotension, and severe anemia, consider mild encephalopthy, but no acidosis and LFTs not reflective of general hypoxia. Initial CT negative. If change in neuro exam or worsening will consider neuro evaluation.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-01 00:00:00.000", "description": "Report", "row_id": 1935209, "text": "Neonatology-NNP Physical Exam\n\n remains stable in RA. Active, irritable, AFOF, sutures opposed, +molding. BBS clear and equal with good air entry. Gr murmur over LRSB, pulses +2, pink/jaundice, CRT < 3 secs. Abdomen soft, non-distended with actve bowel sounds, no HSM, tolerating feeds. Continues to be hypertonic, hyperrefexia in LE, suck uncoordinated at times. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-01 00:00:00.000", "description": "Report", "row_id": 1935210, "text": "NICU NPN 0700-1900\n\n\nPOT SEPSIS: Infant remains on ampi and gent - given as\nordered. Continue to monitor for s/s of sepsis.\n\nCV: Murmur present. HR 130-150's. Pulses nl. Infant is\npink/jaundiced. ECHO done today. BP 76/46(57). Continue to\nmonitor CV status.\n\nF/N: Infant remains ad lib, bottling 70-90cc of E20 q 3-4\nhours today. Infant being bottled with nuk nipple - did not\nlatch well with yellow nipple. Infant's suck somewhat\nuncoordinated and it takes infant a little while to latch\nonto nipple d/t being unconsolable when awake and waiting to\neat. Occasional spits. Abdominal exam benign. Voiding,\nstooling. Stool heme positive today - MD aware. Circ site\nwithout drainage - circ care done q diaper change. Bruised\narea on penis noted this morning - bruise has remained\nunchanged throughout shift - NNP aware. On Fe. Scalp IV\nremains soft. Continue per plan.\n\n: in this afternoon. Updated on infant\nstatus. Present during neuro consult and ECHO. Independent\nwith cares. Continue to support and update .\n\nG/D AND NEURO: Infant remains swaddled in an open crib,\nstable temps this shift. Irritable when awake. Continues to\nhave high pitched cry and is frantic when awake. Difficult\nto settle while bottling. Arching during cares and with\nfeeds. Had neuro consult done today. Continue to monitor\nneuro status and support growth and development.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-02 00:00:00.000", "description": "Report", "row_id": 1935214, "text": "Co-Worker Note 0700-1500\nAgree with above note by co-worker .\n" }, { "category": "Nursing/other", "chartdate": "2171-05-02 00:00:00.000", "description": "Report", "row_id": 1935215, "text": "Neonatology - NNP Progress Note\n\n is active with some hypertonicity to upper ext. Irritable with high pitched cry during exam. AFOF. He is pale pink, well perfused, soft VSD murmur auscultated. He is comfortable in room air. Breath sounds clear and equal. Abd soft, active bowel sounds, no loops. Voiding and stooling. Stable temp in open crib. Please refer to neonatology attending note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-03 00:00:00.000", "description": "Report", "row_id": 1935216, "text": "progress note 1900-0700\n\n\n1 Sepsis\ncontinues on amp/gent treatment. no s/s of infection.\ntemps stable. alert and active. slightly hypertonic.\n\n2 CV\nmurmur heard. hr 120-160s. pulses =. well perfused. pale\npink but slightly jaundiced.\n\n3 FEN\nwt is 3115 grams (-20). remains on adlib/demand schedule.\ntaking 85-110 cc q 3-4 hours. took 212cc/kilo in past 24\nhours. occ irriatable, calms well after feeding. abd\nbenign. +bs. voiding and stooling. c/d/i. no\ndrainage. sm bruise noted.\n\n4 \nno contact thus far.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-03 00:00:00.000", "description": "Report", "row_id": 1935217, "text": "NPN Addendum\n\nAgree with above co-workers note.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-03 00:00:00.000", "description": "Report", "row_id": 1935218, "text": "Neonatology Attending Note\nDOL 6\n\nRA. BS cl and =. RR40-60s. No A&Bs. Known murmur. HR 130-150s. Wt 3115, down 20 gms. PO ad lib (212). Nl voiding and stooling (g+) but buttocks raw. In open crib. Day of amp/gent.\n\nPlan:\n1. Complete abx course.\n2. Check to see when cardiology would like to see him after d/c to f/u on VSD.\n3. Guaiac positive stools presumably d/t buttocks breakdown. Rest of exam benign, tolerating feedings.\n4. Con't on Fe for anemia. K-B still pending.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-03 00:00:00.000", "description": "Report", "row_id": 1935219, "text": "NPN\n\n\n1. ID: Day 6 of 7 of antibiotics. will be discharged\ntomorrow. No s&sx of sepsis.\n3. FEN: TF @ 60/kg/d of D10W with 1 meqnacland 1meqkcl per\n100cc's. All po feeds , taking 80-90 cc's each feeding.\nLikes the nuk nipple. No spits, abd. soft. Voiding and\nstooling qs. Excoriated buttock, desitin applied. A:\nTolerating po feeds P: Continue to po as tolerated.\n4. in today, held and did basic cares independantly.\nDischarge teaching done. Needs Hep B tonight, F/U with\ncardiology at 1 month for vsd. No neuro f/u.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-04 00:00:00.000", "description": "Report", "row_id": 1935220, "text": "progress note 1900-0700\n\n\n1 Sepsis\ntemps stable. no s/s of infection. remains on amp/gent\ntreatment.\n\n2 CV\nmurmur heard. hr 130-160s. pale pink, well perfused.\npulses are =.\n\n3 FEN\nwt is 3150 grams (+35). remains on ad lib schedule of E 20.\n taking 65-90cc q 3-4 hours. abd benign. +bs. voiding and\nstooling. is c/d/i. bruise at base of shaft.\nbuttocks is slightly broken down, applied desitin.\n\n4 PArenting\nno contact thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-04 00:00:00.000", "description": "Report", "row_id": 1935221, "text": "NICU NPN\nI Have read and agree with above co-worker note. Baby examined by RN with cares, IVHL patent, flushing well. Buttocks are excoriated. Will discuss with NNP, ?Criticaid vs desetin.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935204, "text": "Neonatology Attending Note\nDOL 3\n\nRA. Cl and =. HR 130-150s. Wt 3075, down 25 gms. Intake 104 E20 po ad lib. Nl voiding and stooling. Open crib.\n\nBili 8.1/0.3\n\nStudies:\nLP to complete sepsis evaluation - 4 wbcs\nFormal report of CT head - normal, No ICH or other abnormalities (except scalp-soft tissue swelling)\nGent levels - peak 11.3/trough 1.2\n\nA/P:\n1. Anemia - On Fe. Will check another level prior to discharge.\n2. r/o sepsis - day . Gent levels ok. LP results ok, no extended course of abx necessary.\n3. Cardiac murmur still present - will check CXR, EKG, 4 ext BPs, Hyperoxia and discuss with cardiology.\n4. Neurological exam continues to improve. Will con't to follow.\n\nFamily meeting held yesterday at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935205, "text": "Respiratory Therapy\nInfant passed hyperoxia test with a tcPO2 >300.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 1935206, "text": "NICU NSG NOTE\n\n\n#1. Sepsis. O/ Conts on ampi and gent as ordered. Temps\n99.2-99.5, ax. Alert with cares. LP wnl. A/ Day abx. P/\nCont to monitor for s/s sepsis. Cont abx as ordered.\n\n#2. CV. O/ Soft murmur. HR 130-170's. Color\nsallow--jaundiced. Cardiac w/u done. 4 ext BP's wnl as\ndocumented on flow sheet. Passed hyperoxia test. EKG, CXR\ncomplete. A/ Cardiac w/u for murmur. P/ Cont to monitor.\n\n#3. FEN. O/ Conts on ad lib feeds E20. Waking q2-3h and\ntaking 60cc qfeed with yellow nipple. Abd exam benign.\nVoiding and stooling. No spits. A/ Tolerating feeds ad lib.\nP/ Cont to monitor for feeding intolerances. Monitor wts.\n\n#4. Parenting. O/ Mom and dad in this am. Independant with\ncares. Fed infant and stated they would return this eve.\nCirc care info sheet reviewed and given to parents. A/\nUpdated and involved. P/ Cont to provide info and support to\nfamily.\n\n#5. G&D/Neuro. A/ Waking on own for feeds. Temps 99.2-99.5.\nHigh pitched, frantic cry. Hypertonic. MAE. A/ Alt in G&D\nr/t hospitalization. P/ Cont to monitor.\n\nCirc done this am. White petroleum applied to diaper area\nqchange. Site intact with sm amt serosang drn noted. Cont to\nmonitor.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-01 00:00:00.000", "description": "Report", "row_id": 1935207, "text": "NPN:\n\nRESP: Sats 97-100% in RA. No desats or A&Bs. RR=40-60. BBS =/clear.\n\nCV: Soft murmur audible at LUSB. BP=66/35 (46). Cardiology to examine babe today. Color pale pink w/jaundice. Hct=25.5; Retic pending. Remains on FeS04.\n\nBILI: Bili 8.2/ 0.3/ 7.9 (no change from ). ALT=71; AST=40. NNP notified of lab results.\n\n\nFEN: Wt=3135g (+ 60g). Ad Lib feeds. Intake yesterday 160cc/kg/d. Waking for fdgs; bottling 80cc E-20 q 4 h. Small spits after fdg. Abd benign. Voiding ; loose yellow stools.\n\nID: Remains on Amp & Gent (day ).\n\nNEURO: Quite irritable w/high-pitched cry prior to feeds and w/cares. Occasional periods of irritability between feeds. Rested fairly well when swaddled tightly and nested in blankets. AF soft, flat. Small rt cephalhematoma.\n\nG&D: Term babe. Temp stable in crib. Circ site without s/s imflammation; vaseline applied w/each diaper change.\n\nSOCIAL: No contact w/.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-02 00:00:00.000", "description": "Report", "row_id": 1935211, "text": "NPN 7p-7a\n\n\nSepsis: Infant conts on amp and gent. No new signs of\nsepsis. Cx negative to date.\n\nCV: Murmur heard. Jaundice well perfused. Pulses equal. Hr\n130-150's. See flowsheet for bp. Cont to monitor. Await plan\nfrom team.\n\nFen: Infant's wt. 3.135kg ( no change). Conts on ad lib\ndemand feeds of e20. Waking q 3-4hrs for feeds. Po 70-110cc.\nTotal intake for 24 hrs was 181cc/kg. Abd soft. Active bs.\nStooling yellow quiac + stool with each diaper change.\nVoiding qs. Po's better with nuk nipple. Cont with current\nplan.\n\nDev: Temp stable in open crib. Swaddled with boundries in\nplace. Wakes for feeds irritable with cares. Settles well\nonce feed. Sleeping between cares, but wakes irritable.\nHight pitched cry and +clonis noted cares. Circ care given.\nSite d+I pink no drainage noted. Sm bruise on tip. Cont to\nsupport developmental milestones.\n\nParenting: No contact from so far this shift.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-02 00:00:00.000", "description": "Report", "row_id": 1935212, "text": "Neonatology Attending Note\nDOL 5\n\nEvents:\n1. Neuro consult requested due to irritability, increased tone. Team's impression that exam only w/ mild hypertonia and suggested continued monitoring. If concerns continue to consider metabolic and MRI evaluation.\n2. Cardiac consult requested for peristent murmur. ECHO showed small midmuscular VSD.\n\nRA. RR40-60s. No A&Bs. 98-100 sats. + murmur (VSD). HE 130-150s. BP 75/42, mean 55. Wt 3135, no change. PO ad lib. E20. 24 hr intake 181. Tol well. Nl voiding and stooling (tr heme +). done . Stable temp. On amp/gent. Open crib.\n\nPlan:\n1. VSD - will need cardiology f/u.\n2. Anemia - on Fe, Kleihauer-Betke pending. Check crit and retic sat am.\n3. Neuro - appreciate neuro opinion, will con't ususal anticipatory guidance.\n4. ID - complete 7 day of abx Sat am.\n5. DISPO - to home Sat am.\n6. Heme + stools. Exam has been benign, some buttock breakdown and recent , con't to follow.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-02 00:00:00.000", "description": "Report", "row_id": 1935213, "text": "Co-Worker Note 0700-1500\n\n\n1. SEPSIS: O/A: Infant remains on amp/gent for 7 day course.\nCBC shifted @ birth. Blood cx's neg to date. Afebrile. P:\nCont to monitor, adm meds as ordered.\n\n2. CV: O/A: VSD murmur heard. HR 140-150's. Equal pulses.\nSee flowsheet for BP. Last HCT 25.1 (), decreasing since\nbirth. Infant sl. jaundiced, bili 8.2/0.3 (). P: Cont to\nmonitor.\n\n3. FEN: O: Ad lib demand feeds. Bottles ~90cc of E20 q3-4h.\nAbd exam benign, +BS. Voiding and stooling heme +. Team\naware, may be d/t excoriated bottom and/or recent . \ndone yesterday -> C/D/I with some bruising. Sm spit x1. No\nchange in wgt overnoc. A: Tolerating feeds. P: Cont to\nmonitor.\n\n4. : O: Mom and Dad in to visit at noon today.\nUpdated at bedside by RN, NNP re: VSD. Appear anxious.\nIndependent with baby. Asking appropriate questions. A:\nAttentive, caring family. P: Cont to support and educate\nfamily.\n\nNEURO/DEV: O: is alert/active with cares, but remains\nvery irritable at times. Cont to have hi-pitched cry. Suck/\nrooting/grasp/step reflexes intact. MAE. AFOF. Slightly\nhypertonic. Temps stable in open crib. Settles easily\nfollowing feeds. Wakes q3-4h to eat. A: AGA, ?neuro\nabnormalities. P: Cont to monitor, support dev needs.\n\nSee flowsheet for details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-05-04 00:00:00.000", "description": "Report", "row_id": 1935222, "text": " , dol#7 ready for d/c.\n\nIn RA with sats >95%. LS clear and equal. Known VSD murmur. Color pale pink. Hct 26.2 this am. Retic pending. Infnat being sent home on Fe. aware of dose and have bottle for d/c. Ad lib feeds E20. Abd exam benign. Voiding and stooling. Buttocks excoriated. Criticaid applied and given to for d/c. D/C papers reviewed with . Time allowed for all questions to be answered. Hep B given to infant. Pedi appt for . Last PKU . All d/c papers signed by . Infant d/c'd home to .\n" }, { "category": "Nursing/other", "chartdate": "2171-05-04 00:00:00.000", "description": "Report", "row_id": 1935223, "text": "Retic 0.9.\n" }, { "category": "Nursing/other", "chartdate": "2171-05-04 00:00:00.000", "description": "Report", "row_id": 1935224, "text": "Newborn Med Attending\n\nDOL#7. Cont in RA, no spells. AF flfat, clear BS, no murmur, abd soft, MAE. Taking feeds well PO ad lib. Wt=3150.\nA/P: Infant taking full feeds and s/p fetal-maternal hem and TTN. D/C home.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-27 00:00:00.000", "description": "Report", "row_id": 1935189, "text": "Neonatology-NNP Admission Note\n\nRequested by Dr. to attend this vacuum delivery of a full term male infant.\n\nBabyboy is a full term infant born to a 24 year old G1 P0 now 1 mother. PNS: A neg/Ab neg/RPR NR/RI/HbsAg neg neg/GBS neg. Benign pregnancy. Intrapartum Hx: SVD, epidural anethesia, ROM < 24 hrs PTD, no maternal fever, occiput posterior presentation, nuchal cord x 1. Infant emerged with weak cry, HR > 100, pale, tone decreased. PPV given with improvement in respiratory effort and color. Infant remained pale/pink with decreased tone at 5 minutes. Apgars 6, 8. Transferred to NICU.\n\nWeight: 3135g\nLength: 52.5 cm\nHC: 34.75 cm\nTemp: 97.1 R, HR: 168, RR: 70, BP: 56/30(34), O2 sat 100% in RA.\n\nPE: Alert, hypotonic, AFOF, prominent molding, palate intact, clavicles intact, +red reflex OU, BBS clear and equal with good air entry, intermittent grunting, no flaring or retractions. No murmur, nl S1, S2, pale, pulses +2 and equal. Abdomen soft, non-distended with active bowel sounds, no HSM, 3 vessel cord, anus patent, spine intact, no dimple, nl phallus, testes descended bilaterally, no hip click.\n\nAssessment/Plan: Full term non-dysmorphic male infant, most likely delayed transition, nuchal cord x 1. Stable in RA, no sepsis risk factors.\nWill monitor respiratory status closely.\nWill give normal saline bolus 10cc/kg for perfusion.\nWill draw CBC, diff, blood culture and consider abx if change in respiratory status.\nTransfer to NB nursery if BP and respiratory status remains stable.\nParents aware of plan.\n\nPrimary Pedi: Centre Peds\n" }, { "category": "Nursing/other", "chartdate": "2171-04-27 00:00:00.000", "description": "Report", "row_id": 1935190, "text": "Neonatology Attending Admit Note\n\nHistory, exam and management discussed with , NNP. History as stated above.\n\nOn my exam:\nVS per CareView, of note initial mean BP 34, initial d/s ok\nGeneral: hypotonic posture, pale/pink, mild intermittemt grunting\nAF open flat. Significant molding and superficial bruising, over-riding sutures. Palate intact. Suck good but not strong and vigorous. Neck supple. Lungs CTA, = w/ good aeration. CV RRR, no murmur, 2+FP. Abd soft, +BS. No HSM. GU nl phallus testes down bilaterally. Ext centrally pale/pink, peripheral acrocyanosis. Decreased tone.\n\nImpression:\n1. AGA, FT male newborn.\n2. Delayed transition comlicated by nuchal cord, OP positioning and vacuum extraction.\n3. Mild, transitional respiratory distress.\n4. Hypotension.\n5. Sepsis evaluation due to early symptoms of respiratory distress, hypotension.\n6. Hypotonia.\n\nPlan:\n1. Resp distress- Monitor respiratory transition. Distress mild and improving. If fails to continue to improve or worsens, will check CXR.\n2. Hypotension - NS bolus given for low mean BP. Follow closely w additional volume/vasopressors as needed.\n3. Sepsis concern - Will check CBC w diff and bld cx. Will hold abx unless labs abnl or clinical course changes.\n4. Hypotonia - Most likely due to delayed transition, will follow for now.\n5. NPO with maintenance IVF till transition complete.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-28 00:00:00.000", "description": "Report", "row_id": 1935194, "text": "Neonatology - NP Physical Exam\nAwake and alert with cares, temp stable in open crib. In room air, BS clear and equal with symmetrical chest movement, color pale pink. RRR, without murmur on exam (hx of murmur), pulses 2+ and symmetrical. Active bowel sounds, without loops, without HSM, tolerating feeds well. Peripheral IVs in in right hand and right foot patent, without reddness or swelling at site. Uncirced male, testes down bilaterally. Without rashes. Slightly hypotonic, AFSF, PFSF, +suck, +, +plantar reflexes. Please see attending neonatologist note for detailed plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-28 00:00:00.000", "description": "Report", "row_id": 1935195, "text": "Neonatology Attending Note\nDay 1\n\n97-100% in RA. No desats/apnea. RR20-50s. Pale/pink, color and perfusion improved. Off dopa x 24 hours. BP 66/33, 46. HR 120-130s. +soft murmur more prominent on right side. HCT 27.1. Wt 3185, up 50 gms. NPO. D10 w maint fluids. Abd flat, soft. Nl voiding and stooling. d/s 104. On amp/gent. Open crib.\n\n138/3.2/101/21\n\nPlan:\n1. RESP - no active issues. Con't to monitor.\n2. Hypotension - resolved. Monitor.\n3. Nutrition - offer po feedings. Drop TF to 60 cc/k/day.\n4. Anemia - source remains unclear. K-B pending from mother. off PRBCs unless hypotensive, develops O2 requirement. Hct in am.\n5. r/o sepsis - con't amp/gent pending clinical course.\n6. Neuro - tone improving, yet still remains listless, disinterested in po feeds and has high-pitched cry. Head CT done - no obvious bleeding. However, need final report.\n7. Murmur may be flow murmur, due to anemia. Will follow for now.\n\nHave updated parents at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-28 00:00:00.000", "description": "Report", "row_id": 1935196, "text": "NPN 1745\n\n\n#1 ID: continues on antibiotics as ordered. Temps wnl in\nan open crib; moved this afternoon. Infant more alert and\nawake. Blood cultures remain negative.\nA: Stable on antibiotics.\nP: cont antibiotics as ordered.\n#2 CV: Murmur not heard by this RN. BP 66/33 M43. Color\nimproved since yesterday, pink w/ brisk perfusion.\nA: Stable BP today, s/p dopamine yesterday.\nP: Cont to monitor BP's.\n#3 F/N: Received on 80cc/kg/d D10 w/ 2mEq NaCl & 1 mEq\nKCl/100cc infusing at 10.4cc/hr w/o difficulty into a R hand\nPIV. TF decreased to 60cc/kg/d this afternoon and baby\nbottle fed 35cc E20 w/ Iron for parents. IV rate decreased\nto 1cc/hr. Infant is voiding >3.0cc/kg/hr in 18hrs. is\npassing mec. stools. Abd soft, flat, bowel snds present.\nA: Taking po's today, IV weaned.\nP: Cont po feeds, wean IV to heplock.\n#4 Parents: parents up numerous times to visit and hold .\nParents accompanied baby to CT for head scan. Handling baby\nwell, asking appropriate questions.\nA: Invested parents.\nP: Cont parent teaching.\n#5 Neuro status: Infant more awake and alert this afternoon,\ncry remains weak. CT scan of head done for this reason and\nfor low HCT and potential blood loss. Result pending.\nFontanelle is soft and flat, though head is bruised.\nA: Behavior and activity somewhat improved this afternoon.\nP: Cont to monitor for change in status.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-27 00:00:00.000", "description": "Report", "row_id": 1935191, "text": "NICU Nursing Note\nBaby boy admitted from L&D s/p vac assist vaginal delivery with nuchal cord X1- PPV X5breaths in the DR. MD/NNP note for maternal history and delivery room details. G/F/R upon arrival sats 100% in RA. Poor perfusion, NS bolus (10cc/kg) given over 20min with much improvement. MAP's increased from 34 to 58 s/p fluid bolus. D/S stable at 78. VS stable, baby cares given\nA: Transitioning\nP: Continue current plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2171-04-27 00:00:00.000", "description": "Report", "row_id": 1935192, "text": "NPN 1800\n\n\n#1 ID: Infant started on Ampi and Gent after CBC this AM\nrevealed: WBC 16.3 Hct 32.6 Plts 243 Neuts 38 Bands 25\nLymphs 27 Monos 8 Eos 2. Temps on servo control wnl. Infant\nis irritable w/ high pitched cry.\nA: Probable sepsis as seen by CBC.\nP: Cont antibiotics, monitor culture results.\n#2 CV: placed on Dopamine @0900h. Started at 2.5mcgs,\nincreased to 7.5mcg/kg/hr, then weaned to 6mcg/kg/hr.\nInfant's BP maintained 38-43 as ordered. Dopamine d/c'd\nafter weaning to 2.5mcg/kg/hr at 1800h for BP of 56/31 M41.\nHR 120's-150's. No murmur. This AM infant's color pale, now\npink and well perfused.\nA: Stable at present, BP stabilizing.\nP: Cont to monitor.\n#3 F/N: remains NPO. PIV infusing D10 into the right\nhand w/o difficulty at 80cc/kg/d=10.4cc/hr based on BW of\n3.135kg. Abd soft, baby voiding well, stooling mec. Glucose\nchecked X1= 84.\nA: IV fluid at present.\nP: Consider feeds this eve.\n#4 Parents: Parents up X2 today. Very concerned this AM,\nasking appropriate questions. As infant improved parents\nmore relaxed, held this afternoon. Mom plans to bottle\nfeed the baby. Private pedi chosen through \nHospital, Dr. . Parents are prepared at home. Parents\nwould like a circumcision done at d/c.\nA: Invested, loving parents. Appropriately concerned, now\nmore relaxed.\nP: cont parent support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2171-04-28 00:00:00.000", "description": "Report", "row_id": 1935193, "text": "NPN:\n\nRESP: Sats 97-100% in RA. RR=36-50's. BBS =/clear. No spontaneous desats or A&Bs.\n\nCV: Soft murmur audible at LLSB for most of night. HR=120-130's. BP means 43-62; wide pulse pressures at times - e.g., 76/26 (42).\n\nFEN: Wt=3185g (+ 50g). NPO. TF=80cc/kg/d; IV of D-10-W. Elec this a.m. - 138/ 3.2/ 101/ 21 -> NaCl 2mEq, KCl 1mEq/100cc to be added to IV fluid. Dx=81, 102. Abd soft, flat, hypoactive bs, no loops. U/O=2.4cc/kg/h over past 8 h. Mec stools x 2.\n\nBILI: Bili 4.2/ 0.2/ 4.0.\n\nID: CBC, diff, retic this a.m. WBC=13.8, Hct=27.1, Plat=277; diff and retic pending. Remains on Amp & Gent. NNP notified of lab results. Bloood cx pending.\n\nG&D: Temp stable on open warmer w/servo control. Normal flexion of arms throughout night. Minimal flexion of legs early in shift -> much improved this a.m. Overall tone good. Periods of irritability w/high-pitched cry. Sucks on pacifier for comfort after some encouragement. Prominent molding of head w/bruising still present.\n\nSOCIAL: Mother called x 1 for update.\n" }, { "category": "ECG", "chartdate": "2171-04-30 00:00:00.000", "description": "Report", "row_id": 177180, "text": "Sinus rhythm. Prominent R waves in lead VI which may represent right\nventricular hypertrophy. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2196-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1175347, "text": " 8:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): TXCf FRI 12:01 PM\n In comparison to exam, there is significant improvement in degree of\n subarachnoid hemorrhage, as described above.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient with subarachnoid hemorrhage. Assess for interval\n change.\n\n COMPARISONS: Multiple CT head dating back to .\n\n TECHNIQUE: MDCT-acquired axial images through the brain were obtained at 5-mm\n slice thickness without IV contrast.\n\n FINDINGS:\n\n Diffuse subarachnoid hemorrhage within suprasellar cistern with extension into\n frontal and parietal sulci is again visualized, however, appears markedly\n improved in comparison to exam. There is no intraventricular\n hemorrhage. There is no evidence of shift of normally midline structures or\n hydrocephalus. The ventricle and sulci appear normal in size and\n configuration.\n\n There is no cerebral edema or loss of white matter junction differentiation to\n suggest acute ischemia. The paranasal sinuses and mastoid air cells appear\n well aerated. The soft tissues and osseous structures appear unremarkable.\n There are no fractures.\n\n IMPRESSION:\n\n In comparison to exam, there is significant improvement in degree of\n subarachnoid hemorrhage, as described above.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1175348, "text": ", J. NSURG FA11 8:47 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for interval changes\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n eval for interval changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n In comparison to exam, there is significant improvement in degree of\n subarachnoid hemorrhage, as described above.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-09 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1174928, "text": " 12:01 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval c-spine, c-collar in place\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p fall, no recall of events, no loc, + nausea, no vomiting\n REASON FOR THIS EXAMINATION:\n eval c-spine, c-collar in place\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa TUE 3:52 PM\n no acute fracture or malalignment\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall. Known subarachnoid hemorrhage.\n\n TECHNIQUE: Multidetector helical CT scan of the cervical spine was obtained\n without the administration of contrast. Coronal and sagittal reformations\n were prepared.\n\n COMPARISON: None available.\n\n FINDINGS: No acute fracture or malalignment is seen. The atlantoaxial and\n atlanto-occipital articulations are preserved. The prevertebral soft tissues\n are grossly symmetric and unremarkable. Mild multilevel degenerative changes\n are present with no significant encroachment on the spinal canal. Incidental\n note is made of a hypoplastic posterior arch of C1. There is calcification of\n the nuchal ligament.\n\n The included portions of the lung apices are clear. Please see separate\n report for examination of the head. The visualized paranasal sinuses are\n grossly clear. There is minimal opacification of the mastoid air cells at the\n apex on the left.\n\n IMPRESSION: No acute fracture or malalignment.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1174926, "text": " 12:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracranial hemorrhage/embolism\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman s/p fall from standing, no loc, cannot recall event, hematoma\n right occiput\n REASON FOR THIS EXAMINATION:\n eval for intracranial hemorrhage/embolism\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TUE 4:04 PM\n Subarachnoid hemorrage involving the suprasellar, quadrageminal, and adjacent\n cisterns, with extension into frontal and parietal sulci. There is a focus of\n hyperdensity in the anterior suprasellar cistern in the area of the anterior\n communicating artery, raising the possibility of aneurysm rupture. Recommend\n further evaluation with CTA head. Small amount of depending hemorrhage in the\n occipital of the left lateral ventricle.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall from standing, no loss of consciousness. Cannot\n recall event. Right occipital hematoma.\n\n TECHNIQUE: MDCT axial images were acquired through the head without\n administration of IV contrast. Multiplanar reformations were performed.\n\n COMPARISON: None.\n\n FINDINGS: Subarachnoid hemorrhage (SAH) is seen within the suprasellar,\n quadrigeminal, and adjacent basilar cisterns. There is peripheral extension\n of SAH into the frontal and parietal sulci. A small degree of hemorrhage is\n seen in the dependent portion of the left occipital of the lateral\n ventricle. The star-shaped pattern of hyperdensity within the suprasellar\n cistern along with a focus of hyperdensity in the anterior suprasellar cistern\n in the area of the anterior communicating artery is concerning for possible\n aneurysm rupture. There is no evidence of edema, shift of normally midline\n structures, or hydrocephalus. There is no major acute vascular territorial\n infarction. Aside from minimal bilateral mucosal thickening in the maxillary\n sinuses, the visualized paranasal sinuses and mastoid air cells are well\n aerated. The bony calvarium is intact. There is a subgaleal hematoma at the\n apex of the head.\n\n IMPRESSION:\n\n 1. Substantial subarachnoid hemorrhage with a central predominance involving\n the basilar cisterns with extension of hemorrhage into frontal and parietal\n sulci. A focal area of hyperdensity in the anterior suprasellar cistern near\n the anterior communicating artery raises the possibility of aneurysm (that\n ruptured). Recommend further evaluation with CTA.\n\n 2. Small quantity of dependent blood in the occipital of the left\n lateral ventricle.\n\n (Over)\n\n 12:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for intracranial hemorrhage/embolism\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n These findings were reported to at 3:05 p.m. via telephone on the\n day of the study.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-09 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1174964, "text": " 3:27 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: concern for possible aneurysm\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with SAH s/p fall\n REASON FOR THIS EXAMINATION:\n concern for possible aneurysm\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NATg TUE 5:13 PM\n No occlusion, flow limiting stenosis or aneurysm of the intracranial arteries\n No obvious intracranial vascular malformation or dural avm.\n Variants include fenestrated acom, Fetal-type right PCA origin with intact\n right pcom.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: 53-year-old female with subarachnoid hemorrhage,\n question aneurysmal source.\n\n COMPARISON: Non-contrast CT head performed same day.\n\n TECHNIQUE: Axial images were acquired of the head following the\n administration of contrast intravenously. On a separate workstation, MIP and\n VR images were produced and sent to PACS.\n\n FINDINGS: There is redemonstration of diffuse subarachnoid hemorrhage. \n matter/white matter differentiation appears preserved. The ventricles and\n sulci remain normal in size and configuration without hydrocephalus. The\n visualized soft tissues are unremarkable.\n\n CTA: There is no occlusion, flow-limiting stenosis, or aneurysmal dilatation\n of the intracranial arteries. No vascular malformation is noted. Vascular\n anatomic variants include a fenestrated anterior communicating artery, and a\n predominantly fetal-type origin of the right posterior cerebral artery. The\n right P1 segment is intact. The draining cerebral veins are patent.\n\n IMPRESSION:\n 1. No aneurysm, or vascular malformation seen to explain the patient's\n subarachnoid hemorrhage. Given the fall from standing, if clinically\n indicated, this should be further evaluated with catheter angiography to\n exclude CTA occult source of bleeding.\n\n 2. Normal vascular anatomic variants including a fenestrated anterior\n communicating artery and a predominantly fetal-type right posterior cerebral\n artery.\n\n" }, { "category": "Radiology", "chartdate": "2196-02-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1175016, "text": " 7:51 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: pls perform study AM of /11pls eval for interval change.\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n pls perform study AM of /11pls eval for interval change. Thank you.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old female with history of subarachnoid hemorrhage.\n Assess for interval change.\n\n COMPARISONS: CT head without contrast and CTA head of .\n\n TECHNIQUE: Axial MDCT images through the head were obtained without contrast.\n\n FINDINGS:\n\n There is diffuse subarachnoid hemorrhage visualized in suprasellar,\n quadrigeminal cisterns, and interpeduncular fossa with extension into fronal\n and pariatal sulci. In comparison to study obtained the previous day, there\n has been no significant redistribution or resorption of blood products.\n Layering of blood within the left occipital of the lateral ventricle is\n again noted, which appears slightly more prominent from prior exam. There is\n persistent blood within the cistern of the lamina terminalis, highly\n suggestive of aneurysmal bleed of anterior communicating artery origin.\n\n There is no evidence of cerebral edema, loss of -white matter\n differentiation to suggest an acute ischemic event. There is no shift of\n normal midline structures or hydrocephalus.\n\n The paranasal sinuses and mastoid air cells appear well aerated. No acute\n fractures are identified.\n\n IMPRESSION:\n\n 1. Diffuse subarachnoid hemorrhage, essentially unchanged in distribution\n from the study obtained the day before, with no new hemorrhage.\n\n 2. Persistent blood within the cistern of lamina terminalis, as on the\n original study, highly suggestive of bleed originating from aneurysm of the\n anterior communicating artery complex.\n\n" }, { "category": "ECG", "chartdate": "2196-02-09 00:00:00.000", "description": "Report", "row_id": 255392, "text": "Possible baseline artifact in lead V3. Sinus rhythm. Minor ST segment\nabnormalities. No previous tracing available for comparison. Clinical\ncorrelation is suggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2129-08-11 00:00:00.000", "description": "Report", "row_id": 1508805, "text": "neruo-completely intact\n\n\ncv-nsr->st,no ectopy. bp stable. c/o sharp \"twinge\" in her chest region which awakens her. there is no consistency with this pain.\n12 lead ekg obtained. doe.\n\nresp-remains on 100%nrb with 4lnc. sat 92-96%. ls clearing with neb tx. non-prod cough.\n\ng.i.-intact\n\ng.u.-intact.\n\nlabs-no replacement needed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-19 00:00:00.000", "description": "Report", "row_id": 1508830, "text": "RESP CARE,\nPT. GIVEN ALBUTEROL/ATROVENT X 1 FOR WHEEZES. PLACED ON BIPAP 10 WITH 10 O2. SAT 94%. SLEPT WELL. WILL. TO FOLLOW.\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-19 00:00:00.000", "description": "Report", "row_id": 1508831, "text": "P-MICU NSG PROGRESS NOTE 7A-7P\nNEURO: PATIENT A&O X3. PLEASANT AND COOPERATIVE. MAE. AMBULATES TO COMMADE WITH SOB. NO COMPLAINTS OF PAIN.\n\nCARDIAC: HR 76-99 NSR WITH NO ECTOPY. BP 109-135/50-68.\n\nRESP: ON 5L NASAL PRONGS AND 100% NRB. AT REST NO SOB WITH SATS IN LOW 90'S. WITH NRB OFF TO EAT SATS DROP TO 88%. SATS 88-94%. RR 20'S. LS CLEAR AND DIMINISHED AT THE BASES. NOTED TO HAVE COARSE BS ON LEFT SIDE AFTER ACTIVITY. OCCASIONAL PRODUCTIVE COUGH RAISING PALE YELLOW SPUTUM. IN AM SOB WITH AMBULATION TO COMMODE BUT PATIENT STATED THIS EVENING THAT SHE WAS NOT AS SOB WHEN SHE AMBULATED AND THEN WAS ABLE TO WASH SELF BY PACING AND TAKING BREAKS. ENCOURAGE TO USE IS AND CPT DONE. PATIENT STATES THAT HER PEAK FLOWS ARE ~240. CXR DONE TODAY SHOWED PERSISTENT LLL COLLAPSE. ON FLOVENT, SEREVENT. SOLUMEDROL CONTINUES @80NG TID. GUAIFENESIN Q4HRS FOR COUGH.\n\nGI: PATIENT WITH GOOD APPETITE, ADEQUATE FLD INTAKE. BS+ ABD SOFT, NO STOOL. FS @1800 114.\n\nGU: VOIDING IN COMMODE LGE AMOUNTS CLEAR YELLOW URINE.\n\nID: SPUTUM SENT FOR GRAM STAIN AND C&S. WBC 10.4. ON LEVAQUIN FOR INFIL. TMAX 99.7 PO.\n\nSKIN: NO ISSUES.\n\nACCESS: #20G RLA.\n\nPROPHYLAXIS: SQ HEPARIN, PROTONIX.\n\nSOCIAL: PATIENT IS A FULL CODE. HUSBAND HAS BEEN IN/OUT MOST OF DAY.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-20 00:00:00.000", "description": "Report", "row_id": 1508832, "text": "PMICU NSG PROGRESS NOTE:\n\nslept fairly well, awoke 4am with c/o bridge of nose is sore, bipap removed and 100%NRB + 5 L n/c placed on. Pt SOB after getting OOB to commode. Sats 88% while holding bipap in place prior to switching over to other O2.\nvery congested cough but non productive. sputum container in room. Lungs sounds improved as moving more air and less wheezing but is still very DOE and unable to hold sats with any movement.\n\nContinue to support O2 requirement while pneumonia resolves and LLL re expands. cont on antibs and resp treatments.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-20 00:00:00.000", "description": "Report", "row_id": 1508833, "text": "NPN 7a-7p\nNEURO: Afeb. Denies any c/o pain. MAE. OOB to BSC.\n\nCV: Monitor shows SR without ectopy. One episode of ST with activity. PPx4. No edema. New 20g PIV inserted x1 attempt in L wrist. S1S2 no murmur noted.\n\nRESP: Remains on 100% and 5LNC. Sats from 88-95%. Lungs clear. C/O SOB earlier today, but states she feels better now. L lung remains collapsed, flutter valve ordered today. Unable to locate on in house. Team aware.\n\nGI: po well. diet well. ABS. Stool today. Abd S/ND/NT.\n\nGU: Voids clear yellow urine in adquate amounts.\n\nSOCIAL: Husband visits daily. Pt very involved in care. Pt spoke with Dr. re: plan today. Questions answered.\n\nPLAN: Continue aggresive pulmonary toileting. Enc CDB. Try to locate a flutter valve. ? Bronch on Monday if no improvement in resp status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-16 00:00:00.000", "description": "Report", "row_id": 1508821, "text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3. COOPERATIVE WITH CARE.\nRESP- SATS THIS AM 94% ON 100% NRB. BS WITH GOOD AIR MOVEMENT. BS DECREASED AT RIGHT BASE. RECEIVING ALBUTEROL/ATROVENT NEBS PER RESP. SHE WAS WEANED TO 70% COOOL NEB. SATS ON THIS 92-93%. WITH ACTIVITY SATS DECREASE TO HIGH 80'S AND THEN COME BACK UP WITH REST. AT 1600 WHEN PATIENT JUST LYING IN BED SHE BEGAN TO FEEL AS THOUGH HER BREATHING WAS GETTING HEAVY. SAT DOWN TO 84%. HER COOL NEB WAS INCREASED TO 100% WITH SAT AROUND 85%. SHE WAS SWITCHED TO 100% NRB. RESP HERE AND ALBUTEROL/ATROVENT NEB GIVEN. 5L NC ALSO ADDED. SATS SLOWLY CAME UP TO 93%.\nCARDIAC- HR IN THE 80-90'S NSR W/O ECTOPI. SBP 110-120'S.\nGI- TOLERATING REGULAR DIET WELL. ABD SOFT POS BS. NO BM TODAY.\nGU- OOB TO COMMODE. VOIDING IN ADEQUATE QUANITIES.\nSKIN- SKIN INTACT.\n HUSBAND IN TO VISIT AND SISTER CALLED AND UPDATED ON PATIENT'S CONDITION.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-17 00:00:00.000", "description": "Report", "row_id": 1508822, "text": "Resp Care Note:\n\nPt using CPAP @ noc as per Carevue. O2 sats on CPAP w/ 10LPM O2 hovered around >86% overnoc. Pt receiving ALB/ATR via HHN as per Carevue. Cont present regime.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-17 00:00:00.000", "description": "Report", "row_id": 1508823, "text": "MICU NPN 7pm-7am\nNeuro: Alert and oriented x3, able to assist in her care. Pt. given .5mg po ativan prior to placing her on cpap for the night, and she slept throughout the night. This am she states that she feels much better and it is the first time in 7 days that she has gotten a good nights sleep.\n\nResp: lungs clear with occ. wheezes. Pt. started on Robitussin per team to assist in clearing secretions. Pt. with cough but not bringing anything up. Placed on cpap with 8L bleed in to sleep. Pt. tolerated initially however after getting up to use commode, sat's decreased into the 80's. FIO2 increased to 10L, and sat's increased to 88-89%. Pt. sleeping comfortably. Dr. aware, and plan to let pt. sleep with these sat's since she is comfortable. THis am pt. awake and placed back on 100% NRB and 5LNC. Receiving nebs per resp. Pt. states that she feels fine and not sob when sat's are 88%.\n\nCV: BP stable, NSR, no ectopy noted.\nGI: taking po, active bowel sounds.\nGU: voiding in commode\nSee careview for further details\n" }, { "category": "Nursing/other", "chartdate": "2129-08-17 00:00:00.000", "description": "Report", "row_id": 1508824, "text": "RESP. CARE NOTE:\n PT GIVEN 2.5MG ALBUTEROL AND 0.5MG ATROVENT NEBULIZERS X3. PT'S BREATH SOUNDS ARE COARSE WITH SCATTERED RHOCHI AND WHEEZING. PT HAS A LOOSE MIST NON-PRODUCTIVE COUGH. SATS 84-90% ON 100%NRB AND 5 LITERS O2. PT WEARS CPAP OF 10CMH2O WITH 10LITERS O2 BLED-IN, AT NIGHT. FOR FURTHER INFORMATION REFER TO CAREVUE .\n" }, { "category": "Nursing/other", "chartdate": "2129-08-21 00:00:00.000", "description": "Report", "row_id": 1508834, "text": "NPN-MICU\nMs to make slow progress\nResp:pt on 5l NP with 100%NRB till 11pm when placed on Bipap to sleep. Her sats to stay 88-92% with both activity and when resting. She is using her incentive spirometry and coughing up sm amts of sputum. her lung exam has no wheezes but still diminished on the rt base.She remainss afebrile on po antibiotics.She insistes she feels better each day.\nGU:she voids on her own and is taking good po liquid.\nCV:she to have sm bursts of SVT with no intervention needed, mostly associated with activity.\nA/P:Will to encourage C&DB and follow lung exam and O2 sats.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-21 00:00:00.000", "description": "Report", "row_id": 1508835, "text": "NPN\nNEURO: Afeb. Alert and oriented. oob to commode.\n\nCV: Monitor shows SR without ectopy. VSS. PPx4. No edema or swelling noted. Labs this am WNL.\n\nRESP: Continues to have high O2 requirements. Sats in high 80's when awake. While asleep, sats in mid 90's. Plan is to bronch pt today to open up lung. Lung sound clear with diminished bases. pf today 270. using isb to 1l.\n\nGI: NPO for bronch today. Otherwise tolerating diet well. Stool today.\n\nGU: Voids clear yellow urine in adequate amounts.\n\nSOCIAL: Family at bedside today. Updated on POC. Questions answered.\n\nPLAN: Bronch today. Continue pulmonary toilet.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-22 00:00:00.000", "description": "Report", "row_id": 1508836, "text": "NPN-MICU\nMrs to make progress.\nResp: she recovered well post her Bronch. Her o2 sats were up to 98% and only dropped to 91% with activity or O2 being off. She to have a prod cough post her procedure but no blood note only yellow sputum. She states she to feel improvement every day. She did go on her Bipap at 12 to sleep and her sats to be good at 92-96%. Her lung exam has increased aeration on the rt side.\nA/P:stable post bronch with some improvement, will to encourage C&DB and wean FIo2 as she tolerates.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-22 00:00:00.000", "description": "Report", "row_id": 1508837, "text": "PT/RSD\nS: Reports feeling better every day\nO: PT seen to address goals set \nLabs: 31.6>41.1<196\nVital Signs: 126/60, 80's, 88-96% on 100%FiO2\nChest X-ray (): Collapse left lower lobe, patchy opacification right middle and lower lung which may indicate pneumonia\nRx: Chest PT, percussion and vibration to bilateral middle and lower lung fields in sidelying. Deep breathing exercises in supine and sitting.\nA: Pt unable to tolerated chest PT in right sidelying for greater than 5 minutes secondary to shortness of breath. This was relieved with change back to supine.\nP: F/U , progress to breathing exercises in standing\n\nTime Frame: 11:00-11:30am\nPager#: \n" }, { "category": "Nursing/other", "chartdate": "2129-08-14 00:00:00.000", "description": "Report", "row_id": 1508816, "text": "TRANSFER NOTE\nD: PT ADM WITH H/O PNEUMONIA WITH WORSENING SOB, DX WITH PNEUMONIA WITH ASSOC ATELECTASIS ESP R LOWER LOBE.R/O FOR PE, NO EMPYEMA NOTED PER LAT DECUB FILM\nPLEASE REFER TO ICU HISTORY FOR ICU EVENTS.\nNEURO: PT AWAKE, ALERT ORIENTED X 3, PERFORMING ALL ADL ACTIVITIES. MAE.\n\nRESP: PT RR RANGES FROM 16 NON LABORED WHEN AT REST TO 32 APPEARING SLIGHTLY SOB WITH WHEN PT DOES ACTIVITY SHE REQUIRES APPROX 15MINS TO \"SETTLE OUT\" IN REGARDS TO HER RESP RATE AND DIP IN SAT TO 80'S. BS INSPIRATORY WHEEZES NOTED THRU OUT, EXP WHEEZES NOTED IN BASES ONLY. PT SAT 94-95% ON 5LNP AND 70% FM. PT COUGHING WITHOUT RAISING- DRY INFREQ COUGH. PT ENCOURAGED TO DO DB & C AS WELL AS TO OPEN LOWER AIRWAYS- ATLELECTASIS AT BASES ESP RIGHT.- PLEASE REFER OR PT RECEIVING ALBUTEROL/ATROVENT NEBS WITH VARIOUS INHAKER AS ORDERED, PT TAKES ALL INHALERS ON OWN- RESP GIVEN NEB TX. GOAL FOR SAT 90%. PT ON FOR PNEUMONIA- PRESENTLY ON DAY #4.\n\nGI: PT DIET WELL, WHILE EATING PT ONLY ON NP DIP TO 88%- UP EASILY TO 95% WHEN MASK REAPPLIED. BS ACTIVE.\n\nGU: PT VOIDING WITHOUT DIFFICULTY, OOB TO COMMODE- INDEPENDENT- VOIDING IN MOD AMTS--- 600-800CC AT A TIME.\n\nCARDIAC: PT IN NSR RANGING FROM 80'S WHEN AT REST- INC TO 120'S WHEN ACTIVE, BP 116-134/50.\n\nPLAN: PROGRESS AVTIVITY AS , ENCOURAGE DB&C TO OPEN AIRWAYS. PT CONTINUES ON STEROID- ? WHEN WILL START TAPERING DOSE.\nFAMILY AWARE OF PT HUSBAND HERE MOST OF DAY TODAY- APPROP AND VERY ATTENTIVE. DAUGHTERS AND SISTER HAVE CALLED TO CHECK ON STATUS.\nPT FULL CODE.\nPT TO 620 UNDER FIRM.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-14 00:00:00.000", "description": "Report", "row_id": 1508817, "text": "ADDEM: PEAK FLOWW INC TO 240CC TODAY- - 210CC\n" }, { "category": "Nursing/other", "chartdate": "2129-08-14 00:00:00.000", "description": "Report", "row_id": 1508818, "text": "Resp. Care Note\nPt followed today for albuterol and atrovent nebulizers Q4. Overall Pt improved today with less wheezing on exam,less coughing episodes with better recovery time and peak flow 240 today which is 77% of baseline. Cont on O2 at 5L NP and 70% face mask with sats 90-95%. Cont to desat with O2 off. Pt to transfer to floors. Cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-15 00:00:00.000", "description": "Report", "row_id": 1508819, "text": "ADMISSION NOTE TO P-MICU\n53 YO WHITE FEMALE WITH ALLERGIES TO ASA,NSAIDS,IBUPROFEN,PCN,DONNATOL AND BIAXIN. PMH:SEVERE ASTHMA-STEROID DEPENDENT, HYPERCHOLESTEREMIA,NASAL POLYPECTOMY'.CAME TO EW ON WITH C/O COUGH,RUNNY NOSE AND SEVERE CONGESTION X 1 DAY. SHE STATED THAT WHENEVER SHE HAS A COLD SHE DEVELOPS ASTHMA EXACERBATION. IN EW GIVNE IV SOLUMEDROLX2 AND NEBS AND THEN TO CSRU. PT TO RECEIVE IV SOLUMEDROL AND FREQ NEBS Q 2-3 HRS. DX'D WITH PNEUMONIA AND ASSOCATED ATELECTASIS. CTA NEG FOR EMPYEMA AND PT R/O FRO PE. TO 6 ON STILL SOB WITH ANY ACTIVITY AND RECEIVING NEBS AS NEEDED. LAST NOC AT 2400 PT HAD ACUTE ONSET OF SOB AND SHE WAS DUSKY. 100%NRB APPLIED AND O2 SATS SINCE THEN HAVE BEEN HIGH 80'S TO LOW 90'S.ABG THIS AM ON UNKNOWN SPECIFIC AMT OF 02=7.45/38/58/27. PT AGAIN TO P-MICU FOR FURTHER OBSERVATION AND AGGRESSIVE RESP MANAGEMENT.\n\nREVIEW OF SYSTEMS: PT A&O X3. NEURO INTACT.\n\n\nREP: ARRIVED ION 100% NRB AND 5L/M NC WITH O2 SAT=92%. PT SAT UP SO NURSE LUNG SOUNDS AND PT DEVELOPED COUGH AND STATED THAT SOMETHING WAS BLOCKED IN HER THROAT O2 SAT DROPPED TO 86%. NEBULIZER TX GIVEN AND PT COUGHING MOD AMTS OF THICK YELLOW SPUTUM. INSP/EXP WHEEZES BIL. CONTINUES ON LEVAQUIN.\n\nCV: HR 80-90'S NSR WITH RARE PVC'S AND K+ THIS AM=3.9. NBP 115-120'S.\n\nGI: ABD BENIGN ON ASSESSMENT. HAD 1 STOOL ON FLOOR TODAY. POS BOWEL SOUNDS TO ABD. NO C/O N/V.\n\nRENAL: BUN=15 AND CEAT=.7. PT HAS VOIDED A TOTAL AMT OF 350CC'S ON COMMODE TODAY PRIOR TO HER TRANSFER.\n\nACCESS: PT HAS # 20 G SL TO L HAND WHICH IS WNL.\n\nINTEGUMENTARY: SKIN INTACT AND PT RECEIVING SC HEPARIN AS ORDERED.\n\nSOCIAL: PT HAS 2 DAUGHTERS.SPOKESPERSON IS -DAUGHTER ().\n\nPT IS A FULL CODE. PLAN IS TO CONTINUE WITH RESP TOILETING AND NEBS.FOLLOW O2 SATS AND ENCOURAGE PT TO C&DB.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-16 00:00:00.000", "description": "Report", "row_id": 1508820, "text": "MICU NPN 7pm-7am\nNeuro: alert and oriented x3. Pt. oob to commode with no assist.\n\nResp: Received on 100% NRB and 6L NC, satting 92-93%. Pt. only c/o sob with exertion. She would drop sats to 88% when going to commode, or moving around in bed. Taking inhalers on her own, and receiving nebs from resp. Into night pt. c/o of starting to fall asleep and then waking up suddenly. She does have a history of sleep apnea. PT. offered bipap, but initally declined, however as night progressed pt had decreasing sats while sleeping. Dr. aware. Decision made to place pt. on cpap. PT. placed on e=10 and 10L bleed in. Pt. did sleep comfortable with sat's in the 90's. THis am at 6 pt. awake and asking to have cpap mask off. Placed back on nrb and nc. Pt. does have occ wheezing, that clears with nebs. Pt. did not produce any sputum last night.\n\nCV: BP stable, NSR, no ectopy.\n\nGI: tolerating diet. active bowel sounds.\n\nGU: voiding in commode.\n\nSKIN: INtact.\nSee careview for further data. PT. anxious to know what initial sputum culture grew so that she can go home.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-13 00:00:00.000", "description": "Report", "row_id": 1508812, "text": "SHIFT UPDATE.\nPT. ASSESSMENT:\n\nNEURO: A&OX3, MAE TO COMMANDS, DENIES ANY PAIN BUT DOES GET VERY FATIGUED WITH ANY EXERTION. OOB TO COMMODE WITH PORTABLE O2. SIDE RAILS DOWN.\nCARDIAC: INITIALLY HR IN THE 90'S BUT AFTER RECEIVING LG. AMT'S OF NEB TREATMENTS, RESTING HR ELEVATED TO 114, B/P REMAINS STABLE VIA N B/P SYS >120 AND MAP'S >60. R HAND PERIPH IV INTACT.\nRESP: BS VERY DIMINISHED DOWN, WITH INSP/EXP WHEEZES NOTED WITH ANY TYPE OF EXERTION. FIO2 HAVING TO BE INCREASED TO 100% CLOSED FACE MASK WITH 6L NP TO KEEP SAT'S >90%, ABLE TO SLOWLY WEAN FIO2 DOWN TO 70% FACE MASK WITH 6LNP, GOAL IS TO MAINTAIN SAT'S >90. WITH ANY TYPE OF EXERTION O2 SAT'S DECREASING TO AS LOW AS 85%. RECEIVING MULTIPLE NEB TREATMENTS FROM RESP THERAPY. PT. STATES THAT SHE \"DOES NOT FEEL AS WELL AS YESTERDAY AND FEELS THAT HER BREATHING IS SLIGHTLY WORSE THAN YESTERDAY\". PT. ALSO HAVING SEVERAL EPISODES OF VIGOROUS COUGHING SPELLS, BUT CONT. NOT TO BE ABLE TO RAISE ANY SECREATIONS. CONT. RECEIVING INHALERS & ASTHMA MEDICATION. PT. AWAITING PCXRAY. IF PT. CONT. TO HAVE COUGHING SPELLS DURING NIGHT BE ABLE TO RECEIVE ROBITUSION WITH CODIENE.\nGI/GU: VOIDING ON COMMODE WITHOUT DIFFICULTY. + BS THRU-OUT, LG. BM TODAY. TOLERATING REG DIET. BS CONT. TO BE WITHIN CONTROL DESPITE STEROIDS.\nSOCIAL: HUSBAND, CHILDREN AND INTO VISIT AND UPDATE GIVEN. VERY SUPPORTIVE.\nPLAN: PCXRAY, CONT. WITH NEB TREATMENTS AS NEEDED. MONITOR RESP STATUS CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-13 00:00:00.000", "description": "Report", "row_id": 1508813, "text": "Resp. Care Note\nPt followed today for Albuterol and Atrovent nebs Q2-4. Pt cont to have I>E wheezes and overall has not felt as well as yesterday,requiring Rx's a liitle more freq. Peak flow today 200-210, essent. what is was yesterday. Pt cont to have a high FiO2 requirement, currently at 5L NP and 70% face mask. Cont to quickly desat when O2 taken off to eat or talk and also with coughing or any exertion. Pt seems to be coughing more today but still with no sputum production. Specimen cup remains at bedside. Cont to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-14 00:00:00.000", "description": "Report", "row_id": 1508814, "text": "PT CONTINUED ON 70 % CLOSED FACE MASK AND 5L NP WITH SATS 90-95%. ALB/ATROVENT NEBS Q3 HRS THRU NOC. PT FEELS THAT SECRETIONS ARE STARTING TO \"LOOSEN\". PER MICU INTERN ? EMPYEMA ON THE R SIDE BY CHEST XRAY. VOIDING VIA COMMODE IN ADEQUATE AMTS. NO C/O PAIN.\n\nPLAN~? PLEURAL TAP, STILL NEED SPUTUM SPEC~WEAN O2 AS PT TOLERATES.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-14 00:00:00.000", "description": "Report", "row_id": 1508815, "text": "RESP CARE,\nPT. GIVEN ALBUTEROL/ATROVENT X3. E WHEEZES, WHEEZES INCREASE AFTER RX. PF180-210. CONGESTED, NPC. SEE RESP RX SHEET.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-17 00:00:00.000", "description": "Report", "row_id": 1508825, "text": "FOCUS; NURSING PROGRESS NOTE.\nREVIEW OF SYSTEMS-\nNEURO- PATIENT ALERT AND ORIENTED X3. VERY COOPERATIVE.\nRESP- ON 5L NC AND 100% NRB O2 SATS AT REST 88-92%. WITH ACTIVITY SATS DOWN TO LOW 80'S . SATS INCREASED WITH REST THROUGHOUT THE DAY. BS DIMINISHED RIGHT BASE. COARSE OTHERWISE. RESP RATE 18-20. PER DR INFILTRATE NOT IMPROVED ON LEVOQUIN. REPEAT CHEST CT WITH CONTRAST DONE. RESULTS PENDING. WILL REQUIRE CPAP TONIGHT FOR SLEEP.CONTINUES ON INHALERS,STEROIDS, AND NEB TX.\nCARDIAC- HR 85-108 SR-ST. WITH SATS DOWN TO 80% HR UP TO 120'S. HR CAME DOWN WHEN SAT UP IN THE UPPER 80'S. SBP 116 TO 127.\nGI- TOLERATING REGULAR DIET WELL. HAD 2 MEDIUM SIZE GUIAC NEG STOOL TODAY.\nGU- VOIDING IN THE COMMODE CLEAR YELLOW URINE IN ADEQUATE AMOUNTS.\n HUSBAND IN TO VISIT TWICE TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-11 00:00:00.000", "description": "Report", "row_id": 1508806, "text": "NPN\n\nNeuro: Alert and oriented x 3. MAE.\n\nCV: HR 90-100's SR/ST. No ectopy noted. BP 120/50's. Skin warm, dry. Heparin 5000 unit bolus given IV followed by Heparin gtt at 1000u/hr d/t ? PE. To have chest CT/angio this afternoon.\n\nResp: BS with faint inspiratory/expiratory wheezes scattered throughout. Non productive cough. Diminished aeration noted at right lower lobe this afternoon. RR low to mid 20's at rest. Pt w/ DOE during oob to commode activity which returns to baseline with rest. She describes a \"sharp muscular pain in left chest\" which occurs with deep breaths-MD's aware. O2 sats 92-96% on 4L NP and 100% NRB--decrease to 88% with removal of NRB for sips of fluids and during neb treatments. Cont's on IV steroids per orders. Nebs q 2 hours.\n\nGI/GU: Taking small amts of fluids this am without nausea. NPO since 1200 for CT/angio. Voiding adequate amts clear yellow urine.\n\nID: Afebrile. To continue levaquin.\n\nSkin: Intact.\n\nActivity: Bedrest w/ commode priviledges.\n\nA/P Slightly tachycardic. Hemodynamically stable. Cont's with wheezes despite q 2 hour neb treatments. Cont w/ bronchodilators and steroids. Marginal O2 sats given supplemental oxygen. To have CT/angio today to r/o PE. Check PTT and adjust heparin gtt per orders. NPO.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-11 00:00:00.000", "description": "Report", "row_id": 1508807, "text": "RETURNED FROM CT/ANGIO~DR CALLED AND PT ALLOWED TO EAT. O2 SATS 92-97% ON 4L/100%NRB~WHILE EATING DROPS TO 88-89%. PT STATES \"FEELS THE BEST THIS EVENING SINCE HER ADMISSION\". MD AWARE PT RETURNED FROM TEST ~WILL REVIEW RESULTS AND COME UP TO SEE PATIENT. HEPARIN CONTINUES AT 100U/HR~PTT TO BE DRAWN. HUSBAND IN VISITING.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-12 00:00:00.000", "description": "Report", "row_id": 1508808, "text": " 0415 uneventful night. still having wheezes during exertions. should transfer out today. receiving solumedrol tid. sats at 97%\n" }, { "category": "Nursing/other", "chartdate": "2129-08-12 00:00:00.000", "description": "Report", "row_id": 1508809, "text": "ALT RESP STATUS REL TO PNEUMONIA/ASTHMA\nS:\" MY BREATHING IS THE SAME BUT I DON'T FEEL AS SICK.\"\n\nO: STABLE BP, HR(SR/ST), RR WNL. PT APPEARS COMFORTABLE W/ NON-LABORED BREATHING. LUNGS W/ INSP WHEEZES BILAT. HAS REQUIRED NEBS Q 3-4 HRS, W/ IMPROVEMENT OF SX AFTER. ABLE TO MOVE INDEP IN BED AND PARTICIPATE IN CONVERSATION W/O DYSPNEA. DOES DESAT TO 80'S HOWEVER WHEN MASK REMOVED TO EAT OR DRINK. O2 MASK CHANGED TO AEROSOL TO ALLOW WEANING. REMAINS ON 3L NC ALSO. PT UNABLE TO PROVIDE SPUTUM SPEC SO FAR DUE TO NONPRODUCTIVE COUGH. APPETITE GD.\n\nA: FEELING/LOOKING BETTER OVERALL SUBJECTIVELY AND OBJECTIVELY.\n\nP: WEAN O2 SLOWLY AS TOL. CONT LEVAQUIN. SPUTUM CX WHEN ABLE. CONT TO MONITOR GLUC QID WHILE ON STEROIDS. WILL STAY IN ICU TODAY.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-12 00:00:00.000", "description": "Report", "row_id": 1508810, "text": "Resp. Care Note\nPt followed today for Albuterol and Atrovent nebs. Q3-4. Pt initially SOB today after worsening symptoms following coughing spell this morning. Improved over the course of the shift, tolerating Q3-4 hrs between rx's although still with ^ O2 demand. Currently on 3L NP and 100% setting of cool aerosol mask. Sats 91-97%, sats do trend down fairly quickly when off O2 but better in afternoon. BS with insp. wheezes, persistant NPC. peak flow 210 today, pt' states personal best 310-350. Pt using serevent and 4 puffs vent indepen. with good technique. Cont to follow.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-13 00:00:00.000", "description": "Report", "row_id": 1508811, "text": " 0500 uneventful night. able to titrate fio2 to 50%. still having wheezes during exertion. still having nonproductive cough. should transfer out today.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-18 00:00:00.000", "description": "Report", "row_id": 1508826, "text": "MICU NPN 7PM-7AM\nNEURO: ALERT AND ORIENTED X3, PT. MEDICATED WITH .5MG PO ATIVAN PRIOR TO BEING PLACED ON CPAP, AND HAS BEEN RESTING COMFOTABLY THROUGHOUT NIGHT.\n\nRESP: RECEIVED ON 100%NRB AND 5LNC, SAT'S IN THE LOW 90'S. PT. PLACED ON CPAP AT MN FOR SLEEPING WITH 10L BLEED IN. PT. HAS BEEN SATTING IN THE LOW 90'S THROUGHOUT NIGHT. OCCASIONALLY DIPS TO 88%, HOWEVER RESTING COMFORTABLY, AND DOES COME UP ON HER OWN. GETTING NEB TREATMENTS FROM RESP. AND ALSO TAKING INHALERS. LUNGS ARE CLEAR WITH FAINT WHEEZES. PT. GIVEN INCENTIVE SPIROMENTER AND INSTRUCTED ON HOW TO USE IT. SHE IS USING IT WHILE AWAKE. CT SCAN SHOWED COLLAPSED LOWER LOBE. NO C/O OD DISCOMFORT, HOWEVER PT. DOES GET EXTREMELY SOB WITH ANY EXERTION, AND DESATS TO HIGH 80'S. ALSO DESATS RAPIDLY WHEN MASK IS OFF.\n\nCV:BP STABLE, NSR, NO ECTOPY NOTED.\n\nGI: TAKING PO WITHOUT DIFFICULTY.\nGU:VOIDING IN COMMODE.\nSKIN: INTACT.\nSEE CAREVIEW FOR FURTHER DETAILS. WILL PLACE BACK ON FACE MASK AND NC, THIS AM WHEN AWAKE.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-18 00:00:00.000", "description": "Report", "row_id": 1508827, "text": "NURSING PROGRESS NOTE\nNEURO: ALERT AND ORIENTED X4. AFEB. OOB TO CHAIR.\n\nCV: MONITOR SHOWS SR WITHOUT ECTOPY. VSS. PPX4. PIV INTACT. S1S2 NO MURMUR.\n\nRESP: CONTINIUES TO HAVE HIGH O2 REQUIREMENT. REMIANS ON 100% AND 6LNC. SATS IN MID 90'S WHILE ASLEEP, DROPPING TO MID 80'S WITH ACTIVITY. VERY LITTLE RESERVE. LUNGS CLEAR WITH EXP WHEEZING IN BASES, CLEARS WITH COUGHING.\n\nGI: TOLERATING PO WELL. ABS. NO BM.\n\nGU: VOIDS CLEAR YELLOW URINE. GOAL IS TO KEEP +.\n\nINTEG: INTACT. #20G IV TO L WRIST.\n\nPLAN: WEAN O2 AS TOLERATED. CPT AS TOLERATED. KEEP +.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-18 00:00:00.000", "description": "Report", "row_id": 1508828, "text": "7p-11p npn\nRESP: pt remained on 100%NRB and 6 l n/p, rr 28-30, pt able to eat, get oob to commode without help. O2 sats 94% placed on CPAP of 10, at 10:30 pm by resp therapy. pt using IS. cpt ordered. remains on Solumedrol 80 mg IV q 8 hrs, Flovent, Serevent, Beconase, pt w/ strong prod. cough, repeat sputum sent for cx and gram stain. afebrile.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-19 00:00:00.000", "description": "Report", "row_id": 1508829, "text": "PMICU NSG PROGRESS NOTE;\n\nslept well on bipap during night. 4am awoke and reoved bipap to use nasal cannula and 100%NRB due to pain over bridge of nose. Pt sats 92-94 on bipap and 96% on 6l n/c and 100%NRB. Lungs with diminished breath sounds at bases but no wheezes noted. afebrile, wbc pending for today,following blood sugars, will need new peripheral line today.\n\nPlan-follow sats with activity, wean oxygen, follow wbc and bs.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-22 00:00:00.000", "description": "Report", "row_id": 1508838, "text": "P-MICU NSG PROGRESS NOTE 7A-7P\nNEURO: A&O X3. PLEASANT. NO COMPLAINTS OF PAIN. AMBULATING TO COMMODE WITH NO ASSIST. TOLERATING ACTIVITY BETTER,\n\nCARDIAC: HR 80-99 SR WITH NO ECTOPY, BP 98-132/45-79. NO EDEDMA. PPP.\n\nRESP: PATIENT MAKING GOOD PROGRESS. RECEIVED HER AT 5L N/C AND NRB, AND ABLE TO WEAN N/C TO 1L WITH SATS 91-98%. PATIENT STATES ABLE TO TOLERATE ACTIVITY BETTER TODAY AND SATS DROP TO 90% BUT ABLE TO RECOVER QUICKER. RR IN THE 20'S. LS CLEAR ABOVE WITH WHEEZES AT THE BASES. STRONG PRODUCTIVE COUGH RAISING YELLOW THICK SPUTUM. SOLUMEDROL DECREASED TO 80MG . RECEIVING MDI/NEBS/CPT. PATIENT USING INCENTIVE SPIROMETRY FREQUENTLY. PATIENT DID NOT TOLERATE CPT WHEN LYING ON LEFT SIDE.\n\nGI: PATIENT EATING 100% MEALS WITH FLD INTAKE TODAY OF > 2L. ABD SOFT BS+ HAD ONE SOFT BROWN FORMED STOOL. FS AT 1800 146 NO COVERAGE NEEDED.\n\nGU: PATIENT VOIDING IN LARGE AMOUNTS. YELLOW AND CLEAR.\n\nID: WBC 31 THIS AM. TMAX 98.9. ONE SET BLD CX'S, URINE, AND STOOL SENT. CONTINUES ON LEVOFLOXACIN.\n\nSKIN: NO ISSUES.\n\nACCESS: #20G LLA.\n\nSOCIAL: PATIENT IS A FULL CODE. MANY VISITORS TODAY.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-22 00:00:00.000", "description": "Report", "row_id": 1508839, "text": "7A-7P ADDENDUM\nERROR: PATIENT DID NOT TOLERATE CPT ON RIGHT SIDE, NOT LEFT SIDE AS PREVIOUSLY NOTED.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-23 00:00:00.000", "description": "Report", "row_id": 1508840, "text": "resp care note: pt received on nrb mask, at 15lpm. spo2 at that time was 95%. at midnight pt placed on cpap 10 with 10 lpm bled inline. spo2 was 96% at this time. pt does fine on cpap with no coaching needed. all is well at this time.\n" }, { "category": "Nursing/other", "chartdate": "2129-08-23 00:00:00.000", "description": "Report", "row_id": 1508841, "text": "NPN\n\nCV: VSS\n\nPulm: LS clear, on 100% NRB and 1 L NC with good SATs in the upper 90s, states that this is the best that she has felt since she has been admitted. She coughed up some blod tinged sputum, conts to self administer her inhalers. Pt put on CPAP at MN and has tolerated this well, SATs in the mid 90s, able to sleep much of the night.\n\nGI: C/O a burning sensation in her chest/upper gastric area. She denied CP, arm or jaw pain, no SOB. She said that the pain came and went, sitting up seemed to help. She was given Mylanta with relief of the pain.\n\nGU: Great u/o\n\nNeuro: A&O, faily independent considering her limitations\n" }, { "category": "Nursing/other", "chartdate": "2129-08-23 00:00:00.000", "description": "Report", "row_id": 1508842, "text": "FOCUS; NURSING PROGRESS NOTE.\nREVIEW OF SYSTEMS-\nNEURO- ALERT AND ORIENTED X3. CCOPERATIVE WITH CARE.\nRESP- WEANED DOWN TO 50% FM. TOLERATING ACTIVITY BETTER{ IE GETTING OOB TO COMMODE}. BS CLEAR ANTERIORLY. DECREASED AT THE BASES. USING INHALERS AS ORDERED. PT TO COME BY TODAY TO DO CPT. PATIENT DOING IS.\nCARDIAC- HR IN THE 70-80 NSR. SBP 110-120. CONTINUES ON STEROIDS THAT ARE SLOWLY BEING TAPERED.\nGI- TOLERATING REGULAR DIET WELL. HAD LARGE BROWN SOFT STOOL TODAY. ABD SOFT POS BS.\nGU- VOIDING IN LARGE AMOUNTS IN COMMODE.\nSKIN- SKIN INTACT.\nACCESS- HAS PERIPHERAL IV IN LEFT LOWER ARM.\n HUSBAND IN PERIODICALLY THROUGHOUT THE DAY. VERY SUPPORTIVE.\n\n" }, { "category": "Nursing/other", "chartdate": "2129-08-23 00:00:00.000", "description": "Report", "row_id": 1508843, "text": "FOCUS; ADDENDUM\nRESP- WEANED TO 4L NC. SATS 93% ON THIS.\n" }, { "category": "Echo", "chartdate": "2129-08-24 00:00:00.000", "description": "Report", "row_id": 99516, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 64\nWeight (lb): 198\nBSA (m2): 1.95 m2\nBP (mm Hg): 110/54\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 16:31\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thickness, cavity size,\nand systolic function are normal. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nappears structurally normal with trivial mitral regurgitation. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2129-08-15 00:00:00.000", "description": "Report", "row_id": 282121, "text": "Normal sinus rhythm, rate 95\nConsider left atrial enlargement\nBorderline low voltage in frontal leads\nDelayed QRS transition\nPossible prior inferior myocardial infarct, although may be normal\nSince last ECG, probably no significant change\nBorderline ECG\n\n" }, { "category": "ECG", "chartdate": "2129-08-11 00:00:00.000", "description": "Report", "row_id": 282347, "text": "Normal sinus rhythm, rate 97\nConsider left atrial enlargement\nConsider prior inferior myocardial infarct\nAbnormal R wave progression\nAbnormal ECG\n\n" }, { "category": "Radiology", "chartdate": "2129-08-17 00:00:00.000", "description": "CT 100CC NON IONIC CONTRAST", "row_id": 741443, "text": " 4:05 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? INFILTRATE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with asthma, admitted with apparent exacerbation, but with\n persistent hypoxia despite antibiotic treatment for ?lower lobe pneumonia.\n REASON FOR THIS EXAMINATION:\n ? potential etiologies for persistent hypoxia\n please also evaluate right lower lobe infiltrate\n ? small showers of pulmonary embolisms?\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 53 y/o female with asthma, with persistent hypoxia\n despite antibiotic therapy for presumed diagnosis of multilobular pneumonia.\n\n Helical CT of the thorax was performed following intravenous administration of\n 100 cc of Optiray. Non ionic contrast was administered due to history of\n asthma. Images were acquired with 8 mm collimation and 8 mm reconstruction\n intervals. Additionally, a series of 3 mm collimation images were obtained\n through a selected region.\n\n Assessment of the lungs reveals interval development of complete collapse of\n the left lower lobe. Given patency of left lower lobe bronchi on recent chest\n CT of , this is likely due to mucus plugging rather than a fixed\n endobronchial lesion. There is evidence of retained secretions within the\n airways, with a prominent air fluid level within the right bronchus\n intermedius. There is persistent opacification in the right lung base, which\n does not contain air bronchograms, and likely represents an area of\n atelectasis as well. There is some partial aeration of the right lower lobe\n posteriorly and within the superior segment, but a significant portion of the\n right lower lobe is collapsed. The remainder of the lungs is remarkable for\n multiple patchy predominantly peripheral foci of ground glass attenuation with\n an upper lobe predominance. Some of these areas were present on the previous\n scan, but overall, this pattern has increased in prominence in the interval.\n Note is also made of partial atelectasis of the right middle lobe.\n\n On thin section images, an air fluid level is seen within the left lower lobe\n superior segment bronchus, likely due to retained secretions. The right\n middle lobe bronchi are not well demonstrated on this examination.\n\n Assessment of the soft tissue structures of the thorax demonstrate no\n significant mediastinal or hilar lymph node enlargement. The right\n hemidiaphragm remains elevated.\n\n The heart size is normal, and there is no evidence of either pericardial or\n pleural effusion.\n\n Imaging of the upper portion of the abdomen reveals an ill-defined low density\n lesion in the posterior segment of the right lobe of the liver near the dome,\n measuring approximately 2.1 cm in diameter. The remaining imaged portions of\n the liver and spleen are unremarkable. These organs are incompletely imaged\n (Over)\n\n 4:05 PM\n CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: ? INFILTRATE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n on this study. The adrenal glands and kidneys are not included nor is the\n pancreas.\n\n Review of the osseous structures of the thorax demonstrate no significant\n osseous abnormality.\n\n IMPRESSION: 1) Interval development of complete collapse of the left lower\n lobe, likely due to mucus plugging in this patient with history of asthma.\n There is also partial collapse of the right lower and right middle lobes with\n evidence of mucoid impaction.\n\n 2) Multifocal small lobular areas of ground glass opacification in the\n periphery of the lungs, which have slightly progressed in the interval. This\n may be due to evolving pulmonary infection. Less likely considerations would\n include Churg- syndrome in this patient with history of asthma, and\n thromboembolic disease with peripheral infarction. The latter is considered\n unlikely given absence of evidence of pulmonary emboli on recent CT angiogram.\n\n 3) Approximately 2.1 cm diameter low density lesion within the right lobe of\n the liver near the dome. This does not represent a simple cyst. Ultrasound\n is suggested for further characterization, in order to determine whether this\n represents a hemangioma or possibly a malignant neoplasm.\n\n\n" }, { "category": "Radiology", "chartdate": "2129-08-11 00:00:00.000", "description": "CHEST CTA WITH CONTRAST", "row_id": 741116, "text": " 12:44 PM\n CT CHEST W/CONTRAST; CHEST CTA WITH CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Rule out PE, assess lung fields for infiltrates\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with asthma, admitted with apparent exacerbation, but with\n hypoxia and A-a gradient worrisome for PE.\n REASON FOR THIS EXAMINATION:\n Rule out PE, assess lung fields for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Asthma. Hypoxia and AA gradient worrisome for pulmonary embolus.\n\n TECHNIQUE: Helical CT is performed from the lung bases to the apices following\n administration of 100 cc of Optiray for indication of rapid bolus CTA.\n Multiplanar reconstructions were created through the pulmonary vasculature per\n CT pulmonary angiography protocol.\n\n CT CHEST WITH CONTRAST: The pulmonary vasculature is patent, without\n endoluminal filling defects to suggest the presence of pulmonary emboli.\n Within the lung bases, there is a dense consolidation involving the right\n middle lobe, right lower lobe and left lower lobe, which is concerning for a\n multilobar pneumonia. There are no effusions. The heart and great vessels are\n normal in appearance. The bones are unremarkable.\n\n REFORMATIONS: Multiplanar reformations demonstrate patent pulmonary\n vasculature and bibasilar infiltrates.\n\n IMPRESSION:\n 1) No evidence of pulmonary emboli.\n 2) Multilobar pneumonia of the right middle, right lower and left lower lobes.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387321, "text": "(Continued)\n as ordered. Plan for OR next week with plastics for left hand. Continue to provide pain control with Fentanyl. Replace lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387322, "text": "Respiratory Care:\nPatient switched from A/C to CPAP/PSV. Appears to be tolerating this well. Patient also seems to be more responsive to verbal commands. Latest abg results determined a mixed alkalemia with excellent oxygenation.\n\nRSBI = 48.4 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387323, "text": "Nursing Progress note update\n\nHCT 21.4 1U PRBC's ordered, Type and screen sent. Right radial damp and unable to draw, line d/c'd. Following NIBP for now. New to be placed today. Pt on CPAP/PS 5/5/30% ABG WNL as seen in carevue, ?trach mask today if able to tolerate.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-23 00:00:00.000", "description": "Report", "row_id": 1387313, "text": "Respiratory Therapy\nPt remains orally intubated BS clear scant secretions. Sats 100% RSBI 47 this AM placed on SBT per protocol. Sats unchanged No untowared signs of resp. distress.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-23 00:00:00.000", "description": "Report", "row_id": 1387314, "text": "Respiratory Therapy\n\nPt remains orally intubated/mechanically ventilated. Travelled to and from CT for scan of head w/out incident. SpO2 90s. ABGs WNL. BLBS essentially clear, suctioned for scant to no secretions. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain airway protection\n" }, { "category": "Nursing/other", "chartdate": "2149-10-23 00:00:00.000", "description": "Report", "row_id": 1387315, "text": "T/SICU Shift Report 0700-\n32 Year Old Female NKA FULL CODE Universal Precautions\n\nAdmission - S/P GSW to Head\n\nPMH - None Known\n\nInjuries - GSW below Right ear to left temporal lobe (posterior fossa)\n Through and Through GSW to Left hand (open fracture)\n Epidural Hemorrhage\n SAH\n Intraparenchymal Hemorrhage\n\nOR - - Craniotomy with Posterior craniectomy\n Ventricular Drain\n\nShift Events - Repeat Head CT\n Tube Feeding Commenced\n Family Meeting\n\nReview of Systems:\n\nResp - PS/CPAP PEEP 5 PS 5 FiO2 40%. SpO2 100%, RR 15-20bpm, TV 350-450ml. ABG pH 4.49, PaCO2 33, PAO2 203, BE 3. Breath sounds clear thorughout. Minimal secretions on ET suction.\n\nCVS - Sinus rhythm-sinus tachycardia with rare PVCs. HR 90-130bpm, SBP 130-160, MAP 90-120, CVP 3-9, CPP 75-90, Tmax 99.1. HCT 24.7% (post transfusion of 1 unit PRBCs). Peripherally warm/well perfused/palpable pulses. Started on SC heparin, pneumoboots in situ. Commenced on cefazolin.\n\nRenal - UO 45-120ml/hr, +ve 550ml today. IV fluids to KVO. K 4.1, Mg 2.1, Ca 1.18, Phos 3.1, Na 140, Osmolality 289. 20mEq KCL given this am.\n\nNeuro - Propofol discontinued this am. Patient responding to painful stimuli. GCS 7 (e1v1m5). Localizing with BUE to sternal rub, withdrawing with BLE. Spontaneous movement with LUE for the first time. Ventricular drain 5cm above the tragus, open to drainage, 30-40ml Q2, ICP 12-22. Mannitol 25gm Q6 continues. Dexamethasone tapering off.\n\nGI - Started on Tube Feeds started replete with fiber goal rate 50ml/hr. Minimal residuals. soft/nontender/hypoactive bowel sounds. No BM since admission. Blood glucose stable with insulin infusion, currently at 1unit/hr.\n\nSkin - Pressure areas intact. Remains supine as c-spine not clear, and patient is unable to wear c-collar due to posterior craniectomy. Spine to left hand intact (may go to OR for fixation and washout).\n\nAccess - Lines patent.\n\nSocial - Family meeting today with spanish translator to discuss care thus far, and prognosis. Family consented for trach and PEG.\n\nPLAN - Trach/Peg tomorrow or monday\n Q1 Neurochecks\n Taper dexamethasone\n" }, { "category": "Nursing/other", "chartdate": "2149-10-24 00:00:00.000", "description": "Report", "row_id": 1387316, "text": "Nursing Progress Note 7P-7A\n\nEvents-Nicardipine gtt started\n -EKG obtained for ST depression\n -Ventric flushed by neurosurg\n\nNEURO-Continues with sedation off. Pt. becomes hyperdynamic with stimulation. Pupils=4 and briskly reactive bilaterally. Negative corneals. Strong , impaired gag. Pt. localizes to sternal rub with left arm, able to reach to face when mouthcare given. Slight extention noted to right arm, withdraws to nailbed pressure. Bilateral LE's move spontaneously on bed, withdraw to nailbed pressure. Pt. noted for spontaneous eye opening x2. Eyes also opened to command x2. Right EVD at 5cm above. ICP's range 13-22 with CPP's 70's-80's. Ventric noted for dampened waveform, neurosurg at bedside to flush. Mannitol 25gms continues q6hours. Serum osmos and sodium within parameters. Neuro checks q1hour. Fentanyl given for turns 25-50mcgs. C-spine precautions with turns. Maintain HOB at 30 degrees\n\nCV-HR 90's-110's no ectopy seen. St depression noted. EKG obtained and unchanged from admission, no enzymes ordered. Goal to keep SBP <140, Nicardipine gtt started at 1mcg/kg/min SBP120-130's DBP 60-70's. CVP range 2-8. AM HCT stable at 24.7. Bilateral PIV's x2 and right SC TLC. Right radial . 0.9NS daily and carrier. Goal IVF hourly is 70cc. Heparin SQ, P-boots on.\n\nResp-Pt continues on CPAP/PS 5/5/40%. ABG 7.50/36/199/29, no vent changes made. Lung sounds clear bilaterally. Suctioned for yellow thick secretions, scant amount. RR low to mid teen's. Sats maintained at 100%.\n\nGI-Abdomen soft, positive bowel sounds. OGT clamped, TF now on hold for possible OR for trach/peg. TF previously Replete with fiber at goal 50cc/hr. Protonix ordered.\n\nGU-Indwelling foley catheter with clear light yellow urine output. Voiding in adequate amounts. Potassium and Mag replaced this am.\n\nEndo-Insulin gtt currently at 3u/hr, continue with glucose checks q1hour.\n\nSkin-GSW wound to right posterior ear with DSD. Small amount of bloody drainage, dressing changed. Crani site at posterior neck with original OR dressing with dry bloody drainage and intact. Left UE with bullet graze approximately 4cmx4cm open to air, no drainage. Left UE in ace and splint, good CSM. Skin otherwise intact.\n\nID-Ancef continues for drain/L UE fracture coverage.\n\nSocial-No family contact overnight, however family did visit yesterday and spoke at length with social work, please see social work note.\n\nPlan-Possible OR today for trach/peg. Continue q1hour neuro checks. Monitor ICP/CPP. Mannitol q6hours, following osmos and sodium. Continue to taper steroids. Ancef as ordered. Replace lytes as needed. Follow glucose per protocol, titrate insulin gtt as needed. Maintain SBP<140, titrate Nicardipine gtt as needed. Maintain c-spine precautions.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-24 00:00:00.000", "description": "Report", "row_id": 1387317, "text": "Resp Care\nPt. remains intubated/sedated prn. Changed back to at . Vts 400-450 with avg. MV lpm.\nBs: ess. clear equal bilat.\nabgs:hyperoxygenated resp. alkalosis.\nPlan: Cont. current support, possible trach/peg.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387324, "text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex. Received this AM on PSV, weaned to 35% cool mist trach mask around noon this shift, pt tolerating well. SpO2 90s.\n\nPlan: will monitor per airway protocol\n" }, { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387325, "text": "NPN 7a-7p\n\n32 yr s/p GSW to head and left hand, occiptial craniotomy/craniectomy on the 22nd with ventriculostomy placement, trach and peg on the 24th.\n\nNKDA/ no PMH\n\n pt more alert today. eyes open spontaneously, blinks eye and wiggles toes to command but inconsistantly. moves left upper arm and postures outward, withdraws right upper ext. moves bilat LE slightly on bed to command. PERL 3mm brisk, impaired corneals. impaired gag and weak . ICP 5-7. pt recieving mannitol 25mg Q6hrs. Pt to be left supine, hob at 30 degrees and c-spine percautions, no c-collar due to craniectomy. head imobilized with IV bags. Ventriculostomy 5 cm above the tragus draining avg 10-20cc/hr mostly clear CSF. blood tinged after turning.\n\nCV- SR-ST. max rate 130. SBP goal to be < 140. Nicardipine gtt ordered if needed. gtt has been off scince last night. 1 unit PRBC infused for crit 21. repeate crit 24.9 + peripheral pulses. p-boots, and SQ heparin for DVT prophalaxis.\n\nResp- Trach # 8 portex pt placed on TC 35% tol well. sats 99-100% rate 16-25. lung sounds clear. minimal blood tinged secreations. weak .\n\nGI- Replete with fiber via peg tube 50/hr. residuals 120 max. abd soft. + BS. no BM. protonix for prophalxis.\n\nGU- foley clear light yellow urine. good volume. net + 700, IVF KVO this evening. CVP 0-2. neurtra phos given. NA 144 osmo 294.\n\nendo- cont on insulin gtt. 1unit/hr.\n\nID- T-max 100.5 cont on cefazolin. wbc down to 16.\n\nSkin- craini dsg to back of head/neck D&I. right neck enterance wound open red swollen and draining. dsg changed often. left hand splint with ace + cap refill, hand warm. elevated on pillow. left arm bullet graze wound, dry OTA.\n\nSocial- family in to visit alot of support. asking appropraite questions.\n\nplan- cont Q1hr neuro checks. cont trach mask as tol. monitor BS. support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-26 00:00:00.000", "description": "Report", "row_id": 1387326, "text": "TSICU-NPN:1900-0700\nS:n/a\n\n\n\nO: Event: T-Max 101.7, tylenol given, temp down to 100.6 at 0200. Urine.blood cxs sent, CXR ordered.\n\n Neuro: Pt alert, opens eyes spontaneously, purposeful movement with LUE with painful stimuli (blood draw), moves RUE, and both LE's on bed as well. Inconsistantly following commands, and nods/rapidly blinks to indicate \"yes\" and \"no\" at times. 2mm-3mm ,PERRLA-brisk reaction. Morphine given for pain approx. Q2 hrs. with adequate pain control per pt and vital signs. +/+gag reflex. ICP 8-12, Mannitol continues Q6 hrs. Ventric. maintained at 5 cm above tragus, and draining approx 25-50cc q4hrs. Logroll/c-spine precautions maintained.\n\n CV: HR 110-135, no ectopy. NIBP 120's-150's over 60's-80's. IV Labatalol 5mg given once with minimal effect. CVP -2 to 0. +PP, +CSM. Heparin SQ/P-boots for prophlaxis.\n\n Resp: #8 Portex, trach in place, continues on 35% O2 via trach mask. Blood tinged secretions suctioned from trach multiple times, pt's proves to be sufficient enough at times though to clear airway. O2 sats 98-100%, RR 20-28.\n\n GI: Abd soft, no distension, BS+. PEG dsg c/d/i, no erythema or drainage present. Protonix as ordered. Replete with fiber for nutrition via peg runing at 50cc/hr, residuals <5cc.\n\n Renal: Foley draining adequate amounts of clear yellow urine. Na and osmolality WNL. K+ repleted.\n\n Integ: LUE-abrasion, OTA, no drainage. LUE-dsg/splint intact, no drainage present. Posterior head-crani site>dsg changed, mod-lg amounts of serosang. drainage present. Anterior ventric drain site-C/D/I. R lateral neck-(GSW site) erythemous, draining sm amounts od serosang. drainage-dsg. changed. Multi-podus boots in place.\n\n ID: Febrile (see event)tmax 101.7-tylenol given,pan cx. WBC trending downwards-14.5. Continues on Cefazolin.\n\n Endo: Insulin gtt d/c, pt now on RISS, and covered appropriately.\n\n Social: No family calls/visits overnight.\n\nA: 32 y/o female s/p GSW to head tx and LUE, tx to now s/p crani, and trach/PEG.\n\nP: follow up with cx results\n increase nutrition as needed\n pulmonary tolieting\n wound care\n pain management\n update family on POC\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-24 00:00:00.000", "description": "Report", "row_id": 1387318, "text": "Progress Note 0700-\nEvents: Trach/peg placed\n Head CT\n\nReview of Systems:\n\nResp: Trach placed w/out complications. A/C 500x14, Peep 5, FiO2 30. Pt began overbreathing vent by 2-4 breaths this evening, vent changed to CPAP 5/5, however pt experienced long periods of apnea- immediately placed back on A/C. RR 14-22. SpO2 96-100%. 7.44/40/175/28/3. LS clear to coarse bilaterally. Copious amts of thick bloody sputum sxned via ETT.\n\nCVS: Sinus tachy w/ ST depression, no ectopy noted. HR 100-150s, SBP 100-135, MAP 70-100, CVP 1-2, Tmax 99.5. + strong palpable pulses. Cap refill <3 secs in all extremities. Hypertensive/tachycardic w/ stimulation- Nicardipine gtt titrated to 0.08 mcg/kg/hr. ID: Cefazolin Q8H.\n\nNeuro: Opens eyes to voice/noxious stimuli, however unable to track. Unable to follow commands. MAEs- RUE postures, LUE flexes & w/draws & BLE flexes w/ nailbed pressure. Localizes w/ LUE w/ sternal rub. GCS 8 (e3v1m4). Pupils 3mm/3mm, briskly reactive. Ventric 5cm @ tragus- ICP 7-15, CPP 60-80s. Ventric draining 10-20 cc/hr of clear pink tinged fluid. Mannitol dose increased to 50 gm Q6H low serum osmo & Na lvl.\n\nGI: NPO. Hypoactive BS, abd soft, ND. PEG placed w/ no complications. PEG to gravity for 24 hrs. Blood sugars 153-61, insulin gtt infusing at 2 units/hr.\n\nRenal: Foley draining moderate amts light clear yellow urine.\n\nAccess/Skin: Aline, Multi RSC, wnl. PIVs x2. Ventriculostomy intact. Primary OR dsg to back of head, intact. DSD applied to GSW to L hand & placed in splint, wrapped w/ ACE bandage. Abrasion to LUE scabbed over, OTA, no drainage noted.\n\nSocial: Family & friends in to see pt.\n\nPlan of Care: Wean vent settings as tol\n Perform trach care after 9 am tomorrow\n Wean Nicardipine gtt as appropriate\n Maintain SBP < 140\n Q1H neuro checks\n Resume TF tomorrow morn.- goal rate increased to 60cc/hr\n Q1H fingersticks\n" }, { "category": "Nursing/other", "chartdate": "2149-10-24 00:00:00.000", "description": "Report", "row_id": 1387319, "text": "Respiratory Therapy\n\nPt trached at bedside this shift w/ #8.0 Portex trach; peg also placed. Received sedation/paralytic for procedure, pt remains on full mechanical support at this time. Attempted wean back to PSV but no spont resp for >60sec. SpO2 90s. ABG acceptable. Travelled to and from CT for head scan w/out incident. See resp flowsheet for specifics.\n\nPlan: maintain support; wean to PSV as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2149-10-25 00:00:00.000", "description": "Report", "row_id": 1387320, "text": "Nursing Progress Note\n\nEVENTS: Repeat Head CT done on days is not worsened from the previous study, however there is still mass effect on the fourth ventricle and midbrain. Bullet fragments have also migrated posteriorly.\n\nREVIEW OF SYSTEMS-\n\nNEURO-Pt more alert than yesterday. Eyes opening spontaneously, positive tracking, some nystagmus noted. Pt. nodding \"no\" to pain. Able to open mouth, stick out tounge and blink to command, not following commands with extremities. Right UE noted for decrebrate posturing, left UE with flexion to sternal rub. Pt reaches to face when mouth care given. Bilateral lower extremities withdraw to pain. Moves upper extremities spontaneously. Pupils= and briskly reactive. Mannitol ordered 50gms q6hours. Continues on q1hour neuro checks and logroll/c-spine precautions with sandbags in place. Unable to wear c-collar due to right posterior crani site.\n\nPAIN-Pt becoming hyperdynamic at times and reponding appropriately to Fentanyl 25mcgs. Fentanyl ordered q2hours.\n\nCV-SR-ST rate varies from 90's-120's, reaches 140's with stimulation. ST depression seen in V2, otherwise no ectopy. Nicardipine gtt weaned off. Goal to maintain SBP<140. SBP now 110's-130's DBP 60's-70's. CVP range 1-4. HGB/HCT drifting at 7.5/21.5 from 24.7 yesterday. HO aware. Heparin and p-boots as ordered.\n\nACCESS-Right SC TLC with transduced CVP, 0.9NS maintainance at 85cc/hr, 0.9NS carrier and Insulin infusing. Right radial damp at times, crisp wave when wrist flexed. Bilateral AC PIV's expire today.\n\nRESP-Pt weaned to CPAP/PS 5/5/30%. Sats maintained at 100%, RR 12-18. TV 400's. Trached with #8Portex. Suctioning for bloody thick secretions, small plugs at times. Lung sounds clear bilaterally.\n\nGI-Abdomen soft. Positive BS. Peg intact and to gravity. Tube feeds to start this AM. Replete with fiber at goal of 50cc/hr.\n\nGU-Indwelling foley catheter with clear light yellow urine with adequate output. K+3.6 and replaced with 20MEqK+. All other lytes WNL. BUN/creat stable at 12/0.4.\n\nSKIN-GSW entrance wound to right posterior ear region with moderate bloody drainage, DSD intact. Posterior neck/head crani dressing original from OR with old drainage, dressing intact. Bullet graze wound to left upper extremitiy, OTA. Left UE with ace and splint from GSW entrance wound, dressing to be changed by nursing (changed this am) Skin otherwise intact.\n\nENDO-Continues on insulin gtt at 1u/hr. Blood sugars ranging 96-127 with exception of BS 49, amp D50given and pt responded with BS 126.\n\nID-Tmax100.5 rectally, Tylenol given. WBC's trending down 23.6 this am from 36.5. Continues on Cefzolin for drain and LUE fx coverage.\n\nSocial-Brothers and in to visit on days, no family contact overnight. social work note for history.\n\nPlan-Continue q1hour neuro checks. Monitor ICP'sCPP's. Maintain HOB at 30degrees. Keep SBP <140. Mannitol as ordered 50gms q6hours, monitor sodium and osmos. Wean from vent as tolerated. Frequent suctioning. Resume TF after 9am\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387311, "text": "T/SICU Shift Report 1500-1900\nAddendum to 0700-1500 shift report\n\nReview of Systems:\n\nResp - Remains on SIMV, with stable ABG, increasing alkalosis. No secretions on ETT suction.\n\nCVS - HR 95-110bpm, MAP 75-85, CPP 65-80. Phenylephrine remains at 1.0mcg/kg/min. Temperature stable\n\nRenal - UO stable. Lytes repleted.\n\nNeuro - GCS 5 (e1v1m3), abnormal flexion with BLE, abnormal extension with LUE, and no response to noxious stimuli with RUE. Continues on propofol in an effort to reduce respiratory effort and improve alkalosis. Sedation off for neuro exams. Pupils 3-4mm/3-4mm brisk reactive. Continues on 25gm mannitol Q6.\n\nGI - OGT to suction, soft/nontender, NPO, No BM. Started on insulin infusion, titrated up to 3 units/hr.\n\nSkin - Full bed bath, sheet change, and hair wash. Q4 mouth care.\n\nAccess - Aline redressed.\n\nSocial - Parents/brothers into visit\n\nPLAN - Q1 Neuro exams\n Maintain CPP>60\n Maintain SBP<140\n\n" }, { "category": "Nursing/other", "chartdate": "2149-10-23 00:00:00.000", "description": "Report", "row_id": 1387312, "text": "NPN: 1900-0730\nROS: see carevue for details\n\nNEURO: patient remains with poor neurological exam. when lightened from propofol best exam as follows: localizes to sternal rub with all extremities. left upper extremity brisker than right, while both legs only move on bed. when nailbed pressure is applied patient seems to flex arms and legs. no eye opening noted. does not follow commands. , briskly reactive. lightly sedated on propofol in between neuro exams. ventriculostomy drain in place draining small amounts of slightly blood tinged CSF. ICPs ranging in the teens > CPPs acceptable. mannitol & dexameth as ordered.\n\nCV: HR 90-110s, SR. ABP stable. neo gtt weaned off, able to maintain CPPs above 60 without neo. +pp. pboots on\n\nRESP: remains orally intubated and vented on SIMV, settings as charted in carevue. ABG good. LS clear.coarse, O2 sat 98-100%\n\nGI: OGT to lws with brown output. abd soft, nondistended. +bs. protonix as ordered\n\nGU: good urine out via foley cathter. lytes repleted as indicated.\n\nENDO: INsulin drip cont to titrate to BS <120\n\nID: afebrile. IV ABX as ordered.\n\nsocial: family home over night. back to visit early am. family meeting needed.\n\nplan: cont. to monitor neuro status. ? start diet when appropriate. monitor & support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387306, "text": "Resp Care\nPt received from the o.r. s/p gunshot wound to head. Pt is intubated with 7.5 oral et tube taped at 21 cm/lip. Bilateral breath sounds -clear.Pt remains sedated and paralysed, ventilated on assist/control.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387307, "text": "T/sicu Nursing Admit Note\nS: unresponsive\n\nO: patient s/p mult. GSW. one to head (entry wound behind right ear), one to left hand (entry & exit wounds). patient brought to by ambulance, immediately medflighted to . found to have bullet lodged in left posterior fossa with intraparenchymal and subarachnoid hemmorhage and mass effect on pons at level of middle cerebellar penduncles with effacement of the quadrigeminal cistern. also found to have graze wound to left shoulder and through & through wound to left hand. brought to OR immediately with n- for post occipital craniectomy and ventricular drain placement. arrived in t/sicu for OR on neo drip with ventriculostomy drain in place right head. VSS on admission, axillary temp registering at 91.4, bair hugger was placed.\n\nA:\nNEURO: patient unresponsive. no movement noted to extremities. no response to painful stimuli (nailbed pressure or sternal rub). no eye opening noted. not following commands. ventric drain in place, right side of head > leveled at 5cm above tragus, open to drainage. transduced q1h for ICP measurement, ICPs ranging rom . goal to maintain CPP above 60> neo drip restarted this morning. -corneal reflex, -gag reflex, +, , brisk. given fentanyl x1 for increase in BP with turning\n\nCV: HR 90-100s, SR. EKG done for K+ = 2.7. NEO drip restarted this morning to maintain CPP above 60. HCT stable. goal to maintain CPP above 60 and SBP<140\n\nRESP: remains orally intubated and ventilated on CMV, as charted in carevue. LS clear, suctioned for thick brown secretions > ?aspiration. O2 sat 100%\n\nGI: abd soft, nondistended, +hypoactive bs. OGT to LWS with bilious output. protonix as ordered\n\nGU: foley catheter with large light yellow u/o. mannitol as ordered. lytes repleted as indicated\n\nENDO: bs covered with RISS\n\nID: afebrile. IV ABX as ordered.\n\nSKIN: entry wound to back of right ear > irrigated and dsd placed. left hand with GSW entry & exit wounds > x-rayed, irrigated and redressed with DSD. posterior head midline incision with primary dressing intact. s/s drainage noted. ventric. drain in place with transparent dressing intact. left upper arm with graze wound draining s/s fluid > dsd intact. face/head swollen mostly on right side.\n\nSocial: apparently patient was shot by boyfriend, has 2 children 11(son) & 9(daughter) y/o > daughter was grazed by a bullet and treated at a local hospital and released. boyfriend is in custody in . PD is aware of situation and has been in contact with LPD. Father, brothers and sister-in-laws in t/o night. brother spoke with n- immediately post-op. family appropriately upset and anxious. will need family meeting asap.\n\nPlan: 32 y/o woman s/p GSW to head now s/p crani and ventric. placement. cont. to monitor neuro status. follow up head ct for 10 am today. family meeting regarding poor prognosis. NEOB has been contact & will follow up this afternoon. cont. to maintain BP for CPP and SBP goals using neo or ni\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387308, "text": "T/sicu Nursing Admit Note\n(Continued)\npride as indicated. monitor & support as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387309, "text": "Nursing Progress Note:\nEvents: Repeat head CT done this am, unchanged. Multi-lumen central line placed in RSC.\n\nNeuro: Pt is on propofol, currently 50mcg/kg/hr. When off propofol pt is unarousable. PERRLA 3mm, brisk. Absent corneals. Flexion in bilat LE with nailbed pressure, decorticate posturing in bilat UE with nailbed pressure. +, -gag. Vent drain at 5cm above the tragus draining 30-40 ml q2h. ICP's . CPP >60. Mannitol q6hrs.\n\nCV: NSR-ST, no ectopy. HR 100-120. SBP 100-120, MAP'S>75. Pt on Neo currently at .8mcg/kg/min titrated to maintain CPP >60. Cap refill <3 sec in all extremeties. All pulses palpable. Pt repleted with total of 20 meq KCL, 2 gm Ca Gluc, and 2gm Mg. New CL in RSC placed.\n\nResp: SIMV 14, Peep: 5, Fio2 40%. ABG's trending towards normal. Sats 100%, Pt overbreathing vent by 8 breathes/min. LSCTAB. Sx several times producing sm amts thick tan sputum.\n\nGI: NPO. Abd softly distended. BS hypoactive. OGT to LCS, draining sm amts bilious fluid.\n\nGU: Foley draining lrg amts clear light yellow urine.\n\nID: Tmax 100.5. Pt currently on Flagyl, gentamycin, vancomycin.\n\nEndo: Pt on insulin drip started at 1400, effective coverage pending.\n\nSkin: Through and through wound to L hand. Unable to visualize d/t dsd. Draining sm amts s/s fluid. Craniectomy to posterior head draining lrg amts s/s fluid. Graze wound to LUE, draining scant amts s/s draining, covered with dsd. Gunshot wound behind L ear draining sm amts s/s fluid, covered with DSD.\n\nSocial: Family and brothers to visit. Coping appropriately. Social services and cahtolic priest involved.\n\nPlan: Neuro checks q1hr. Titrate Neo to maintain CPP >60. keep SBP <140. Titrate insulin to maintain BS. Cont to replete lytes. Cont family support.\n" }, { "category": "Nursing/other", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 1387310, "text": "Resp. care note - Pt. remaines intubated and vented, weaned to SIMV, tol ok at this time.\n" }, { "category": "ECG", "chartdate": "2149-10-23 00:00:00.000", "description": "Report", "row_id": 207539, "text": "Sinus rhythm. Non-specific T wave flattening in leads III and aVF. Compared to\nthe previous tracing of no significant change.\n\n" }, { "category": "ECG", "chartdate": "2149-10-22 00:00:00.000", "description": "Report", "row_id": 207540, "text": "Normal sinus rhythm with short P-R interval. Non-specific ST-T wave\nabnormalities. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-02 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 938455, "text": " 12:23 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD.PAIN.FEVERS.?ABSCESS/PERITONITIS\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Field of view: 31 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with abd pain and fevers r/o abcess. CT with PO contrast\n\n REASON FOR THIS EXAMINATION:\n r/o peritonitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Abdominal pain and fevers.\n\n COMPARISON: CT abdomen/pelvis .\n\n TECHNIQUE: Multidetector CT images were obtained through the abdomen and\n pelvis with oral and intravenous contrast. Coronal and sagittal reformatted\n images were obtained.\n\n CT ABDOMEN WITH CONTRAST: The lung bases show an unchanged focal opacity at\n the right lung base. The left lung base is clear. A nasogastric tube courses\n through the imaged distal esophagus into the stomach. The liver, gallbladder,\n pancreas, spleen, and adrenal glands are normal in appearance. The kidneys\n enhance symmetrically and excrete contrast normally. There is no evidence of\n hydronephrosis or hydroureter. The gastrostomy tube has been removed from the\n stomach. Otherwise, the stomach and intra-abdominal loops of small and large\n bowel are normal in appearance and caliber. There is no evidence of bowel\n wall thickening or bowel dilatation. There is no free air or pathologically\n enlarged mesenteric or retroperitoneal lymphadenopathy.\n\n CT OF THE PELVIS WITH CONTRAST: The rectum, sigmoid colon, intrapelvic loops\n of small and large bowel, distal ureters, and bladder are normal in\n appearance. The uterus contains an intrauterine metallic device. The adnexa\n are unremarkable. There is no pathologically enlarged inguinal or pelvic\n lymphadenopathy. There is a small amount of intrapelvic free fluid in the\n cul-de-sac.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions.\n\n CT REFORMATS: Sagittal and coronal images confirm the axial findings.\n\n IMPRESSION:\n 1. No evidence of intraabdominal abscess.\n 2. Unchanged right lower lung lobe air space opacity which probably\n represents atelectasis.\n (Over)\n\n 12:23 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD.PAIN.FEVERS.?ABSCESS/PERITONITIS\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Field of view: 31 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2149-11-10 00:00:00.000", "description": "PL HAND (AP, LAT & OBLIQUE) PORT LEFT", "row_id": 939471, "text": " 8:19 AM\n HAND (AP, LAT & OBLIQUE) PORT LEFT Clip # \n Reason: check fracture\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with CRPP\n REASON FOR THIS EXAMINATION:\n check fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old woman with fracture.\n\n COMPARISON: .\n\n TECHNIQUE: Three views of the left wrist were obtained.\n\n FINDINGS: Again noted comminuted fracture of the second metatarsal with K-\n wires in place, without evidence of hardware related complication. Overlying\n splint has been removed in the interval.\n\n IMPRESSION: Unchanged appearance of comminuted fracture of the distal\n second metatarsal without hardware related complication.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-22 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 937009, "text": " 5:55 AM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: ?FB, ?Fx -- Please make this film portable as this patient i\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW head and L hand, s/p craniectomy. L hand wound in\n web space btwn index and thumb dorsally and just proximal to mcp thumb volarly,\n bone exposed.\n REASON FOR THIS EXAMINATION:\n ?FB, ?Fx -- Please make this film portable as this patient is and\n cannot be moved from TSICU at this time\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Left hand, three views, .\n\n HISTORY: 32-year-old woman with gunshot wound to the left hand. Evaluate for\n fracture and radiopaque foreign bodies.\n\n FINDINGS: There is a severely comminuted fracture involving the distal aspect\n of the left second metacarpal. Several bony fragments are seen in this area\n and the fragments are extending through an exit wound along the dorsal aspect\n of the hand. There is soft tissue swelling identified. No radiopaque foreign\n densities are seen. The rest of the bony structures are intact.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938450, "text": " 10:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: NG tube position check. Needs to go to CT with PO contrast A\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman s/p NG tube placement.\n REASON FOR THIS EXAMINATION:\n NG tube position check. Needs to go to CT with PO contrast ASAP. Contrast will\n be given via NGT.Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: NG tube placement.\n\n One portable view. Comparison with the previous study done . The\n lungs remain clear. The heart and mediastinal structures are unremarkable in\n appearance. A tracheostomy tube and right subclavian catheter remain in\n place. A nasogastric tube has been inserted and terminates below the\n diaphragm. The tip is in the region of the body of the stomach. The side\n port appears to lie above the level of the diaphragm.\n\n IMPRESSION: The nasogastric tube is slightly high.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938733, "text": " 9:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p NG tube placement.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gun shot to the head.\n REASON FOR THIS EXAMINATION:\n s/p NG tube placement.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Surveillance after nasogastric tube placement. History of recent\n gunshot to the head.\n\n COMPARISON: Prior chest x-ray from .\n\n The nasogastric tube appears in place, with its radiopaque tip (Dobhoff) at\n the level of the vertical portion of the stomach. The cardiomediastinal\n silhouette is unremarkable. The lungs are clear. The tracheostomy tube is\n stable in position. There has been interval removal of the right subclavian\n central venous line. Metallic staples are noted on the midline at the\n cervical level.\n\n CONCLUSION: Nasogastric tube in place. Interval removal of the right\n subclavian central venous line. Otherwise, unchanged appearance.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938646, "text": " 4:20 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval PNA\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gun shot to the head. Temperature spike follow up\n \n REASON FOR THIS EXAMINATION:\n eval PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP portable chest x-ray at 16:45.\n\n COMPARISONS: Comparison is made to the prior portable film from 10:35 p.m. on\n .\n\n The heart is normal in size. There is a right subclavian central line\n terminating at the SVC-caval junction. There is an endotracheal tube located\n approximately 4 cm above the carina. The patient is noted to have a\n nasogastric tube, with the side port well within the stomach. The mediastinal\n and hilar contours are normal. The pulmonary vascularity is normal. The\n lungs are clear. There is no evidence of pleural effusions. The soft tissues\n and osseous structures are otherwise unremarkable.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-03 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 938647, "text": " 4:21 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval placement of dobhoff\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman s/p NG tube placement.\n\n REASON FOR THIS EXAMINATION:\n eval placement of dobhoff\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN\n\n INDICATION: 32-year-old female status post NG tube placement, for evaluation\n of tube placement.\n\n COMPARISON: None.\n\n SUPINE PORTABLE ABDOMEN: Dobbhoff tube is seen coursing below the diaphragm,\n with its tip located in the region of the stomach. Abdominal bowel gas\n pattern is otherwise unremarkable. No dilated loops of bowel are identified.\n Contrast is seen throughout the colon, consistent with a recent administration\n of contrast. Intrauterine device is seen within the lower pelvis. Osseous\n structures are unremarkable.\n\n IMPRESSION: Dobbhoff tube properly positioned below the diaphragm.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937048, "text": " 10:19 AM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: look for continued bleeding***Please do at 10am****\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman s/p bilateral posterior crani and EVD placement. s/p GSW to\n head\n REASON FOR THIS EXAMINATION:\n look for continued bleeding***Please do at 10am****\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gunshot wound to head, trauma, status post posterior craniectomy.\n\n COMPARISONS: Nine hours earlier.\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the head.\n\n CT HEAD WITHOUT IV CONTRAST: Post-surgical changes from suboccipital\n craniectomy and right frontal approach intraventricular catheter with the tip\n terminating near the foramen of are stable. There is no evidence of\n hydrocephalus and the -white matter differentiation is intact throughout\n bilateral cerebral hemispheres.\n\n A metallic fragment within the left side of the posterior fossa compatible\n with a bullet, degrades imaging of the posterior fossa. The left cerebellar\n hematoma seen previously appears to have been evacuated, with persistent edema\n and mass effect, which effaces the fourth ventricle, as before. Small,\n bilateral posterior subdural hematomas and subarachnoid hemorrhage in the\n basilar cisterns is unchanged. No new intracranial hemorrhage is identified.\n\n IMPRESSION: Stable short-interval appearance, status post suboccipital\n craniectomy and right frontal intraventricular drain placement. Stable\n appearance of posterior fossa edema with effacement of the fourth ventricle\n and mass effect on the midbrain.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-22 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 937049, "text": " 10:20 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: fracture\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gunshot to head s/p craniectomy\n REASON FOR THIS EXAMINATION:\n fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Gunshot to the head, trauma, status post craniectomy.\n\n COMPARISONS: None.\n\n TECHNIQUE: Axial non-contrast MDCT images were obtained through the cervical\n spine. Coronal and sagittal reconstructions were obtained.\n\n CT C-SPINE: The alignment of the cervical spine is unremarkable. There is\n preservation of the vertebral body and intervertebral disc space heights\n throughout, without evidence of fracture.\n\n Post-surgical changes from suboccipital craniectomy are partially imaged, with\n intracranial air and fragmentation of the occipital bone from known gunshot\n trauma. Subcutaneous emphysema tracks down the posterior neck.\n\n There is a comminuted fracture of the angle of the mandible on the right with\n fragmentation extending medially, likely along the tract of a second bullet.\n The right temporomandibular joint appears intact. A small amount of air is\n seen within the temporomandibular joint. There is a large surrounding\n hematoma around the right side of the mandible.\n\n IMPRESSION:\n 1. No CT evidence of fracture or subluxation of the cervical spine.\n 2. Post-surgical changes after suboccipital craniectomy. Subcutaneous\n emphysema tracks down the posterior neck.\n 3. Comminuted fracture of the angle of the mandible on the right with\n fragmentation medially, secondary to 2nd bullet trajectory.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 938181, "text": " 5:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gun shot to the head. Temperature spike follow up\n \n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 32-year-old woman status post gunshot wound to head with a\n fever.\n\n CHEST, PORTABLE AP VIEW: Comparison is made to . A right\n subclavian central venous catheter terminates near the cavoatrial junction. A\n tracheostomy tube is in similar position. A feeding tube is present in the\n left upper quadrant, not fully characterized. The cardiac and mediastinal\n contours are unchanged, and the lungs appear clear. There is no pneumothorax\n or effusion.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2149-11-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 938832, "text": " 8:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for HCP s/p EVD removal ****PLEASE DO AT 7PM TONIGHT **\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n FINAL ADDENDUM\n The above-noted amended findings were discussed with you this morning ()\n at 9AM, via telephone.\n\n\n 8:19 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for HCP s/p EVD removal ****PLEASE DO AT 7PM TONIGHT **\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW to head\n REASON FOR THIS EXAMINATION:\n eval for HCP s/p EVD removal ****PLEASE DO AT 7PM TONIGHT ****** THANK YOU !\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Gunshot wound to head, status post ventricular drain removal.\n\n COMPARISON: CT dated .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: Soft tissue hypodensity and a tiny amount of gas is present within\n the ventricular drainage catheter tract. The ventricles are not significantly\n changed in size or configuration compared to the previous study. The\n appearance of the posterior fossa is unchanged, aside from possible slightly\n smaller size of the quadrigeminal cistern and perhaps the subarachnoid space\n overlying the superior aspect of the right cerebellar hemisphere. There is\n circumferential mucosal thickening in the left maxillary sinus, and moderate\n opacification of the ethmoid sinuses bilaterally, and sphenoid sinus. Moderate\n opacification in the mastoid air cells on the left is unchanged, as well as\n mild opacification of the mastoid air cells on the right.\n\n IMPRESSION: Interval removal of the ventricular drainage catheter with\n otherwise stable appearance of the brain and ventricles compared to the study\n of , aside from minimal posterior fossa changes, noted above.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-29 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 937987, "text": " 1:36 PM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: s/p CRPP L 2nd metacarpal fracture\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW head and L hand, s/p craniectomy. L hand wound in\n web space btwn index and thumb dorsally and just proximal to mcp thumb volarly,\n bone exposed.\n REASON FOR THIS EXAMINATION:\n s/p CRPP L 2nd metacarpal fracture\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fracture.\n\n Three radiographs of the left hand demonstrate interval pinning of the\n previously seen comminuted second metacarpal head fracture. Assessment of\n fine osseous detail and the overlying soft tissues is limited by dressing\n material. Joint spaces are unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 938673, "text": " 8:13 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ******PLEASE DO AT 8PM TONIGHT ***** PT WITH CLAMPED EVD\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with EVD S/P GSW\n REASON FOR THIS EXAMINATION:\n ******PLEASE DO AT 8PM TONIGHT ***** PT WITH CLAMPED EVD\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post gunshot wound. Ventricular drainage catheter\n clamped.\n\n COMPARISON: CT head dated .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The ventricular drainage catheter appears to be retracted somewhat\n compared to the previous exam, with tip now present between the lateral\n ventricles in a more superior location. The right lateral ventricle is mildly\n increased in size compared to the previous exam. The left lateral ventricle\n has not significantly changed compared to the previous exam. There is no\n midline shift. There is no evidence of acute intra- or extra- axial\n hemorrhage. Evaluation of the posterior fossa is very limited from streak\n artifact. Hypodensity in the left cerebellar hemisphere is again noted and\n not significantly changed.\n\n IMPRESSION: Interval slight retraction of the ventricular drainage catheter,\n now terminating between the lateral ventricles at a more superior level. The\n right lateral ventricle is slightly large compared to the previous exam.\n\n The above was discussed with Dr. shortly after completion of the exam.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-11-06 00:00:00.000", "description": "PERC PLCMT GASTROMY TUBE", "row_id": 939014, "text": " 7:33 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: PEG placement, since she could not remove NG tube.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Contrast: OPTIRAY Amt: 35\n ********************************* CPT Codes ********************************\n * PERC PLCMT GASTROMY TUBE PERC PLCMT GASTROSOTMY TUBE *\n * MOD SEDATION, FIRST 30 MIN. MOD SEDATION, EACH ADDL 15 MIN *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman s/p infraoccipital craniectomy for gunshot, with dysphagia\n REASON FOR THIS EXAMINATION:\n PEG placement, since she could not remove NG tube.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Percutaneous gastrostomy tube placement.\n\n CLINICAL HISTORY: 32-year-old female status post gunshot wound to the head\n with dysphagia. Requires gastrostomy tube placement for feedings and\n aspiration risk reduction.\n\n INFORMED CONSENT: Procedural informed consent was obtained from the patient.\n The patient acknowledged understanding of the indications for the procedure as\n well as the attendant risks and potential complications including but not\n limited to bleeding, infection, peritonitis, colon injury, liver injury and\n inability to place the catheter. Signed witnessed informed consent was\n obtained and placed in the medical record.\n\n OPERATORS: , M.D. (IR staff present and attending throughout\n the procedure.).\n , M.D. (IR fellow).\n\n DESCRIPTION OF PROCEDURE: Timeout was performed to identify the patient, the\n procedure to be performed, the site of the procedure, appropriate requisition,\n and appropriate informed consent. Once the above were verified, the patient\n was positioned in supine fashion on a special procedure/angiography table. The\n epigastric region was prepped and draped in usual sterile fashion for the\n procedure. The pre-positioned NG tube was accessed. Air was injected via the\n NG to insufflate the stomach. Under fluoroscopy, a suitable access point was\n selected on the skin surface. The skin and subcutaneous tissues were\n infiltrated with 1% Xylocaine for local anesthesia.\n Two, Brown- T-fasteners were placed for anterior gastropexy.\n Subsequently, an 18-gauge needle was inserted into the gastric lumen at the\n level of the gastric body. Access was confirmed using test injection of\n contrast through the axis needle. A guidewire was steered to the level of the\n duodenum. The subcutaneous tract was then dilated serially. The 12.5 French\n Wills- gastrostomy tube was then delivered over the guidewire with\n formation of the pigtail within the gastric lumen. Confirmation is\n satisfactory, position was confirmed using test injection of contrast by way\n of the catheter. Catheter was sutured at the skin insertion site using 0 silk\n as a retention suture. The entrance site was then dressed with drain sponges\n and overlying gauze secured with paper adhesive tape. The patient tolerated\n (Over)\n\n 7:33 AM\n PERC G/G-J TUBE PLMT Clip # \n Reason: PEG placement, since she could not remove NG tube.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Contrast: OPTIRAY Amt: 35\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the procedure well. No immediate complications were encountered.\n\n MEDICATIONS: 1% Xylocaine with 1% buffered lidocaine, 30 cc total,\n intradermal subcutaneous infiltration.\n\n MODERATE SEDATION was provided by administering 50 mcg of Fentanyl and 1 mg of\n Versed throughout the intraservice time of 50 minutes during which the\n patient's hemodynamic parameters were continuously monitored.\n\n IMPRESSION: Successful placement of 12.5 French Wills- gastrostomy\n tube. Post-procedural orders were written.\n\n NG tube should be maintained to low intermittent suction for 24 hours. The\n newly placed gastrostomy tube should not be accessed for 24 hours. The two,\n Brown- gastropexy T-fasteners should be removed in days and\n allowed to pass intestinally.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 938256, "text": " 10:31 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Assess for hydrocephlus\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with ventriculostomy drain being weaned a\n REASON FOR THIS EXAMINATION:\n Assess for hydrocephlus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old woman with a ventriculostomy catheter being weaned.\n Assess for hydrocephalus.\n\n TECHNIQUE: Non-contrast head CT was performed.\n\n FINDINGS: Since the prior examination, the bullet fragment overlying the\n posterior fossa has not changed in position. There is a hypodensity within\n the left cerebellar hemisphere as before, consistent with infarct. There is a\n small amount of pneumocephalus present as before.\n\n The right frontal ventriculostomy catheter again terminates in the third\n ventricle. There is no change in the size or configuration of the lateral\n ventricles with fullness to the left lateral ventricle as before. There is no\n evidence of worsening hydrocephalus. The mass effect in the posterior fossa\n is also unchanged.\n\n There is a suboccipital craniectomy. A small amount of blood relating to the\n recent surgery is also present in posterior fossa.\n\n IMPRESSION: No change in the size or configuration of the lateral ventricles,\n with the right frontal ventriculostomy catheter.\n\n Left cerebellar hemisphere hypodensity could represent an evolving infarct.\n\n Unchanged mass effect in the posterior fossa.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 937072, "text": " 12:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? line position, ? pneumothorax.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gun shot to the head, now s/p RSC CVL placement.\n REASON FOR THIS EXAMINATION:\n ? line position, ? pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of right central venous line placement.\n\n Portable AP chest radiograph was reviewed. The film is slightly\n overpenetrated. The ET tube tip is 5 cm above the carina. The NG tube tip is\n within the stomach. The right subclavian central venous line tip is in the\n low SVC. There is no pneumothorax or pleural effusion identified. The heart\n size is normal. The mediastinal position, contour, and width are\n unremarkable. The lungs are clear. There is no left pleural effusion.\n\n IMPRESSION: Standard position of tubes and lines. No pneumothorax. No lung\n pathology identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937351, "text": " 2:37 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ?worsening mass effect? Please perform this afternoon approx\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with s/p gunshot to posterior fossa, recent CT showed ?mass\n effect\n REASON FOR THIS EXAMINATION:\n ?worsening mass effect? Please perform this afternoon approx 2pm\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old woman status post gunshot wound to posterior fossa,\n mass effect on recent CT.\n\n COMPARISON: Multiple head CTs, most recent dated .\n\n TECHNIQUE: Routine head CT without intravenous contrast.\n\n FINDINGS: This exam is again significant limited by metallic bullet\n fragments. Mass effect on the fourth ventricle continues to be present, and\n is not worsened from the previous study. Ventricular size is stable, with\n ventriculostomy catheter in the right lateral ventricle. There is no new mass\n effect. The bullet fragments appears to have changed position and tubular\n gated even more posteriorly on the current examination than on the study of\n . There is small amount of blood in the left posterior fossa.\n\n Soft tissues and osseous structures are stable status post craniotomy.\n\n IMPRESSION: Stable appearance of the brain, status post left occipital\n craniotomy and right frontal ventriculostomy. Continues mass effect on the\n fourth ventricle and the mid brain, no new hemorrhage or mass effect\n identified. Bullet fragment appears to be located more posteriorly on the\n current exam than the study of .\n\n" }, { "category": "Radiology", "chartdate": "2149-10-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 936994, "text": " 12:59 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Post op CT\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with Gun shot wound to head s/p sub occipital cranitotomy\n REASON FOR THIS EXAMINATION:\n Post op CT\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post gunshot wound to the head and suboccipital craniotomy\n and drain placement.\n\n COMPARISON: Non-contrast head CT from .\n\n FINDINGS: The patient is status post occipital craniotomy. Multiple foci of\n air are now seen in the posterior fossa. A metallic foreign body, purportedly\n a bullet is again seen. There remains effacement of the basal cisterns and\n mass effect on the pons at the level of the middle cerebellar peduncles. This\n is difficult to image and compare given the differences in patient head\n positioning and extensive metallic artifact. There has been interval\n placement of a ventricular drain, which crosses the right frontal lobe and\n terminates in the third ventricle. There has been interval decrease in size\n of the lateral ventricles.\n\n IMPRESSION:\n\n 1. Status post occipital craniotomy and ventricular drain placement with\n pneumocephalus and unchanged effacement of the basal cisterns and mass effect\n on the pons.\n\n COMMENT: There is marked fragmentation of the visualized right side of the\n mandible and gross swelling of the contigous masticator musculature. A small\n amount of emphysema is noted in the posterior upper cervical fasical planes\n between the muscles in that locale.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937728, "text": " 2:34 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for hydrocephalus\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman s/p gunshot wound to head\n REASON FOR THIS EXAMINATION:\n assess for hydrocephalus\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for developing hydrocephalus in a patient who has had a\n gunshot to the posterior fossa.\n\n COMPARISON EXAMINATION: .\n\n FINDINGS: There is a right frontal ventriculostomy catheter with the tip in\n the third ventricle. The size and configuration of the lateral ventricles is\n unchanged from before with a small right lateral ventricle and a slightly\n enlarged left lateral ventricle. There does not appear to be any increased\n mass effect. Again, there are bullet fragments within the superficial\n posterior fossa with a suboccipital craniotomy. There continues to be mass\n effect upon the fourth ventricle. However, newly apparent, there is an area\n of low-density overlying the medial internal portion of the left cerebellar\n hemisphere. This area was previously obscured by metallic streak artifact.\n This could represent an underlying infarct. These findings were telephoned to\n Dr. on 2:50 p.m. on .\n\n The true extent of this infarct is uncertain due to the overlying metallic\n streak artifact.\n\n IMPRESSION: No change in the size and configuration of the lateral\n ventricles. Right frontal ventriculostomy catheter in position.\n\n Stable posterior fossa edema with effacement of the fourth ventricle and mass\n effect upon the midbrain as before.\n\n A newly apparent left cerebellar hemisphere infarct.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 936990, "text": " 10:10 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: GSW\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW\n REASON FOR THIS EXAMINATION:\n Eval\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old woman with gunshot wound to the head.\n\n TECHNIQUE: Routine non-contrast head CT.\n\n FINDINGS: There is a large metallic foreign body in the left posterior fossa,\n reportedly a bullet. At the left cerebellopontine angle is a 2.4 cm focus of\n intraparenchymal hemorrhage. There is diffuse subarachnoid hemorrhage within\n the basal cisterns. There is a large degree of mass effect on the pons at the\n level of the middle cerebellar peduncles, left greater than right and\n effacement of the quadrigeminal cistern. The supratentorial ventricles and\n sulci are grossly normal. The -white matter differentiation is preserved.\n The surrounding soft tissue structures show soft tissue swelling over the\n right lateral face with air tracking into the medial to the right mandibular\n condyle and within the temporal fossa. The surrounding osseous structures\n show fracture of the left skull base with few bony fragments sitting in the\n inferior aspect of the left posterior fossa. The imaged portions of the\n paranasal sinuses show mucosal thickening within the ethmoid air cells and\n fluid filling the nasopharynx.\n\n IMPRESSION: Metallic foreign body, reportedly a bullet within the left\n posterior fossa with intraparenchymal and subarachnoid hemorrhage and mass\n effect on the pons at the level of the middle cerebellar peduncles with\n effacement of the quadrigeminal cistern. These findings were immediately\n discussed with the neurosurgical team caring for the patient who went\n emergently to the OR for surgical decompression.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937541, "text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for pneumonia.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with gun shot to the head. Temperature spike.\n REASON FOR THIS EXAMINATION:\n Assess for pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 06:06 HOURS.\n\n HISTORY: Gunshot wound to the head.\n\n COMPARISON: Multiple priors, the most recent dated .\n\n FINDINGS: The patient has undergone tracheostomy in the interval. An\n indwelling right subclavian central venous catheter is stable in position. A\n nasogastric tube has been removed and a gastric tube port has been placed.\n Lung volumes are diminished. A very subtle opacity is noted in the right lung\n base. The mediastinum is unremarkable. There is no pleural effusion or\n pneumothorax. The visualized osseous structures are unremarkable.\n\n IMPRESSION: Very subtle opacity in the right lung base, which may be\n confluence of structures or atelectasis. However, given history, a small\n early developing pneumonia cannot be entirely excluded. Recommend empiric\n treatment and followup radiographs to document reproducibility and/or\n resolution.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-28 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 937833, "text": " 10:32 AM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: evaluate status of left hand\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW head and L hand, s/p craniectomy. L hand wound in\n web space btwn index and thumb dorsally and just proximal to mcp thumb volarly,\n bone exposed.\n REASON FOR THIS EXAMINATION:\n evaluate status of left hand\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Gunshot wound.\n\n Three radiographs of the left hand demonstrate diffuse demineralization.\n Again noted is a severely comminuted fracture of the distal metadiaphysis of\n the second metacarpal. Soft tissues are unremarkable. Fracture configuration\n is similar to that seen on . Intercarpal spaces are maintained.\n\n IMPRESSION:\n Second metacarpal fracture, unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937190, "text": " 10:04 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: GSW TO HEAD\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman gunshot to head\n REASON FOR THIS EXAMINATION:\n ?subarachnoid bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: 32-year-old woman with gunshot wound to head.\n\n COMPARISON: Multiple prior studies, most recent dated at\n 10:32 a.m.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: The exam is significantly limited by motion and the metallic bullet\n fragments. Again seen are changes related to the ventricular drain from a\n right frontal approach and left occipital craniotomy and hematoma evacuation.\n Again seen is a small amount of blood in the left posterior fossa. Subdural\n hemorrhage along the tentorium is again noted and stable. There continues to\n be mass effect on the fourth ventricle and mid brain. Ventricular size is\n stable. There is no new mass effect or hemorrhage identified. Evaluation for\n sulcal effacement is limited on this exam. Osseous and soft tissue structures\n are stable.\n\n IMPRESSION: Limited exam secondary to motion and artifact from the bullet\n fragments, however the appearance of the brain appears overall stable status\n post left occipital craniotomy and right frontal intraventricular drain\n placement. Continued effacement of the fourth ventricle and mass effect on\n the mid brain. No new hemorrhage or mass effect identified.\n\n\n\n NOTE ADDED AT ATTENDING REVIEW: the bullet fragment appears to have changed\n position and to be located more posteriorly on the current examination than\n on the study of .\n\n" }, { "category": "Radiology", "chartdate": "2149-10-30 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 938207, "text": " 10:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD PAIN, FEVER.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with abd pain and fevers r/o abcess\n REASON FOR THIS EXAMINATION:\n Approved per on call radiology IV contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old female with abdominal pain and fevers. Please\n evaluate for intraabdominal abscess.\n\n COMPARISON: None.\n\n TECHNIQUE: Continuous MDCT acquired axial images were obtained from the lung\n bases to the pubic symphysis after the administration of 130 cc of Optiray\n intravenous contrast. Multiplanar reformatted images were obtained and\n reviewed. Oral contrast was administered.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The visualized lung bases are notable for\n a focal airspace opacity in the right lower lobe.\n\n The timing of the contrast bolus is very delayed, and suboptimal for\n evaluation of the intraabdominal solid organs and vasculature. The liver is\n grossly unremarkable. There is no evidence of intra- or extra-hepatic biliary\n ductal dilatation. There is no ascites. The gallbladder, spleen, pancreas,\n and adrenal glands are unremarkable. The kidneys are normal in appearance and\n excrete contrast symmetrically. A gastrostomy tube is seen within the\n stomach. Opacified loops of intraabdominal bowel are unremarkable. A\n moderate amount of stool is seen throughout the length of colon. No free air,\n free fluid, or pathologic mesenteric or retroperitoneal lymphadenopathy is\n identified.\n\n CT OF THE PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, pelvic loops of\n bowel, uterus, and adnexa are unremarkable. An intrauterine device is seen\n within the uterine fundus. The urinary bladder is decompressed, and a Foley\n catheter balloon is seen within. No free fluid is seen within the pelvis, and\n there is no evidence of abnormal pelvic or inguinal lymphadenopathy.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified.\n\n IMPRESSION:\n\n 1. No evidence of intraabdominal abscess.\n\n 2. Focal air space opacity in the right lower lobe may represent infectious\n infiltrate versus atelectasis.\n\n 3. Moderate amount of stool throughout the colon.\n (Over)\n\n 10:48 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: ABD PAIN, FEVER.\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n Field of view: 36 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n A preliminary report was called to Dr. at 4:45 a.m. on \n by Dr. .\n\n\n" }, { "category": "Radiology", "chartdate": "2149-10-21 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 936989, "text": " 9:51 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old female status post gunshot wound to the head.\n\n PORTABLE AP CHEST: Examination is limited by overlying trauma board. The\n endotracheal tube terminates 3.3 cm above the carina. Nasogastric tube is\n coiled in the stomach. The cardiac size and cardiomediastinal and hilar\n contours are normal. The lung fields are clear. There is no pleural effusion\n or pneumothorax. There is gaseous distention of the stomach.\n\n AP PELVIS: Examination is limited by overlying trauma board. An intrauterine\n device and a Foley catheter are identified. There is no evidence for pelvic\n fracture. The hip joints are seated normally within the bilateral acetabuli.\n\n IMPRESSION:\n 1. Endotracheal tube and nasogastric tube in appropriate position.\n 2. Gaseous distension of the stomach.\n 3. No evidence for pneumothorax or pelvic fracture.\n\n" }, { "category": "Radiology", "chartdate": "2149-10-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 937831, "text": " 10:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o changes from previous scan\n Admitting Diagnosis: GUN SHOT WOUND TO HEAD\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 32 year old woman with GSW to head\n REASON FOR THIS EXAMINATION:\n r/o changes from previous scan\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 32-year-old with gunshot wound to the head.\n\n COMPARISON: Series of studies, most recent dated .\n\n TECHNIQUE: Routine head CT without intravenous contrast.\n\n FINDINGS: Right frontal ventriculostomy catheter tip in the third ventricle\n is again noted. Size and appearance of the lateral ventricles is unchanged\n from previous study. Patient is status post suboccipital craniotomy, with\n bullet fragments noted within the superficial posterior fossa. There\n continues to be mass effect upon the fourth ventricle, without apparent\n change. Again noted is an area of low density overlying the medial internal\n portion of the left cerebellar hemisphere, that could represent an underlying\n infarct.\n\n Again seen is a small amount of blood in the posterior fossa, as well as small\n amount of air, presumably related to the surgery.\n\n IMPRESSION:\n 1. Stable posterior fossa edema, with mass effect upon the midbrain and\n effacement of the fourth ventricle, unchanged.\n\n 2. No change in size and appearance of the lateral ventricles, with a right\n frontal ventriculostomy catheter in place.\n\n 3. Left cerebellar hypodensity that could represent an evolving infarction.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2129-06-16 00:00:00.000", "description": "Report", "row_id": 1532467, "text": "CCU NPN\nSee FHPA for full admission details.\n\nS-\"I wish I could sit up.\"\n\nO-Neuro: A&Ox3, MAE. C/O back discomfort from laying down, repositioned, given backrub and tylenol w/ good effect.\n\nCV: Tele SR 70s no VEA. BP 110s-120s/40s-50s. Off of pressors, to restart norvasc and toprol XL in AM. L groin ecchymotic, unable to appreciate hematoma, no bleeding. Palp distal pulses. Finished 1uPRBC, to have Hct check @ 1900.\n\nPulm: LS w/ crackles @ R base, otherwise CTA. Sats 96-98% on 2L NC. Denies dyspnea.\n\nGI/GU: +BS, abd soft, non-tender. Tol sips of g'ale, no more episodes of N/V. Foley patent, draining cl yellow urine.\n\nSocial: Pt lives alone, has son close by who is her power of attorney.\n\nA/P: Monitor Hct, transfuse for Hct<30. Bedrest o/n. Restart antihypertensives in AM. be d/c to home tomorrow if stable o/n. AVR on Monday.\n" }, { "category": "Nursing/other", "chartdate": "2129-06-17 00:00:00.000", "description": "Report", "row_id": 1532468, "text": "NEURO: A&O X3. PLEASANT & COOPERATIVE.\n\nRESP: O2->2L NP. BS CLEAR. RR 15-25. O2 SAT 94-99%. PERIODS OF APNEA WHILE SLEEPING, DROPPING O2 SATS 70-80'S VERY BRIEFLY.\n\nCARDIAC: HR 60-82 SR WITH RARE-OCC. PVC. BP 93-135/38-59. +BPPP. L. GROIN REMAINS ECCHYMOTIC. NO EXTENSION OF HEMATOMA. POST-TRANSFUSION HCT 32.2. RE-CHECK HCT 0100->28.3. GIVEN ADDITIONAL 1U PRBC. K 4.7,\nCA 8.2, MG 1.9, PO4 3.7. DENIES PAIN. DISCOMFORT D/T BEDREST RELIEVED WITH REPOSITIONING.\n\nGI: ABD. SOFT. BS+. NO STOOL. DENIES NAUSEA/VOMITTING.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 40-100CC/HR.\nBUN/CREAT 27/0.8.\n\nID: AFEBRILE.\n\nPLAN: AVR/MVR SCHEDULED FOR MONDAY. PLAN WAS TO SEND PT HOME FOR WEEK-END & RETURN MONDAY FOR OR. ??? TO STAY IN HOSPITAL OVER WEEK-END IN LIGHT OF RETRO-PERITONEAL BLEED POST-CATH.\nRE-CHECK HCT 0730-0800(POST-TRANSFUSION).\n" }, { "category": "Radiology", "chartdate": "2129-06-16 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 825787, "text": " 11:26 AM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: r/o retroperitoneal bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old woman with carotid artery disease, s/p peripheral angiogram\n REASON FOR THIS EXAMINATION:\n r/o retroperitoneal bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Coronary artery disease, status post peripheral angiogram. Question\n of retroperitoneal hematoma.\n\n TECHNIQUE: Helically-acquired contiguous axial images of the abdomen and\n pelvis were obtained without oral or intravenous contrast.\n\n ABDOMEN CT WITHOUT CONTRAST: There is dependent atelectasis at both lung\n bases, greater on the left. Coronary artery calcifications and stents are\n noted. The aorta and its branches are extensively calcified. There is a\n hiatal hernia of moderate size.\n\n There are rim calcifications around the left lobe of the liver and the spleen,\n pancreas and adrenal glands are unremarkable. Intravenous contrast from the\n preceding angiogram is noted in the renal collecting systems bilaterally.\n There is a 3.9 x 3.6 cm simple cyst in the upper pole of the left kidney. The\n bowel is not opacified with contrast, and it appears unremarkable. There is\n no free air.\n\n PELVIS CT WITHOUT CONTRAST: There is a large hematoma extending from the left\n groin into the retroperitoneum in the left posterior pararenal space, up to\n the level of the left renal hilum. This was communicated to Dr. at\n 3:25PM on .\n\n There is contrast within the bladder, secondary to the preceding angiogram.\n There is also a Foley catheter within the bladder. The uterus and adnexa are\n unremarkable.\n\n BONE WINDOWS: The visualized osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1) Large hematoma extending from the left groin into the left retroperitoneum.\n\n 2) Left renal cyst.\n\n" }, { "category": "ECG", "chartdate": "2129-06-16 00:00:00.000", "description": "Report", "row_id": 165464, "text": "Sinus rhythm\nPremature atrial contractions\nSince previous tracing, atrial premature complexes new\n\n" }, { "category": "ECG", "chartdate": "2129-06-16 00:00:00.000", "description": "Report", "row_id": 165465, "text": "Sinus rhythm\nBorderline first degree A-V block\n\n" } ]

[ { "category": "Radiology", "chartdate": "2116-01-01 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 993539, "text": " 9:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for post-op hemorrhage**please do within 4 hours**\n Admitting Diagnosis: HEADACHE\n Field of view: 25\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p left frontal meningioma resection\n REASON FOR THIS EXAMINATION:\n evaluate for post-op hemorrhage**please do within 4 hours**\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with left frontal meningioma resection. Please\n evaluate for postoperative hemorrhage.\n\n TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast.\n\n FINDINGS: The patient is status post left frontal craniotomy. There is\n significant amount of subdural pneumocephalus in the anterior portion of the\n left frontal region and mild on the right. Mild compressive effect on the\n underlying left frontal lobe is noted. Small amount of intraparenchymal gas\n and hemorrhage is also noted within the left frontal lobe surgical bed. The\n vasogenic edema of the left frontal lobe appears relatively unchanged. There\n is still 6-mm subfalcine herniation which has decreased in size compared to\n the preop images. The paranasal sinuses and mastoid air cells are clear.\n Significant tissue swelling and subcutaneous emphysema is noted within the\n left frontal and temporal region and right frontal region.\n\n IMPRESSION:\n 1. Status post left frontal craniotomy with bifrontal subdural air\n accumulation, left greater than right and small amount of intraparenchymal\n hemorrhage and gas in the left frontal surgical bed. There has been interval\n decrease in the subfalcine herniation. Left frontal vaso genic edema is\n unchanged.\n\n Study is somewhat limited due to motion artifacts.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 993292, "text": " 12:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval of left frontal head\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with brain mass\n REASON FOR THIS EXAMINATION:\n eval of left frontal head\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with headache and brain mass seen on outside CT.\n\n TECHNIQUE: Axial MDCT images of the head were obtained with no IV contrast\n administration.\n\n No comparison is available.\n\n FINDINGS: There is a large mass in the left frontal region measuring 4.4 x\n 4.4 cm, which has its base on the adjacent falx and the left frontal bone.\n This extra axial mass is most likely a meningioma. Moderate amount of\n vasogenic edema is noted adjacent to the mass. There is an 8 mm of subfalcine\n herniation. The mass has a hyperdense appearance with a central hypodensity.\n No intracranial hemorrhage is noted. The left lateral ventricle is mildly\n displaced by the mass. There is also obliteration of the sulci adjacent to\n the mass. The bone windows do not demonstrate any fracture. IMPRESSION:\n\n CONCLUSION: Left hyperdense frontal mass is associated with 8 mm of subfalcine\n herniation and the moderate amount of vasogenic edema. The mass most likely\n represents meningioma. However, MRI of the brain with gadolinium is helpful\n for further characterization.\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 993584, "text": " 7:44 AM\n MR HEAD W & W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: Please evaluate for any residual mass\n Admitting Diagnosis: HEADACHE\n Contrast: MAGNEVIST Amt: 20CC\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p right frontal meningioma resection\n REASON FOR THIS EXAMINATION:\n Please evaluate for any residual mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n Patient is status post left frontal craniotomy, with moderate amount of\n pneumocephalus and areas of increased signal in the left frontal surgical bed,\n related to hemorrhage. The study is limited due to significant motion\n artifacts and lack of IV contrast.\n\n IMPRESSION:\n\n 1. Incomplete study due to patient motion artifacts.\n\n Patient will be sedated and brought back for repeat study.\n\n 2. Status post left frontal craniotomy with moderate amount of pneumocephalus\n in the left frontal region and small areas of hemorrhage in the surgical bed;\n mild shift of the midline structures as noted on the recent CT scan done on\n .\n\n" }, { "category": "Radiology", "chartdate": "2116-01-03 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 993769, "text": " 9:20 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Erratic behavior rule out new bleed or swelling\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man s/p craniotomy for meningioma\n REASON FOR THIS EXAMINATION:\n Erratic behavior rule out new bleed or swelling\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47-year-old man with erratic behavior status post meningioma\n resection.\n\n COMPARISON: CT head of .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n FINDINGS: There is a slight increase in the extra-axial hyperattenuating\n material at the left frontal craniotomy site, consistent with expected\n postoperative change. A small amount of pneumocephalus is unchanged. There\n is no evidence of acute hemorrhage, edema or infarction. There is a small\n interval increase in soft tissue swelling at the craniotomy site. No other\n interval change is seen.\n\n IMPRESSION: Expected postoperative changes without acute hemorrhage, edema or\n infarction.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 993876, "text": " 4:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA, effusion, PTX\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with left frontal mass s/p crani. Intubated. Decreased PO2.\n +large secretions.\n REASON FOR THIS EXAMINATION:\n ? PNA, effusion, PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, 4:54 A.M.:\n\n CLINICAL HISTORY: 47-year-old man with left frontal mass status post\n craniotomy. Intubated. Decreased oxygen saturation. Large amount of\n secretions. Evaluate for pneumonia, effusion, or pneumothorax.\n\n There is an endotracheal tube in place with its tip at the level of the\n superior margin of the clavicular heads. The nasogastric tube is seen with\n its tip in the stomach. Large amount of radiopaque contrast is seen in the\n colon. There has been interval development of air space opacities projecting\n over the both lower lungs (right greater than left). There is no evidence of\n pneumothorax.\n\n IMPRESSION: Interval development of airspace opacities in both lower lobes.\n Diagnostic considerations include pneumonia and less likely pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2115-12-31 00:00:00.000", "description": "CT CHEST W&W/O C", "row_id": 993337, "text": " 12:58 PM\n CT CHEST W&W/O C ; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: assess for metastases\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with left frontal brain mass.\n REASON FOR THIS EXAMINATION:\n assess for metastases\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left frontal brain mass. Assess for metastases.\n\n TECHNIQUE: Contrast-enhanced CT of the chest, abdomen and pelvis with\n multiplanar reformatted images.\n\n COMPARISON: None.\n\n CT CHEST WITH CONTRAST: The lungs are clear. The heart and great vessels of\n the mediastinum are unremarkable. There is no pathologic adenopathy.\n\n CT ABDOMEN WITH CONTRAST: The liver, pancreas, spleen, stomach, adrenal\n glands, kidneys, small bowel loops are normal. There is no pathologic\n adenopathy. There is no free air or free fluid.\n\n CT PELVIS WITH CONTRAST: The colon, bladder, prostate are normal. There is\n no pathologic adenopathy. Note is made of bilateral fat-containing inguinal\n hernias.\n\n BONE WINDOWS: No suspicious lesions are identified.\n\n IMPRESSION: No evidence for metastatic disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 993646, "text": " 1:16 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ETT placement, Dobhoff placement\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with 8cm frontal mass\n REASON FOR THIS EXAMINATION:\n ETT placement, Dobhoff placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cranial mass; for ET tube and Dobbhoff placement.\n\n FINDINGS: No previous images. Relatively low lung volumes, most likely\n accounts for the prominence of the transverse diameter of the heart. No acute\n pneumonia.\n\n The endotracheal tube lies at the upper clavicular level, approximately 5.5 cm\n above the carina. Nasogastric tube extends to the gastric antrum. Of\n incidental note is residual contrast material within the colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2115-12-31 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 993308, "text": " 7:22 AM\n MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: Please evaluate mass.\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with new brain mass.\n REASON FOR THIS EXAMINATION:\n Please evaluate mass.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD WITH AND WITHOUT CONTRAST \n\n HISTORY: 47-year-old man with new brain mass.\n\n Sagittal and axial short TR, short TE spin echo imaging was performed through\n the brain. Axial images were performed with long TR, long TE fast spin echo,\n gradient echo, FLAIR, and diffusion technique. After administration of\n gadolinium intravenous contrast, sagittal, axial, and coronal short TR, short\n TE spin echo imaging were performed. An MR arteriogram also was performed.\n Comparison to a head CT of .\n\n FINDINGS: Again identified is a large extra-axial mass in the left frontal\n region. This appears to arise from the inner table of the calvarium and front\n of the falx. There is associated white matter edema. This causes substantial\n mass effect upon the brain and produces left to right midline shift. The mass\n enhances largely homogeneously after contrast administration. This appearance\n is most typical of a meningioma.\n\n No other intracranial lesions are identified. There is no evidence of\n hemorrhage.\n\n Incidentally noted is mild mucosal thickening in the paranasal sinuses.\n\n CONCLUSION: Left frontal extra-axial mass most likely a meningioma.\n\n\n" }, { "category": "Radiology", "chartdate": "2116-01-02 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 993718, "text": " 10:14 PM\n MR HEAD W & W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: eval mass\n Admitting Diagnosis: HEADACHE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with left frontal mass s/p crani and acute delirium\n REASON FOR THIS EXAMINATION:\n eval mass\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate for mass.\n\n COMPARISON: CT head performed and MR brain performed .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the\n brain before and after the administration of IV gadolinium contrast.\n\n FINDINGS: Post left frontal craniotomy changes including pneumocephalus and a\n tiny amount of extraaxial hemorrhage is within the spectrum of post- surgical\n change. Diffusion- weighted images are unremarkable without evidence of acute\n infarct. Mooderate left frontal edema with 7mm shift of midline syructres the\n right is similar to . Minimal enhancement in the periphery of the\n surgical bed may represent vessel enhancement, although minimal residual mass\n cannot be excluded. Minimal mastoid air cell thickening is noted bilaterally.\n\n IMPRESSION:\n 1. Post left frontal craniotomy changes including pneumocephalus and small\n areas of hemorrhage in the surgical bed are within the spectrum of post-\n surgical change.\n\n 2. Small amount of enhancement peripherally may represent vessel enhancement,\n although minimal residual mass cannot be excluded. Recommend followup as\n clinically indicated to rule out residual mass.\n\n" }, { "category": "Radiology", "chartdate": "2116-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 993982, "text": " 4:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess PNA\n Admitting Diagnosis: HEADACHE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old man with\n REASON FOR THIS EXAMINATION:\n assess PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia.\n\n Single portable radiograph of the chest demonstrates persistent increased\n opacities projecting over both lungs, similar to that seen on .\n Support lines are unchanged. The cardiomediastinal contours are normal.\n Trachea is midline. No pneumothorax detected.\n\n IMPRESSION:\n\n No interval change.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-01-03 00:00:00.000", "description": "Report", "row_id": 1619902, "text": "Update\nO: See carevue flowsheet for specifics.\nNeuro: pserl brisk at 2mm . When ppfl paused x 5mins q4h pt restless, mae, thrashing head side to side-> not following any commands. Withdraws to nailbed pressure w q1h neuro exam. Lt eye edema w ecchymosis, hob at 45 degrees to minimize edema. Cranial dsg w old staining ss drng, intact.MRI w & w/o contrast done at 2215, tol well w ppfl infusing at 55-60 mcg/kg/m.Med currently w dilaudid prior to 0400 wakeup for presumed surgical site pain.\n\nCv: sr no ectopy. Sbp goal < 140, transient > 140 w stimuli when awoke for neuro exam otherwise sbp 110-130's. Skin /dry, distal pulses palp.\n\nResp: remains intubat on cmv mode. fio2 50% tv 550 rr 12 peep 5 w )2 sats 98-100%. VAP protocol maintained. Lavage and suct for thick brwn sputum.Oral care done q4h, suct for mod amts bl tinge oral secretions.\n\nGi: npo, abd soft, nt/nd/+bowel snds. Ngt lt nares to lws w mod bilious to dk brwn drng at times. H2 blocker png given.\n\nGu: foley to gd w qs c/y/u.\n\nHeme/Id: am labs pending. afebrile. tmax 98, shivering x1 w bath afebrile at time.\n\nPsych/Soc/Family: pt remains sedated overnight,no calls overnight from family.\n\nA/P: cont q1h neuro checks. ? wean from vent in am if pt tolerates wakefulness w/o agitation. Cont w Icu care.Vap protocol while intubated. Pulm toilet.? Change gi prophylax to ppi in view of dk brwn ngt drng.Goal sbp < 140, titrate snp if bp > 140 off sedation.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-03 00:00:00.000", "description": "Report", "row_id": 1619903, "text": "Respiratory Care\nPt intubated on vent support. PT transported to and from MRI w/o incident. Sx for very thick tan secretions, BS clear after Sx. AM RSBI 25, vebt support weaned to PSV tol well. No ABGs, SpO2 100% all shift.\nPlan: wean to extubation later in am.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-03 00:00:00.000", "description": "Report", "row_id": 1619904, "text": "Please See Carevue for Specifics.\n\nPt remains sedated on 70mcg/kg/min of Propofol. Propofol was briefly stopped this morning for neuro exam: Pt would open eyes, shake head side to side, MAE's, attempted to pull out ETT, would not follow commands. At his time HR increased to 120's and SBP 160's. Neuro Surgical team to witness and eval and psych consult ordered and seroquel 25mg started. Psych eval this afternoon suggested stopping seroquel and starting Haldol 5mg prn to assist with behavior and extuabtion. 5mg IV Haldol adm at 1600 and Propofol slowly weaned to 50mcg/kg/min; however, even with Haldol adm pt started to shake, rapidly move head side to side, HR increased to 120's, and SBP increased to 156. Family at bedside trying to comfort pt without success. Propofol gtt increased to 70mcg/kg/min.\n\nNSR, no ectopy. SBP 100-120's. Lungs are diminished at bases and clear upper lobes. Suctioned infrequently for thick tan secretions. Abd is soft, +BSX4. No stool this shift. Foley with c/y/u. Skin is intact.\n\nPOC: Continue to adm Haldol and attempt to wean propofol. Monitor neuro status, respir and hemodynamics. Social Work to follow pt and pt family. Wean to extubate. Continue to offer emotioanl support to pt and pt family.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-03 00:00:00.000", "description": "Report", "row_id": 1619905, "text": "Patient post op for large (L)frontal mass,CT Scan today.Suctioned for moderate amount of thick yellow secretion.Sedated for anxiety, tend to increase BP and HR when anxious;No recent ABG seen will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-02 00:00:00.000", "description": "Report", "row_id": 1619899, "text": "SICU NPN:\nNEURO: On q1hr neuro checks with pupils equal and reactive to light. Equal strength to all extremities. Slight facial droop noted to R side - neurosurg. aware. Speech garbled at times and at other times clear. A&Ox3. Sleeping but easilly arousable to voice. Tounge midline. Given prn percocet and dilaudid for head pain. No nausea or vomitting.\nCV: Afeb. HR 90s-120s SR/ST, no ectopy noted. On nipride gtt to maintain goal SBP <140. Going by cuff pressures since a-line much higher. NS with 20meq KCL at 75cc/hr. Pt. with three peripheral ivs and a-line to R radial. Pneumoboots on. RESP: On 3L O2 via NC with O2 Sat >94%. LS clear throughout. No cough or SOB.\nGI/GU: Abd. soft with hypoactive bowel sounds. NPO except meds. Foley draining clear yellow urine >40cc/hr. Glucose requiring humalog coverage per ss.\nSKIN: DSD to head with small amts old bloody drainage on dsg. Notable head swelling to L side of head/face- to be expected per neurosurgery and expected to get worse.\nPLAN: Q 1hr neuro checks to assess for any changes in neuro exam. Plan for MRI of head today - checklist completed and faxed-in front of chart.\nWife and daughter into visit and updated on pt's condition and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-02 00:00:00.000", "description": "Report", "row_id": 1619900, "text": "Resp Care\nPt became combative and was restrained in unit. Pt electively intubated in unit due to AMS. Pt remains intubated. Current vent settings: A/C 550 x 12 5P 50%. MRI has been scheduled for Pt. No other changes noted.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-02 00:00:00.000", "description": "Report", "row_id": 1619901, "text": "Please See Carevue for Specifics.\n\nPt at start of shift was A+OX3, MAE, following commands, denied pain. Pt was unable to tolerated MRI this morning and received 2.5mg IV ativan and 2mg Versed without effect. Pt was screaming and moving in scanner. Neuro team aware of uncomplete scan and was brought back to the SICU. On arrival to the SICU pt became agitated, confused, crawling out of bed, combative to nurse, pulling out IV's, and broke through soft wrist restraint. Pt placed in four point leather restraints for 1.5 hour before pt was intubated for safety and repeat MRI. Pt sedated on Propofol. Since intubation SBP 100-120's without Nipride, MAE, PERL. Pt is easily arousable wean propofol stopped. Lungs are clear and slightly diminished at bases. Suctioned for scant amount of thick yellow secretions. NGT placed for medictions. Pt remians NPO. No stool this shift. Foley with c/y/u. Skin is intact.\n\nPOC: MRI this evening. Extubate . Continue to closely monitor neuro status. Continue to offer emotional support to pt and pt family throughout hospital stay.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-04 00:00:00.000", "description": "Report", "row_id": 1619906, "text": "Update\nO: See carevue flowsheet for specifics.\nPt continues to be sedated on ppfl at 70mcg/kg/min. Attempts to wean dwn ppfl unsuccessful despite haldol 5mg q4h and dilaudid 1mg q4h. Ppfl lifted q4h for neuro exam w pt become very restless and thrashing about in bed. Pt's family present early pm to witness pt restless periods.Family attempts to calm pt when awoken unsuccessful at this time. Pt spont mae but not to cmmand, pserl at 2mm brisk. Htn w sys 170-190/tachy to 120's with wakefulness. Htn/tachy resolved w resedation.\nCV:some st-t wave depression noted, 12 lead ekg done no acute change over last ekg, ck w troponins sent w am labs.\nResp:Remains intub on cpap w peep ^ to 8cm for pao2 84.Copious amts of thick yellow to rust color secretions.Bbs diminish to coarse upper lobes diminish at bases. Sput c&s sent w pan cult for temp over 101.VAP protocol maintained w q4h oral care.\n\nGi: npo ngt to lws w bilious secretions in sm amts.Abd soft, + bowel snds.glucose wnl\n\nGu: foley to gd w qs clear yellow to green tinge urine.U/A & c&s sent.\n\nHeme/ID: hct stable. Tmax 101.2, pan cultured & tylenol given for temp.Cranial incision cl and intact staples no drainage noted.\n\nPsych/Soc/Family: Pt cont w restlessness & agitation when awake req haldol and dilaudid. Family in to visit early pm asking approp questions re: pt neuro exam & cond., fevers. Questions answered and emot support provided to family.\n\nA/P: Pt restlessness persists even on ppfl, ? increas haldol dose in order to wean ppfl prior to wean from vent to extub when pt more fully awake & able to manage secretions.Check cultures for results. Aggressive pulm toilet & vap protocol maintained. Provide emot support to family.Neuro checks q1h.Pcxr to be done this am.Check for results of cardiac enzymes.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-01-04 00:00:00.000", "description": "Report", "row_id": 1619907, "text": "Respiratory Care:\nPt remains intubated and vented. Suctioning new large amts of yellow to rusty secretions. Remains on propofol dose, otherwise is very combative and thrashes about. Peep level increased to 8 earlier for oxygenation. 6am abg much improved. Morning RSBI = 27. Still unsure of plan for today in regards of possible extubation.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-04 00:00:00.000", "description": "Report", "row_id": 1619908, "text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL\nETT IN PLACE. CURRENTLY ON PS 5/8 PEEP .50 AS PER\nCV AND APPEARS COMFORTABLE. ABG C/W A PART. COMP.\nMETABOLIC ALKALOSIS AND STABLE OXYGENATION. SX\nFOR VERY THICK SECRETIONS/ TAN. PT GETS VERY\nAGGITATED WHEN SEDATION TAPERED. POSSIBLE\nEXTUBATION IN NEXT 24-48 HOURS. WILL C/W PS\n5 AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-31 00:00:00.000", "description": "Report", "row_id": 1619895, "text": "focus update note\nAfebrile- heart rate 70-80s nsr- goal sbp < 140, initially pt on nipride gtt, titrating by blood pressure cuff per icu resident - as aline exhibiting fling 40 point difference between cuff pressure and aline. nipride gtt now off since mg po lopressor given.\n\npt went for MRI of Brain and Ct of torso today. neurosurgery spoke with pt and pt family in depth regarding surgery for thursday for removal of probable menigioma.\n\npt neurologically intact- pupils perla 3mm and brisk, pt exhibits good strength in all 4 extemities. follows commands consistently, appropriatley conversive.\n\nresp: lung sounds are clear, pt on r/a o2 sat 95%\n\nGU/GI: pt voiding into urinal approx 400cc q 4 hours, no bm, bowel sounds present, post MRI/CT scans pt tolerating regualr diet well.\n\npt on decadron following fingerstick glucoses q 6 hours, at 1400 fs 161 pt rec'd 4 units regular insulin.\n\nplan: pt to have crani removal of mass on thursday, continue to monitor neuro status, Kssp abp < 140, provide support to family and pt as needed.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-31 00:00:00.000", "description": "Report", "row_id": 1619896, "text": "Nursing Progress Note\nPlease see careview for details.\n\nNeuro: intact. Possibly for OR at 0730 am.\n\nCV: stable, afebrile, nsr. bp < 140 systolic.\n\nPulm: bs clear, room air sat 95-100.\n\nGI: tol po well. nPO after mn, for or.\n\nGU: u/o qs, voiding\n\nEKG, urine for u/a being done.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 1619897, "text": "SICU NPN:\nNEURO: A&Ox3. Pleasant and cooperative. Anxious to have surgery and asking appropriate questions. No neuro deficits noted. OOB with assist to walk around room and using urinal without difficulty. Denies any pain or headache. Pupils 3mm and briskly reactive to light. On dilantin with level pending from am labs.\nCV: Afeb. Although noted to sweat during night which he says he always does. HR 70s-90s SR, no ectopy noted. BP stable with SBP <140. Palp. pedal pulses bilat. IVF NS with 20meq KCL infusing at 75cc/hr.\nRESP: On RA with O2 Sat >95%. LS clear throughout. No SOB.\nGI/GU: Abd. soft with positive bowel sounds. NPO since midnight for possible OR today. No BM. Voiding clear yellow urine in urinal- UA sent.\nSKIN: Intact. Two peripheral IVs intact and patent.\nOTHER: Wife in room visiting. Awaiting OR- checklist started and place in front of chart.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-01 00:00:00.000", "description": "Report", "row_id": 1619898, "text": "Please See Carevue for Specifics.\n\nPt returned from OR at 1840. Craniotomy performed on frontal mass. Prior to OR pt was pleasantly A+OX3, MAE, following commands. After OR pt agitated, speech garbled, oriented to self to place, PERL. SBP on arrival 190's-220's. Received 30mg IV labetalol over 10 minute period, 20mg Iv hydralazine, 0.5mg Ativan. 15 minutes later recieved an additioanl 20mg Iv labetalol. SBP goal less than 140's, awaiting Nipride gtt from Pharm. Lungs are clear, O2 weaned to 3L NC. Abd soft, NPO.\n\nPOC: SBP less than 140, Nipride gtt. Head CT this evening and MRI schedule for tomorrow. Continue to closely monitor neuro status and hemodynamics. COntinue to offer emotional support to pt and pt family.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-07 00:00:00.000", "description": "Report", "row_id": 1619920, "text": "See data, MD notes/orders.\n\nNeuro: Alert, oriented x3. Needs intermitent redirection. MAE, PERRL, follows commands and converses well and with occasional inappropriate responses. Tylenol/percocet prn for HA with good relief.\n\nCV: SR/ST no ectopy, sbp 130's - 160's.\n\nPulm: RA sat >96%, lungs clear bilaterally, respitory effort unlabored.\n\nGU: Uo 45-120cc/hr clear yellow.\n\nGI: Abd soft, bs present, med BM on bedpan. Pt now taking regular diet with good appetite and no dysphagia.\n\nSkin: Surfaces grossly intact, craniotomy staples open to air, clean and dry. left frontal swelling present, left eye orbit ecchymotic. Peripheral pulses palpable.\n\nAct: Seen by PT today, oob to chair x 3. Stood and pivoted this am, now able to take several steps to chair.\n\nSoc: Wife and daughter at bedside most of the day and are encouraged by pts improved mental status.\n\nP: Continue Q2hr neuro checks, reorient prn, continue 1:1 sitter for pt safety. Prn tylenol/percocet as above. Prn ativan for aggitation in smallest dose that is effective. Prn labetelol/hydralazine for sbp >160. Increase activity as tolerated, keep family up to date on poc, validate feelings/concerns. Transfer to step down unit when bed available.\n" }, { "category": "Nursing/other", "chartdate": "2115-12-31 00:00:00.000", "description": "Report", "row_id": 1619894, "text": "Nursing admission note\nPlease see careview for details\n\nAdm from ED at 0315.\nNeuro: nvs stable. For MRI today. ? OR\nCV: Nipride at 1 mcg/kg/min. to maintain sbp<140. afeb.\nPulm: bs clear, room air sats >95.\nGI: NPO, no bm, bs present.\nGU: voiding\n\n" }, { "category": "Nursing/other", "chartdate": "2116-01-06 00:00:00.000", "description": "Report", "row_id": 1619917, "text": "NPN\nPlease see carevue for further details\nExtubated this morning. Was following simple commands, opening eyes. ? seizure this a.m. with eye deviation to the right and BUE jerking movements. Nsurg at bedside. EEG done showing no apparent seizure activity per EEG tech. Dilantin level 8.1 this morning. Dilantin bolus given. Extubated at noon. Tol well. At times agitated and tearful. Frequently apologizing. Haldol discontinued per neurology recs for the possibility of ? reduction of seizure threshold. Ativan prn with min effect. BLSCTA even unlabored. copious secretions this morning while intubated. Aggressive chest PT done. + gag and strong productive cough. Sats 96-98 on 50% face tent. + BS x4 abd soft nt/nd. TF held overnight for extubation. Hold until this evening per team. NSR/ST 80-100s. SBP 130-160s. Lopressor increased to TID. Hydralazine added q6 to maintain SBP goal <160. Foley draining large amounts of urine, green at begining of shift (? r/t propofol) and currently clear yellow. Family at bedside - supportive. SW contact for pt's wife.\nPLAN: Aggressive chest PT and closely monitor respiratory status. Ativan and Haldol (d/w team). Resume TF o/n. Monitor for agitation/restlessness. Provide comfort and support.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-06 00:00:00.000", "description": "Report", "row_id": 1619918, "text": "nursing addendum\nhypertensive to 170s most of the afternoon. Lopressor, Labetalol given with min effect. 10 mg IV Diltiazem given with good effect. HR 90s, SBP 130s. Haldol given x1 for agitation and aggression this afternoon. Family at bedside. Dr. notified of changes in pt's condition. Continue to closely monitor.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-07 00:00:00.000", "description": "Report", "row_id": 1619919, "text": "Nursing progress Note\nPlease see careview for details\n\nNeuro: perl. talking in low voice making it difficult to hear and understand him. expressing desire to call a cab and go home, get OOB to take a shower, etc. Pt is confused and restless, trying to get OOB often, with legs over side rails. Med with ativan several times with transient effect. Bilat wrist restraints to keep him from pulling out ng, iv's. OOB to chair with 2 assists, legs weak when standing.\n\nCV: continues to be hypertensive intermittently, usually when restless. Metoprolol increased to 50 mg po TID, 1st dose at 0600. Hydralazine as ordered with temporary effect. low grade temp. HR nsr to ST when restless.\n\nPulm: bs clear but coarse in right base. NP at 4 l. sats 95-98. Coughing and swallowing.\n\nGI: tube feeds via ng tol well. bowel sounds, medium BM. pt was asking for ice cream, given ice and swallowed well. taking water without difficulty. Pt attempting to pull out ng tube continually, HO agreed to d/c ng. Pt seems more comfortable without it, napping.\n\nGU: u/o amber, qs via foley/ sample sent for lytes, osmo.\n\nactivity: pt OOB to chair with assist x 2, legs weak,\n\nSocial: wife daughter here until 2300, will return this am. family is encouraged by pt's interaction.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-05 00:00:00.000", "description": "Report", "row_id": 1619913, "text": "Nursing note (0700-1900) 16:15\n\n\nNeuro.\nAttempted wean of sedation for possible extubation, Propofol stopped at 12 noon after being given 10mg Haldol, pt seemed to do well, was following commands, opening eyes, moving all four limbs to command. Pt became anxious so was given 1mg Ativan with good effect. Pt gradually became more aggitated, was given a further 1mg of ativan at 2pm with no effect, decision made with MD pt. Now back on propofol at 70mcg/kg and 5mg Haldol Q2hrs.\n\nResp.\nVent settings unchanged, pt has had increased blood tinged secretions this shift requiring Q30min Sxn at times, pt has very strong cough, able to clear secretions to end of ETT. LS coarse to UL's, dim to bases. Tachypnic when aggitated, RR 15-20 when sedate.\n\nCVS.\nRemains in NSR 70-80 unless aggitated, then becomes tachycardic to 110's. BP 95-200 depending on sedation.\n\nGI/GU.\nTF's now re-started as not going to be extubated today, +BS with small soft BM this am.\nFoley patent for clear green urine, pt seems to have large output related to hypertensive episodes.\n\nSocial.\nWife and sister in to visit throughout the day, updated as to condition and plan.\n\nPLAN.\nMonitor response to increase of Haldol.\n?? wean for extubation in am verses discussion about Trach.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-06 00:00:00.000", "description": "Report", "row_id": 1619914, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds coarse suct sm=>mod th bld tinged sput. Pt in NARD on current vent settings; no vent changes required overnoc. Cont PSV.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-06 00:00:00.000", "description": "Report", "row_id": 1619915, "text": "Nursing Progress Note\nPlease see careview for details\n\nNeuro: sedated on Propofol at 50-70 mcg, prop held for neuro exam, pt follows commands, shook his head \"no\" when asked if he head any pain. restless, turning head side to side and moving arms and legs while on propofol at 50 mcg. haldol 5 mg q 4 hrs, ativan 1 mg iv x 2. occasional swings in sbp, from high 80's to 160's. Low sbp appears to be related to iv haldol and ativan.\n\nCV: see neuro. QTC wnl. afebrile, SB when deeply sedated. ST when restless and propofol held.\n\nPulm: bs fairly clear. sx thick yellow/blood tinged. sats 99-100 on 50% with 5 IPS, 5 cpap.\n\nGI: tube feeds at 60/hr. ? hold this am for possible extubation. tol well, bowel sounds present.\n\nGU: u/o qs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2116-01-06 00:00:00.000", "description": "Report", "row_id": 1619916, "text": "RESPIRATORY CARE: PT EXTUBATED TODAY AFTER A SUCCESSFUL\nSBT AND AN RSBI OF ABOUT 50. PROPOFOL OFF AND NOT TOO AGGITATED AND FOLLOWING COMMANDS. RECIEVED HALDOL AND ATIVAN FOR AGGITATION.COUGH AND GAG ARE GOOD/ RAISING THICK BLOOD-TINGED TAN SPUTUM. WILL MONITOR RESPIRATORY STATUS CLOSELY.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-04 00:00:00.000", "description": "Report", "row_id": 1619909, "text": "Nursing note (0700-1900) 16:50.\n\nNeuro.\nRemains sedated on 70mcg/kg of Propofol, requires haldol also to remain calm, given 1mg Dilaudid this am with little effect.\nbecomes very aggitated when sedation stopped, opens eyes to painful stimuli/speach when sedation off. Not following commands as yet.\n\nResp.\nRemains vented on %, no repeat abg's done by team. Sxn'd for large amounts of thick secretions, initially rusty coloured, now tan/yellow.\nStarted on Vanc and Zosyn for ? aspiration PNA to Right lower lobe.\n\nCVS.\nPt becomes tachy and hypertensive when awake, settles after sedation back on. Team aware of ST depression, was present on previous EKG's also.\n\nID.\nPt now a-febrile, awaiting further culture results.\n\nGI/GU.\nTF's started, advanced to 20cc/hr, tolerating well at present.\nFoley patent for adequate amounts of urine, has periods of large autodiuresis (400cc/hr).\n\nSocial.\nWife present most of day, updated as to condition and plan.\n\nPLAN.\nIf remains fairly stable overnight, team may plan on extubation in am.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-05 00:00:00.000", "description": "Report", "row_id": 1619910, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds rhonchi throughout improve with freq suct sm=>mod th bld tinged sput. Pt in NARD on current vent settings; no vent changes made overnoc. Cont PSV/wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-05 00:00:00.000", "description": "Report", "row_id": 1619911, "text": "Nursing Progress Note\nPlease see careview for details.\n\nNeuro: sedated on propofol, up to 100 mcg for rotation of ETT, bp 80's, with return to baseline after prop held and resumed at 30-50mcg/kg/min. PERL, 3 mm, moving all extremities, purposeful movement toward ETT, but not following commands, even after Prop off for 30 mins. Restless despite prop, med with haldol q 4 hrs (qtc within normal limits) and ativan 1 mg x 2 tonight.\n\nCV: decrease in SBP only after higher propofol dose used to sedate pt for ETT rotation. bp return to baseline with propofol off for 30 mins. low grade temp. HR nsr-st.\n\nPulm: bs clear to coarse, sx copiuos amts pink tinged. Plan for the AM is to stop propofol and extubate when pt awake.\n\nGI: tube feeds up to 40/hr, tol well, stopped and d/cd for possible extubation this am. passing flatus.\n\nGU: u/o green tinged, qs to 900cc for am. will monitor cloisely for signs of DI.\n\nIncison: clean and dry, staples intact.\n" }, { "category": "Nursing/other", "chartdate": "2116-01-05 00:00:00.000", "description": "Report", "row_id": 1619912, "text": "RESPIRATORY CARE: PT REMAINS INTUBATED W/ A 7.5 ORAL\nETT IN PLACE. CURRENTLY ON A PS 5/5 .50 AND APPEARS\nCOMFORTABLE W/ AN RSBI 50-60. SX FOR LGE AMTS OF\nTHICK BLOOD-TINGED SPUTUM. PLAN AS PER SICU TEAM IS\nTO INCREASE HALDOL/ ATIVAN AND THEN TURN OFF HIS\nPROPOFOL TO DETERMINE WHETHER PT WILL BE CALM\nENOUGH TO EXTUBATE. PRECEDEX ALSO BEING CONSIDERED\nFOR AGGITATION BY SICU-TEAM. PT'S COUGH AND GAG REFLEX\nARE GOOD AND IS ABLE TO FOLLOW SOME SIMPLE COMMANDS.\nPLAN IS TO PROBABLY EXTUBATE PT LATER IN SHIFT TODAY.\n" }, { "category": "ECG", "chartdate": "2115-12-31 00:00:00.000", "description": "Report", "row_id": 303838, "text": "Sinus rhythm. Non-specific inferolateral ST segment sagging. No prior\ntracings are available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2116-01-04 00:00:00.000", "description": "Report", "row_id": 303609, "text": "Artifact is present. Sinus rhythm. Diffuse ST-T wave changes which may be\nrelated to ischemia or myocardial infarction. Compared to the previous tracing\nST-T wave changes are slightly worse.\n\n" }, { "category": "ECG", "chartdate": "2116-01-02 00:00:00.000", "description": "Report", "row_id": 303610, "text": "Sinus tachycardia. Diffuse ST-T wave changes. Compared to the previous\ntracing of the sinus rate is faster.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2189-12-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1162310, "text": " 12:02 PM\n CHEST (PA & LAT) Clip # \n Reason: Interval changes, infectious process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61F w/CHF & metastatic pancreatic neuroendocrine carcinoma, s/p 6 cycles of\n chemo, XRT and TACE who is admitted s/p TACE . O2 req and SOB w/hydration,\n productive cough, afebrile.\n REASON FOR THIS EXAMINATION:\n Interval changes, infectious process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased oxygen requirement and shortness of breath\n in a patient with metastatic pancreatic neuroendocrine carcinoma.\n\n PA and lateral upright chest radiographs were reviewed in comparison to\n and CT torso from .\n\n Cardiomegaly is pronounced, unchanged. Mediastinal contours are stable.\n There is interval improvement of pulmonary edema. There is more focal right\n suprahilar opacity that is new since the prior studies and might represent\n interval development of infectious process versus aspiration. The lung bases\n are essentially unremarkable with small amount of pleural effusion potentially\n can be present. There is no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164591, "text": " 5:25 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any resolving pulmonary process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with unlcear respiratory failure s/p intubation\n REASON FOR THIS EXAMINATION:\n any resolving pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Respiratory failure, intubated patient.\n\n Comparison is made with prior study performed a day earlier.\n\n ET tube tip is 6.3 cm above the carina, the cuff is overdistended, appears to\n be high, could be as high as in the hypopharynx. There are low lung volumes.\n Enlargement of the cardiac silhouette is unchanged. Multifocal opacities have\n worsened in the right lung and minimally improved in the left lung, likely\n infectious in etiology. There is no pneumothorax. Right PICC tip appears to\n be in the right axillary vein.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-08 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1162070, "text": " 8:06 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Please eval liver s/p TACE for distribution of ethiodol\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 yo F w/ PMH of metastatic neuroendocrine CA s/p TACE \n REASON FOR THIS EXAMINATION:\n Please eval liver s/p TACE for distribution of ethiodol\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AJy TUE 10:45 AM\n extensive hyperdense ethiodol newly present in left lobe, concentrated at\n sites of previously noted enhancing lesions, c/w TACE. there is also new\n hyperdense material noted at the bilateral lung bases likely reflecting\n presence of intrahepatic portosystem shunt. no further extrahepatic ethiodol\n deposition noted. underlying fatty liver noted. known pancreatic mass and\n numerous hepatic mets not well seen without contrast.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old female with metastatic neuroendocrine carcinoma\n status post chemoembolization, . Evaluate Ethiodol distribution.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast imaging of the abdomen was performed. Multiplanar\n reformats were prepared and reviewed.\n\n CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST:\n\n There is dependent atelectasis at the bilateral lung bases without effusion or\n focal consolidation to suggest pneumonia. Some hyperdensity is newly seen at\n the lung bases, which most likely reflects systemic ethiodol distribution\n secondary to small intrahepatic portosystemic shunt. Coronary calcifications\n are noted.\n\n Hyperdense material within multiple right lobe liver lesions is stable from\n , compatible with sequelae of prior chemoembolization.\n Additionally, there is newly noted extensive hyperdense material within the\n left lobe of the liver and caudate lobe, most concentrated at the sites of\n previously noted arterially-enhancing lesions, compatible with recent left\n hepatic artery chemoembolization. Other than the aforementioned hyperdensity\n at the lung bases, there is no definite evidence of extrahepatic Ethiodol\n uptake. Hyperdense material dependently within stomach appears intraluminal,\n most likely reflecting ingested medication.\n\n The spleen, adrenal glands, and kidneys remain unremarkable. Contrast in the\n collecting system reflects recent angiography. There are no contour-altering\n renal mass lesions. The pancreatic tail is again noted to be atrophic. The\n known pancreatic head mass is not well appreciated without intravenous\n contrast. Stranding inferior to the pancreatic head is noted, possibly\n reflecting the sequelae of prior pancreatitis. There is a metallic common bile\n duct stent in standard position, with left lobe pneumobilia compatible with\n (Over)\n\n 8:06 AM\n CT ABDOMEN W/O CONTRAST Clip # \n Reason: Please eval liver s/p TACE for distribution of ethiodol\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n stent patency.\n\n The stomach, duodenum, and intra-abdominal loops of small and large bowel are\n normal in caliber and configuration. There is no bowel distention or bowel\n wall thickening. There is no free fluid or free air identified.\n\n BONE WINDOWS: No suspicious lytic or sclerotic osseous lesions identified.\n\n IMPRESSION:\n 1. Extensive Ethiodol uptake within the left lobe of the liver, most\n concentrated at the site of previously noted arterially-enhancing lesions seen\n on .\n\n 2. Hyperdensity at the lung bases is most compatible with Ethiodol, likely\n secondary to a small intrahepatic porto-systemic shunt. There is no further\n evidence of extrahepatic Ethiodol uptake.\n\n 3. Common bile duct stent in standard position. Left lobe pneumobilia is\n compatible with stent patency. Known pancreatic head mass is not well\n appreciated given lack of intravenous contrast.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164497, "text": " 3:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Re- evaluation of ET tube placement.\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with respiratory failure of unknown etiology had adjustment\n of ET tube.\n REASON FOR THIS EXAMINATION:\n Re- evaluation of ET tube placement.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf TUE 7:11 PM\n 1. Endotracheal tube 7.1 cm above the carina with slightly overinflated cuff.\n\n 2. Unchanged right greater than left dense consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Reevaluation of endotracheal tube placement.\n\n TECHNIQUE: Semi-upright portable radiograph of the chest compared to the\n study of .\n\n COMPARISON: Chest radiograph \n\n FINDINGS: Endotracheal tube ends 7.1 cm above the carina. Nasogastric tube\n courses in the stomach and out of view. Right PICC line ends in unclear\n location with tip obscured by overlying objects. The extensive dense bilateral\n right greater than left alveolar consolidation is unchanged from the prior\n study. No pneumothorax or definite pleural effusion identified.\n\n IMPRESSION:\n 1. Endotracheal tube 7.1 cm above the carina with slightly overinflated cuff.\n This was discussed with on the team at 1645 on \n by Dr. .\n 2. Unchanged right greater than left dense consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164498, "text": ", S. MED 3:08 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Re- evaluation of ET tube placement.\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with respiratory failure of unknown etiology had adjustment\n of ET tube.\n REASON FOR THIS EXAMINATION:\n Re- evaluation of ET tube placement.\n ______________________________________________________________________________\n PFI REPORT\n 1. Endotracheal tube 7.1 cm above the carina with slightly overinflated cuff.\n\n 2. Unchanged right greater than left dense consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163444, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for interval changes\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with CHF and pna, now with worsening oxygen requirement\n REASON FOR THIS EXAMINATION:\n pls eval for interval changes\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf WED 1:37 PM\n Worsening right greater than left opacifications, consistent with pneumonia\n versus edema.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF and pneumonia.\n\n TECHNIQUE: Portable radiograph of the chest.\n\n COMPARISON: Chest radiographs, most recently and chest CT,\n .\n\n FINDINGS: Right PICC is seen, likely in the lower SVC. Worsening aeration of\n the right lung is seen with increased prominence of the air bronchograms,\n suggesting worsening infection or edema. Aeration of the left lung is\n unchanged with persistent opacities, though less severe than on the right.\n Cardiomediastinal silhouette is unchanged. There is no pneumothorax.\n\n IMPRESSION: Worsening right greater than left opacifications, consistent with\n pneumonia versus edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163445, "text": ", M.F. OMED 11R 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pls eval for interval changes\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with CHF and pna, now with worsening oxygen requirement\n REASON FOR THIS EXAMINATION:\n pls eval for interval changes\n ______________________________________________________________________________\n PFI REPORT\n Worsening right greater than left opacifications, consistent with pneumonia\n versus edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-23 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1164697, "text": " 2:44 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Status of infiltrate\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n Field of view: 38\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with pnemonia and sepsis with intersitial disease on CXR\n REASON FOR THIS EXAMINATION:\n Status of infiltrate\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia, sepsis, interstitial lung disease on chest x-ray,\n evaluate pulmonary opacities. Background of neuroendocrine tumor with\n metastases to liver, treated with transarterial chemoembolization.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n without intravenous or oral contrast. Images are presented for display in the\n axial plane at 1.25- and 5-mm collimation. Multiplanar reformation images are\n also submitted for review.\n\n COMPARISON: CT chest dated .\n\n FINDINGS: The endotracheal tube is high lying and its balloon is\n overdistended in the laryngopharynx. The distal tip is 3 cm above optimal\n position.\n\n The nasogastric tube is in satisfactory position. The tip of the right\n peripherally inserted central venous catheter lies at the mid superior vena\n cava.\n\n There is no pathologic enlargement of the supraclavicular or axillary lymph\n nodes. The largest node is in the mediastinum measures 11 mm at the right\n paratracheal station. Atherosclerotic calcification of the aortic arch is\n mild. Right atrial enlargement is mild. Hypodensity of the blood pool within\n the heart suggests anemia. Mitral annulus calcification is mild. Bilateral\n small pleural effusions have developed since .\n\n The central airways are patent, although as previously mentioned, the\n laryngopharynx is distended by the endotracheal tube cuff. Below the level of\n the endotracheal tube tip, the aorta is tortuous and deviates to the right.\n\n Diffuse ground-glass opacity affecting both lungs, sparing only the apices and\n costophrenic angles has worsened significantly since .\n\n The study is not tailored for subdiaphragmatic evaluation, only to confirm\n small volume ascites, an irregular liver contour, multiple liver lesions\n opacified with Ethiodol (used for chemoembolization), a spleen at the upper\n limits of normal in size (13cm), and two 9-mm celiac lymph nodes, unchanged\n since .\n\n Anterior osteophytosis of the lower thoracic spine is moderately severe.\n (Over)\n\n 2:44 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Status of infiltrate\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n Field of view: 38\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Diffuse ground-glass opacity which has worsened since , while drug\n reaction is still considered possible, acute interstitial pneumonia/ARDS is\n now more likely given the diffuse involvement.\n 2. High-lying endotracheal tube which is 3 cm above optimal location, with\n concomitant overdistended endotracheal tube cuff within the laryngopharynx.\n\n Dr. , clinical team member, at approximately 1600 hours,\n .\n\n" }, { "category": "Radiology", "chartdate": "2189-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164378, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval intrapulmonary change\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with neuroendocrine ca intubated for ? PNA vs. pneumonitis\n REASON FOR THIS EXAMINATION:\n interval intrapulmonary change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intubation for possible pneumonia.\n\n FINDINGS: In comparison with the study of , allowing for some\n differences in technique, there is probably little change in the diffuse\n pulmonary consolidation that could reflect ARDS, chemical pneumonitis, and\n multifocal pneumonia. The tip of the endotracheal tube lies approximately 5.5\n cm above the carina. Nasogastric tube again extends well into the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164909, "text": " 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening reticular disease\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with NSIP vs ARDS based upon chest CT after chemo\n REASON FOR THIS EXAMINATION:\n worsening reticular disease\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 10:54 AM\n Unchanged right greater than left opacifications. Satisfactory position of\n monitoring and support devices.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: NSIP versus ARDS based upon chest CT; after chemo, assess for\n wirsebubg retucykar dusease disease.\n\n COMPARISON: Chest radiograph, .\n\n TECHNIQUE: Semi-upright portable radiograph of the chest.\n\n FINDINGS: Left PICC line terminates in the mid-to-lower SVC. Endotracheal\n tube ends 2.2 cm above the carina. Nasogastric tube courses into the stomach\n and out of view. Metallic biliary stent is seen. Diffuse right greater than\n left opacification is unchanged without pleural effusion or pneumothorax.\n Cardiomediastinal silhouette is also unchanged.\n\n IMPRESSION: Unchanged right greater than left opacifications. Satisfactory\n position of monitoring and support devices.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164818, "text": " 10:41 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ET placement (please reposition patient for optimal view of\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with intersitial pna\n REASON FOR THIS EXAMINATION:\n ET placement (please reposition patient for optimal view of ET tube)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endotracheal tube placement.\n\n FINDINGS: The tip of the endotracheal tube now measures approximately 2.2 cm\n above the carina. No change in the appearance of the heart and lungs.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164910, "text": ", S. MED 8:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening reticular disease\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with NSIP vs ARDS based upon chest CT after chemo\n REASON FOR THIS EXAMINATION:\n worsening reticular disease\n ______________________________________________________________________________\n PFI REPORT\n Unchanged right greater than left opacifications. Satisfactory position of\n monitoring and support devices.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164518, "text": " 4:23 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: evaluation for tube adjustment.\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with respiratory failure had ET tube adjustment\n REASON FOR THIS EXAMINATION:\n evaluation for tube adjustment.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 61-year-old female patient with respiratory failure, had ETT\n adjustment, evaluate position.\n\n FINDINGS: AP single view of the chest again obtained with patient in\n semi-upright position demonstrates moderate degree of patient rotation towards\n the right, similar as before. The ETT appears to be in unchanged position,\n which indicates rather large distance between the tip of the ETT and the\n carina of approximately 6-7 cm. No pneumothorax has developed. No indwelling\n other tubes are seen. There is a right-sided PICC line which projects rather\n much to the right related to patient's rotation. The right-sided PICC line\n reaches clearly within the heart shadow and thus reaches the upper portion of\n the right atrium. This finding existed already on the first study of the same\n date, . Withdrawal by approximately 5 cm is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163989, "text": " 5:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change in cardiopulmonary proce\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with pancreatic neuroendocrine CA metastatic to the liver and\n diastolic CHF, with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change in cardiopulmonary processes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:51 A.M., \n\n HISTORY: Neuroendocrine pancreatic carcinoma metastatic to the liver.\n Diastolic CHF. Respiratory failure.\n\n IMPRESSION: AP chest compared to through 19:\n\n Pulmonary consolidation has been severe in the right lung since .\n Today, it has progressed dramatically in the left upper lobe. Whether this is\n pneumonia or pulmonary hemorrhage is radiographically indeterminate. Sparing\n of left lower lobe suggests that it is not edema. Severe cardiomegaly\n persists along with mediastinal and hilar vascular engorgement. Tip of the\n endotracheal tube is above the upper margin of the clavicles, no less than 3\n cm from the carina. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1162017, "text": " 7:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pulmonary edema?\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with new O2 req post TACE\n REASON FOR THIS EXAMINATION:\n Pulmonary edema?\n ______________________________________________________________________________\n WET READ: SPfc MON 8:42 PM\n Mild bilateral, right worse than left, interstitial edema is new. Mild\n cardiomegaly is unchanged. Note is made of left basilar subsegmental\n atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 7:31 P.M. ON \n\n HISTORY: Oxygen requirement, possible pulmonary edema.\n\n IMPRESSION: AP chest compared to .\n\n The pulmonary vasculature is now engorged, and cardiomediastinal silhouette\n have increased in size, and new mild interstitial edema all attests to cardiac\n decompensation. Pleural effusion, if any, is minimal. No pneumothorax. Dr.\n was paged.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163815, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any change in pulmonary process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic neuroendocrine pancreatic carcinoma with\n extenisve Right airspace disease\n REASON FOR THIS EXAMINATION:\n any change in pulmonary process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SHSf FRI 11:55 AM\n Slightly improved right greater than left diffuse hazy opacities.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic neuroendocrine pancreatic carcinoma with extensive\n right airspace disease, assess for interval change.\n\n TECHNIQUE: Portable semi-upright radiograph of the chest.\n\n COMPARISON: Chest radiograph, .\n\n FINDINGS: Endotracheal tube ends 2.3 cm above the carina. Nasogastric tube\n courses into the stomach and out of view. Right PICC line terminates in the\n mid-to-lower SVC.\n\n Right greater than left opacification is again seen with improved aeration\n bilaterally. Otherwise, cardiomediastinal silhouette is unchanged, and no\n pneumothorax is seen.\n\n IMPRESSION: Slightly improved right greater than left diffuse hazy opacities.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163816, "text": ", MED 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: any change in pulmonary process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic neuroendocrine pancreatic carcinoma with\n extenisve Right airspace disease\n REASON FOR THIS EXAMINATION:\n any change in pulmonary process\n ______________________________________________________________________________\n PFI REPORT\n Slightly improved right greater than left diffuse hazy opacities.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-14 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1163187, "text": " 3:33 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval interval changes s/p TACE, ethiodol at lung base\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 yo F w/ PMH of metastatic neuroendocrine CA w/hypoxia and persistent O2\n requirement, s/p TACE.\n REASON FOR THIS EXAMINATION:\n Please eval interval changes s/p TACE, ethiodol at lung bases, R peri-hilar\n infiltrate\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXKc MON 5:14 PM\n 1. Interval development of diffuse ground-glass opacities throughout the\n lungs, most severe within the upper lobes bilaterally. The differential\n diagnosis includes infection (including atypical organisms such as PCP and\n fungal if immunocompromised), pulmonary edema, or pulmonary hemorrhage.\n 2. Previously noted hyperdensities in the lung bases related to Ethiodol are\n less apparent on this study.\n 3. Extensive Ethiodol uptake within the left lobe of the liver\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic neuroendocrine cancer presenting with hypoxia and\n persistent oxygen requirement, status post TACE. Evaluate for interval\n changes, with previous CT abdomen noting Ethiodol at the lung bases. Recent\n chest radiographs noted right perihilar infiltrate.\n\n COMPARISON: Chest radiograph and CT abdomen and CT torso .\n\n TECHNIQUE: MDCT of the chest was performed without contrast. Axial images\n were displayed at 1.25-mm and 5-mm collimation. Coronal and sagittal\n reformations were obtained.\n\n FINDINGS:\n\n The heart is normal in size. Mitral annular calcifications are noted.\n Atherosclerotic calcifications of the aortic arch are present. Low\n attenuation of the intracardiac blood pool suggests underlying anemia. There\n is a right central venous catheter, with tip terminating within the SVC.\n\n A right paratracheal lymph node is mildly enlarged measuring 15 mm, which is\n larger from prior study, and is likely reactive.\n\n The airways are patent to the subsegmental level.\n\n There is interval development of diffuse ground-glass airspace opacities, most\n severely involving the upper lobes. These findings are new compared to a CT\n Torso from .\n\n The previously seen hyperdense foci within the lower lobes suggestive of\n extra-hepatic Ethiodol are less apparent on this study. The previously seen\n (Over)\n\n 3:33 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: Please eval interval changes s/p TACE, ethiodol at lung base\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n dense consolidation of the lower lobes are also improved.\n\n There is no pleural or pericardial effusion.\n\n This examination is not tailored for subdiaphragmatic evaluation. Extensive\n Ethiodol uptake within the left lobe of the liver is again noted.\n\n Osseous structures reveal no suspicious lesion.\n\n IMPRESSION:\n 1. Interval development of diffuse ground-glass opacities throughout the\n lungs, most severe within the upper lobes bilaterally. The differential\n diagnosis includes infection (including atypical infections from PCP or fungal\n if the patient is immunocompromised), pulmonary edema, and pulmonary\n hemorrhage.\n 2. Previously seen hyperdense foci in the lung bases felt to represent\n extra-hepatic Ethiodol are less apparent on this study.\n 3. Extensive Ethiodol uptake within the left lobe of the liver.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164786, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: status of pulmonary infiltrates\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with pnemonia/sepsis\n REASON FOR THIS EXAMINATION:\n status of pulmonary infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Pneumonia and sepsis, to assess for change.\n\n FINDINGS: In comparison with the study of , the tip of the endotracheal\n tube now measures only 1.1 cm and it should be pulled back approximately 2 cm.\n Continued low lung volumes with unchanged enlargement of the cardiac\n silhouette. Multifocal areas of opacification in the right lung again are\n consistent with pneumonia.\n\n IMPRESSION:\n Low ET tube. This information was discussed with the resident on call. Some\n of this apparent low position may reflect the low position of the clavicles\n and the patient leaning forward. A repeat study will be obtained with the\n patient appropriately positioned to determine the true relationship of the ET\n tube with the carina.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-06 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1161795, "text": " 12:25 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic neuroendocrine carcinoma\n REASON FOR THIS EXAMINATION:\n Infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL VIEWS OF THE CHEST\n\n REASON FOR EXAM: Preop evaluation. Metastatic neuroendocrine carcinoma.\n\n Comparison is made with prior study of .\n\n Cardiomegaly is stable. Aside from linear atelectasis in the left base, the\n lungs are clear. There is no pneumothorax or pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-07 00:00:00.000", "description": "EA ADD'L VESSEL AFTER BASIC A-GRAM", "row_id": 1161965, "text": " 2:27 PM\n CHEMOEMBO LIVER Clip # \n Reason: Can you please chemo-embolize left hepatic lobe?\n Contrast: OPTIRAY Amt: 75\n ********************************* CPT Codes ********************************\n * EMBO NON NEURO INITAL 3RD ORDER ABD/PEL/LOWER *\n * -53 INCOMPLETE/UNSCUCCESSFUL INITAL 3RD ORDER ABD/PEL/LOWER *\n * -59 DISTINCT PROCEDURAL SERVICE VISERAL SEL/SUPERSEL A-GRAM *\n * EA ADD'L VESSEL AFTER BASIC A- TRANCATHETER EMBOLIZATION *\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 *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with extensive metastatic disease to the liver from\n pancreatic neuroendocrine carcinoma primary.\n REASON FOR THIS EXAMINATION:\n Can you please chemo-embolize left hepatic lobe?\n ______________________________________________________________________________\n FINAL REPORT\n MEDICAL HISTORY: 60-year-old woman with extensive metastatic disease from\n pancreatic neuroendocrine tumor requires chemoembolization of the left lobe of\n liver.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure.\n Dr. , the attending radiologist, was present throughout the procedure.\n\n PROCEDURE:\n 1. Common hepatic artery and left hepatic artery arteriogram.\n 2. Transarterial chemoembolization of the left lobe of liver.\n 3. Angio-Seal closure device deployment to the right common femoral artery\n access site.\n\n ANESTHESIA: Moderate sedation was provided by administering divided doses of\n Versed (1 mg) and fentanyl (50 mcg) throughout the total intraservice time of\n 1 hour 10 minutes during which the patient's hemodynamic parameters were\n continuously monitored.\n\n PROCEDURE: Informed consent was obtained in the outpatient clinic outlining\n the risks and benefits of the procedure involved. Following this, the patient\n was brought to the angiography suite and placed supine on the imaging table.\n The right groin was prepped and draped in the usual sterile fashion. A\n preprocedure huddle and timeout were performed as per protocol.\n\n Fluoroscopy was used to identify the right femoral head and optimal arterial\n access point. Following administration of 1% lidocaine to the skin, the right\n common femoral artery was accessed with a micropuncture needle. An 0.018\n nitinol wire was advanced into the common iliac artery. Following\n confirmation of satisfactory arterial access level on fluoroscopy, the needle\n was removed and replaced with a 4 French micropuncture sheath. The inner\n dilator and nitinol wire were removed and wire advanced into the\n lower aorta. The 4 French sheath was exchanged for a 5 French vascular access\n (Over)\n\n 2:27 PM\n CHEMOEMBO LIVER Clip # \n Reason: Can you please chemo-embolize left hepatic lobe?\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n sheath. The sheath was attached to continuous heparinized saline sidearm\n flush.\n\n A 5 French C2 Glide catheter was advanced over the wire and formed in\n the aorta. The catheter was used to selectively cannulate the celiac axis. A\n digital subtraction arteriogram was performed at this point, demonstrating\n multiple arterial enhancing masses. Through this catheter, a Renegade high-\n flow microcatheter with guiding transcend 0.018 wire was used to selectively\n cannulate the left hepatic artery. Digital subtraction arteriograms were\n performed at this point and thoroughly evaluated. Chemotherapeutic was\n administered via the microcatheter under continous flouroscopic guidance. The\n total chemotherapy dose was 60 mg of doxorubicin, with 20 mg of lipoidol. In\n addition, 20 mL of intra-arterial lidocaine was administered. Following\n administration of chemotherapeutic , one and a half vials of 100-300\n microspheres were injected. All injections were performed under continuous\n fluoroscopic guidance. Satisfactory angiographic result was achieved. The\n microcatheter and glide catheter were removed over the wire. A 6 French\n Angio-Seal vascular closure device was deployed at the right common femoral\n artery access point and good hemostasis was achieved. A sterile dressing was\n applied. There were no immediate complications.\n\n FINDINGS:\n 1. There is conventional celiac axis anatomy as demonstrated on previous\n arteriograms.\n 2. Common hepatic artery arteriogram demonstrates multiple arterially\n enhancing masses throughout both lobes of liver.\n 3. The left hepatic artery arteriogram confirmed large enhancing masses in\n the left lobe of liver, which was successfully targeted with the\n chemotherapeutic , with 60 mg of doxorubicin, 20 mL of lipoidol, and 20\n mL of intra-arterial lidocaine, and one and a half vials of 100-300 micron\n Embospheres administered.\n\n IMPRESSION: Satisfactory left hepatic artery chemoembolization\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163704, "text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: any change in pulmonary process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic neuroendocrine pancreatic carcinoma with\n extenisve Right airspace disease\n REASON FOR THIS EXAMINATION:\n any change in pulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n DATE: .\n\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 61-year-old female patient with metastatic neuroendocrine\n pancreatic carcinoma with extensive right airspace disease. Evaluate for\n possible change in pulmonary process.\n\n AP single view of the chest has been obtained with patient in sitting\n semi-upright position. Comparison is made with the next preceding similar\n study dated . Position of ETT has been adjusted and is now\n terminating in the trachea 3 cm above the level of the carina. Position of NG\n tube unchanged. No pneumothorax has developed. Previously described diffuse\n hazy infiltrates more marked on right than on left appear unchanged.\n\n IMPRESSION: Stable findings, no evidence of new abnormalities. Well adjusted\n position of ETT.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164085, "text": " 4:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval cardiopulmonary changes\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with pancreatic neuroendocrine CA metastatic to the liver and\n diastolic CHF, with respiratory failure, intubated\n REASON FOR THIS EXAMINATION:\n interval cardiopulmonary changes\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:59 A.M., \n\n HISTORY: Pancreatic neuroendocrine carcinoma metastatic to the liver.\n Diastolic CHF and respiratory failure.\n\n IMPRESSION: AP chest compared to through :\n\n Severe pneumonia of right lung unchanged for several days. Mild pulmonary\n edema, best seen in the left mid lung, which developed since , is\n stable since :\n\n Tip of the endotracheal tube is 2 cm above the upper margin of the clavicles,\n and measures 3 cm from the carina. I would advance the tube to the upper\n margin of the clavicles.\n\n Moderate cardiomegaly unchanged. Pleural effusions are small, if any. No\n pneumothorax. Nasogastric tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165502, "text": " 3:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with neuroendocrine tumor with hypoxic respiratory failure\n and bilateral infiltrates\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypoxic respiratory failure.\n\n AP chest radiograph was compared to prior study obtained at p.m.\n\n The ET tube tip continues to be very low, impinging the carina and pointing\n towards the right main bronchus and should be repositioned.\n Communicated to the clinical team\n\n" }, { "category": "Radiology", "chartdate": "2189-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164213, "text": " 9:55 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Please repeat CXR given prior film's position reassess intra\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with neuroendocrine ca intubated for ? pneumonia vs.\n pneumonitis\n REASON FOR THIS EXAMINATION:\n Please repeat CXR given prior film's position reassess intrapulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Neuroendocrine carcinoma, respiratory distress with subsequent\n intubation. Evaluate for pneumonia versus pneumonitis.\n\n COMPARISON: Multiple prior radiographs dated back to and most\n recently .\n\n FINDINGS: Diffuse pulmonary opacity is relatively unchanged since the most\n recent radiograph at , 04.46 hours. Moderate cardiomegaly is\n unchanged. The endotracheal tube tip is now 1 cm above optimal position at\n the level of the clavicular heads, it also closely abuts the left lateral wall\n of the trachea, at which point the trachea abruptly courses to the right. A\n nasogastric tube is in satisfactory position.\n\n IMPRESSION: Diffuse pulmonary consolidation, adut respiratory distress\n syndrome, chemical pneumonitis and multifocal pneumonia are diagnostic\n possibilities.\n\n The tracheostomy tube tip is 1 cm above optimal position, it also closely\n abuts the left lateral margin of the trachea, below which there is an acute\n angulation to the right, which may impact on ventilation. This result was\n communicated to Dr. at 11:45 hours on .\n\n" }, { "category": "Radiology", "chartdate": "2189-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164467, "text": " 12:56 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for ET tube placement\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with ETT adjustment\n REASON FOR THIS EXAMINATION:\n eval for ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 61-year-old female patient with endotracheal tube adjustment.\n Assess position.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position. Comparison is made with the next preceding\n similar study obtained seven hours earlier during the same day. The ETT\n terminates rather high in the trachea. The distance between the tip and the\n carina measures 6 cm. No pneumothorax has developed. An NG tube reaches far\n below the diaphragm as before. Extensive infiltrates again most marked in the\n right hemithorax. Diffuse haze favors no aeration of the right lung supported\n also by the mediastinal shift towards the right seen on multiple previous\n examinations as well. No significant interval change since the next preceding\n study short of that the ETT terminates in the trachea about 3 cm higher than\n before.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-16 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1163482, "text": " 10:18 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: eval for DVT\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with pancreatic CA and acute hypoxemia;please perform\n portable study as patient is clinically unstable\n REASON FOR THIS EXAMINATION:\n eval for DVT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 61-year-old woman with pancreatic cancer and acute\n hypoxemia. Requires evaluation for DVT in bilateral lower limbs.\n\n TECHNIQUE: Bilateral lower extremity evaluation with ultrasound, Doppler and\n spectral waveforms was obtained using 8 MHz transducer. Color and -scale\n images were obtained and available for viewing.\n\n FINDINGS: On the available images, the findings are:\n\n The deep veins of bilateral lower extremity, namely the common femoral vein,\n the superficial femoral vein, the popliteal vein, the peroneal and the\n posterior tibial veins proximally in the calf region are patent, show normal\n caliber, compressibility, and phasicity. On spectral wave Doppler, good\n augmentation and phasicity waves are noted. There is no evidence of acute or\n chronic thrombus at this time .\n\n IMPRESSION: No evidence of deep venous thrombosis in the bilateral lower\n extremity deep veins on the available images at the time of the study.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165220, "text": " 4:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with PNA v. pneumonitis\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient with pneumonia versus\n pneumonitis.\n\n Portable AP chest radiograph was compared to and several prior\n chest radiographs. The ET tube tip is 2.2 cm above the carina but the\n patient's neck is in flexion . There is no change in the cardiomediastinal\n silhouette and extensive parenchymal consolidations since ,\n except for left upper lobe worsening is noted. On the other hand, when\n compared to , overall worsening of the entire involvement of the\n lungs is present. The NG tube and the right PICC line are in unchanged\n position.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163579, "text": " 7:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ET tube placement\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with hypoxic respiratory failure s/p intubation.\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n WET READ: JBRe WED 9:08 PM\n ETT ends 1 cm above the carina. Unchanged diffuse bilateral (R>L) lung\n opacities (DDx. multifocal PNA vs. edema vs. hemorrhage).\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Hypoxic respiratory failure, post intubation.\n\n Comparison is made with prior study performed the same day earlier in the\n morning.\n\n ET tube tip is low, it is only 1 cm above the carina, can be withdrawn a\n couple of centimeter to more standard position. Cardiomediastinal silhouette\n is partially obscured by the lung abnormalities. Right PICC remains in place.\n NG tube tip is out of view below the diaphragm. Diffuse bilateral, right\n greater than left opacities are unchanged. Differential diagnosis is\n pneumonia versus edema . There is no evidence of pneumothorax, pleural\n effusions, or new lung abnormalities.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1164178, "text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluation of pumonary process\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with respiratory failure unclear infectious vs. chemo induced\n pneumonitis.\n REASON FOR THIS EXAMINATION:\n Evaluation of pumonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure, background of metastatic neuroendocrine\n tumor. Treated with chemoembolization.\n\n Evaluate for pneumonia versus chemotherapy-induced pneumonitis.\n\n COMPARISON: Radiographs dating back to and most recently .\n\n FINDINGS: Diffuse ground-glass opacity in both lungs has slightly improved\n since , particularly in the left lung. There is no evidence of\n effusion or new consolidation. Moderate cardiomegaly is unchanged. The tip\n of the nasogastric tube is not included in the field of view of this\n radiograph but appears to be well below the diaphragm. The tip of the\n endotracheal tube is 5 cm from the carina and 2 cm above optimal position.\n\n IMPRESSION:\n 1. Persistent diffuse ground-glass opacity, mild interval improvement in the\n left lung; a diffuse drug-induced pneumonitis or multifocal pneumonia are\n considered possible.\n\n 2. Malposition of endotracheal tube which should be advanced by approximately\n 2 cm. A subsequent radiograph at 10.27 hours demonstrated the tube tip 1cm\n above optimal position and this was communicated to Dr , clinical team\n member, at approximately 11.30 hours.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1163000, "text": " 3:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: s/p r 40cm picc\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with ca requiring iv abx\n REASON FOR THIS EXAMINATION:\n s/p r 40cm picc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST \n\n CLINICAL INFORMATION: PICC.\n\n FINDINGS: Frontal view of the chest is compared to the prior study from\n . Right PICC terminates in superior vena cava. There is\n patchy airspace opacification of the right lung with increased interstitial\n markings. Could represent a combination of infection and mild congestive\n failure.\n\n IMPRESSION: Right PICC terminates in the superior vena cava.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165098, "text": " 5:09 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman intubated with likely interstitial pneumonitis\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient intubated with most likely\n interstitial pneumonitis.\n\n Portable AP chest radiograph was compared to .\n\n The ET tube tip is low, 1.8 cm above the carina, but the patient's neck is in\n flexion, which might explain the low position of the ET tube. The NG tube tip\n is in the stomach. Cardiomediastinal silhouette is unchanged as well as there\n is no change in widespread interstitial and right lower lobe alveolar\n abnormalities.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165471, "text": " 8:11 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: has her tube shifted?\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman instubated, RT has had trouble passing suction\n REASON FOR THIS EXAMINATION:\n has her tube shifted?\n ______________________________________________________________________________\n WET READ: YGd MON 8:31 PM\n No acute cardiopulmonary process. Mild cardiomegaly with LV prominence,\n unchanged. x \n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient intubated with difficulty\n plus infection.\n\n Portable AP chest radiograph was compared to prior study obtained on , , at 05:18 a.m.\n\n ET tube tip is currently pointing towards the right main bronchus and should\n be pulled back for at least 3 cm cm. Widespread parenchymal opacities are\n unchanged and the NG tube tip is in the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2189-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165332, "text": " 4:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change?\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with hx of pancreatic cancer on ventilatory for respiratory\n failure.\n REASON FOR THIS EXAMINATION:\n interval change?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:18 A.M., \n\n HISTORY: Pancreatic cancer. On a ventilator for respiratory failure,\n question interval change.\n\n IMPRESSION: AP chest compared to through 28:\n\n Severe bilateral pulmonary opacification has improved on the left, worsened on\n the right, at least some of which is due to pulmonary edema, though concurrent\n pneumonia is quite likely. Severe cardiomegaly is unchanged. Small right\n pleural effusion is presumed. ET tube is in standard placement. No\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165685, "text": " 5:32 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change?\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic pancreatic cancer intubated respiratory\n failure in setting of presumed TACE induced pneuomoni\n REASON FOR THIS EXAMINATION:\n Interval change?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Metastatic pancreatic cancer with respiratory failure.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Continued enlargement of the cardiac silhouette with\n diffuse bilateral pulmonary opacifications consistent with some combination of\n pulmonary vascular congestion and multifocal pneumonia. Probable bilateral\n pleural effusions with some atelectatic changes at the bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-28 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1165341, "text": " 7:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? please evaluate for cholecystitis, choleycstitis, and \n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic neuroendocrine CA, please evaluate for\n cholecystitis, choleycstitis, and stent placement\n REASON FOR THIS EXAMINATION:\n ? please evaluate for cholecystitis, choleycstitis, and stent placement\n ______________________________________________________________________________\n FINAL REPORT\n ULTRASOUND UPPER ABDOMEN\n\n INDICATION: Query cholecystitis. Query stent placement.\n\n COMPARISON: CT, and ultrasound, upper abdomen, .\n\n FINDINGS:\n\n Again there are multiple lesions demonstrated throughout both lobes of the\n liver in keeping with known metastatic liver disease. The largest measures\n 3.9 x 3.9 x 3.1 cm within segment II of the liver (series 1, image 44). It is\n difficult to determine growth as this US is compared to prior CT scans and the\n left lobe of the liver has recently been treated with ethiodol. The main\n portal vein is patent.\n\n No evidence for intrahepatic biliary dilatation. The common bile duct\n measures 7 mm. The stent is seen within the distal CBD and duodenum as\n previously seen on the prior CT abdomen, unchanged in position since prior\n imaging.\n\n There is evidence for ascites. The gallbladder is not distended. There is\n mild gallbladder wall thickening of 4 mm. Mild pericholecystic fluid\n consistent with perihepatic ascites is also identified. Some sludge is also\n identified within the gallbladder.\n\n The spleen measures approximately 14 cm.\n\n Again there is a known lesion identified in the head of the pancreas,\n measuring 1.4 x 1.5 x 1.1 cm, stable and unchanged when compared to prior CT.\n\n\n\n IMPRESSION:\n 1. Multiple liver lesions in keeping with known metastatic disease.\n 2. Nondistended gallbladder with gallbladder wall thickening, which may be\n related to perihepatic ascites. There is some sludge but no evidence for\n cholelithiasis.\n 3. Metallic stent is seen in distal CBD and duodenum, unchanged in position\n since prior CT. No evidence of intrahepatic biliary dilatation.\n 4. Ascites.\n 5. Known pancreatic head neuroendocrine lesion as described.\n (Over)\n\n 7:21 AM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: ? please evaluate for cholecystitis, choleycstitis, and \n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2189-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1165576, "text": " 12:39 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Where is the ET tube.\n Admitting Diagnosis: PANCREATIC CANCER\\CHEMO EMBOLIZATION LIVER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old woman with metastatic pancreatic cancer intubated respiratory\n failure in setting of presumed TACE induced pneuomonitis\n REASON FOR THIS EXAMINATION:\n Where is the ET tube.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: 61-year-old female patient with metastatic pancreatic cancer,\n intubated because of respiratory failure in setting of presumed therapy\n induced pneumonitis. Check position of ETT.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n sitting semi-upright position.\n\n Comparison is made with the next preceding similar study obtained nine hours\n earlier during the same day.\n\n The position of the ETT has been adjusted and is now seen to terminate in the\n trachea some 3 cm above the level of the carina. Thus, the previously\n threatening partial occlusion of the airways has been eliminated. Previously\n described widespread interstitial and parenchymal infiltrates persist. No\n pneumothorax is seen.\n\n" }, { "category": "Echo", "chartdate": "2189-12-21 00:00:00.000", "description": "Report", "row_id": 76572, "text": "PATIENT/TEST INFORMATION:\nIndication: Interval change cardiac function. Left ventricular function.\nHeight: (in) 61\nWeight (lb): 176\nBSA (m2): 1.79 m2\nBP (mm Hg): 101/53\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 17:32\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: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Estimated cardiac index is high (>4.0L/min/m2).\nNo 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 (?#). No valvular AS. The increased\ntransaortic velocity is related to high cardiac output. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is elongated. Left ventricular wall thickness, cavity size and\nregional/global systolic function are normal (LVEF >55%). The estimated\ncardiac index is high (>4.0L/min/m2). Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (?#) appear structurally\nnormal with good leaflet excursion. There is no valvular aortic stenosis. The\nincreased transaortic velocity is likely related to high cardiac output. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , left\nventricular systolic function is more dynamic and the heart rate is higher.\nThe estimated pulmonary artery systolic pressure is now higher.\n\n\n" }, { "category": "Echo", "chartdate": "2189-12-11 00:00:00.000", "description": "Report", "row_id": 76573, "text": "PATIENT/TEST INFORMATION:\nIndication: Pulmonary hypertension. Shortness of breath. Hypoxia. Left ventricular function. Right ventricular function.\nHeight: (in) 61\nWeight (lb): 180\nBSA (m2): 1.81 m2\nBP (mm Hg): 96/40\nHR (bpm): 79\nStatus: Outpatient\nDate/Time: at 16:16\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal regional LV\nsystolic function. Low normal LVEF. 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 descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild mitral annular\ncalcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. Regional left ventricular wall motion is normal.\nOverall left ventricular systolic function is low normal (LVEF 50-55%). Right\nventricular chamber size and free wall motion are normal. The ascending aorta\nis mildly dilated. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are structurally normal. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. The estimated pulmonary artery systolic pressure\nis normal. There is no pericardial effusion.\n\nIMPRESSION: Normal biventricular cavity sizes with preserved regional and low\nnormal global left ventricular 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": "2189-12-06 00:00:00.000", "description": "Report", "row_id": 196195, "text": "Moderate baseline artifact. Normal sinus rhythm with occasional ventricular\npremature beats. Left ventricular hypertrophy. Compared to the previous tracing\nof there is probably no diagnostic interval change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2105-12-22 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1167923, "text": " 5:47 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx, effusion - icu provider is , please page h\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p AVR/CABG - cardiac surgery patient, icu provider is\n , please page him if there is concern with findings\n REASON FOR THIS EXAMINATION:\n ptx, effusion - icu provider is , please page him if there is\n concern with findings\n ______________________________________________________________________________\n WET READ: AJy TUE 11:22 PM\n\n ett 8 cm above carina. ng extends to stomach, tip not well seen. bilateral\n drains noted. lucencies along the right heart border are c/w postoperative\n pneumomediastinum. there is basilar atelectasis and likely small effusions.\n mediastinal widening is likely post-operative and exagerraetd by rotation. no\n ptx.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH, 6:03 P.M. ON \n\n HISTORY: Immediate post-cardiac surgery.\n\n IMPRESSION: AP chest compared to preoperative chest radiograph on :\n\n Tip of the ET tube is less than 8 cm from the carina, with the chin mildly\n elevated, 3 cm above optimal placement. Bibasilar atelectasis is substantial,\n greater than generally seen initially after heart surgery. Pneumomediastinum\n is generally of no clinical import. Left pleural effusion is small. The\n caliber of the postoperative cardiomediastinal silhouette is not unexpected\n given the preoperative appearance.\n\n Right internal jugular Swan-Ganz catheter passes into the right atrium, but\n the tip is indistinct. Nasogastric tube passes below the diaphragm and out of\n view. Midline and left pleural drains in place. No definite pneumothorax.\n\n was paged at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-17 00:00:00.000", "description": "CAROTID SERIES COMPLETE", "row_id": 1167099, "text": " 9:48 AM\n CAROTID SERIES COMPLETE Clip # \n Reason: eval for cardiac surgery\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 yo M with h/o CAD, HTN, aortic stenosis p/w shortness of breath\n REASON FOR THIS EXAMINATION:\n eval for cardiac surgery\n ______________________________________________________________________________\n FINAL REPORT\n\n Standard Report Carotid US\n\n Study: Carotid Series Complete\n\n Reason: Pre op Aortic stenosis repair, CAD\n\n Findings: Duplex evaluation was performed of bilateral carotid arteries. On\n the right there is mild heterogeneous plaque with calcifications in the ICA.\n On the left there is moderate heterogeneous plaque with calcifications in the\n bulb and ICA.\n\n On the right systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 115/17, 76/12, 57/13 cm/sec. CCA peak systolic\n velocity is 62 cm/sec. ECA peak systolic velocity is 104 cm/sec. The ICA/CCA\n ratio is 1.9. These findings are consistent with 40-59% stenosis.\n\n On the left systolic/end diastolic velocities of the ICA proximal, mid and\n distal respectively are 173/33, 61/15, 54/19 cm/sec. CCA peak systolic\n velocity is 68 cm/sec. Bulb peak systolic/end diastolic velocities\n are195/27cm/sec. ECA peak systolic velocity is 176 cm/sec. The ICA/CCA ratio\n is 2.5. These findings are consistent with 60-69 stenosis.\n\n There is antegrade right vertebral artery flow.\n There is antegrade left vertebral artery flow.\n\n Impression: Right ICA 40-59% stenosis.\n Left ICA/bulb 60-69% stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-24 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1168211, "text": " 11:54 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check line placement\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p AVR/CABG\n REASON FOR THIS EXAMINATION:\n check line placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Line placement.\n\n FINDINGS: In comparison with study of , the right IJ catheter extends to\n almost the junction with the right subclavian vein. Otherwise, little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1167009, "text": " 5:16 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: preop eval for aortic valve replacement, CABG\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with h/o CAD, HTN, aortic stenosis p/w shortness of breath\n REASON FOR THIS EXAMINATION:\n preop eval for aortic valve replacement, CABG\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JMGw WED 6:43 PM\n extensive calcification of the aortic valve and thoracic aorta. LCX, LAD and\n right main CAD. proximal throacic aorta above valve measures 3.5cm, distal to\n left subclavian measures 3.4cm, and at diaphragm measures 2.6cm. severe spinal\n DJD with flowing ostophytes raises concern for ankylosing spondylitis or DISH.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Aortic stenosis, coronary artery disease, hypertension, shortness\n of breath.\n\n TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed\n without intravenous contrast. The images are presented for display in the\n axial plane as 1.25 and 5 mm collimation. Multiplanar reformation images were\n also submitted for review.\n\n COMPARISON: No prior CT is available.\n\n FINDINGS: Clips in the left axilla indicate prior surgery. There is no\n pathologic enlargement of the axillary, supraclavicular or mediastinal lymph\n nodes. The largest lymph node in the mediastinum at the right hilum,\n subaortic and precarinal stations measure 8, 8 and 7 mm respectively (2:26,\n 29).\n\n The thoracic aorta is normal in caliber: the supravalvular aorta measures 47\n mm in transverse dimension. There is no calcification of the aortic root or\n the ascending thoracic aorta for a distance of approximately 6cm beyond the\n aortic valve. Distal to this point, atherosclerotic calcification of the\n anterior and right anterolateral aortic arch and descending thoracic aorta is\n moderately severe. Mild fusiform dilatation of the aortic arch, distal to the\n takeoff of the left subclavian artery measures 33 mm in transverse dimension\n (2:20). Atherosclerotic calcification at the origin of the brachiocephalic,\n left common carotid and left subclavian arteries is moderately severe. The\n left vertebral artery has a direct origin from the aortic arch (2:16). There\n is bilateral moderately severe pulmonary arterial enlargement suggesting the\n presence of pulmonary hypertension, the right pulmonary artery measures 34 mm\n and left pulmonary artery 26 mm. The main pulmonary artery measures 36 mm in\n transverse dimension. Aortic valvular calcification is severe.\n Atherosclerotic calcification of all coronary arteries is also severe. Mitral\n annulus calcification is mild-to-moderate. The cardiac size is normal without\n evidence of pericardial effusion.\n\n There is no pleural effusion. The central airways are patent without evidence\n (Over)\n\n 5:16 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: preop eval for aortic valve replacement, CABG\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n of respiratory secretions. The lungs are normal in appearance.\n\n The study is not tailored for subdiaphragmatic evaluation only to confirm\n normal-appearing adrenals and atherosclerotic calcification of a tortuous\n abdominal aorta, and its branches. On the last image of this chest CT, there\n is mild abdominal aortic enlargement and while this may relate in part to\n tortuosity, an abdominal aortic aneurysm below the field of view of the CT is\n considered possible.\n\n Anterior flowing osteophytosis suggests diffuse idiopathic skeletal\n hyperostosis. Fusion of the spinous processes and posterior longitudinal\n ligament also raises the possibility of ankylosing spondylitis, although the\n typical kyphotic configuration of the upper thoracic spine is not present.\n\n IMPRESSION:\n\n 1. Aortic arch and descending thoracic aortic atherosclerotic calcification,\n which spares the proximal 6 cm of the ascending aorta.\n\n 2. Severe aortic valvular calcification.\n\n 3. Incidental finding of possible abdominal aortic enlargement, not fully\n evaluated by the thoracic CT, abdominal aorta ultrasound would be an\n appropriate first step in its evaluation.\n\n 4. Diffuse idiopathic skeletal hyperostosis of the thoracic spine. Fusion of\n the posterior elements on posterior longitudinal ligament of thoracic spine\n also raises the possibility of ankylosing spondylitis.\n\n 5. Probable pulmonary arterial hypertension.\n\n" }, { "category": "Radiology", "chartdate": "2105-12-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1168084, "text": " 3:23 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p cabg and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after CABG and chest tube\n removal.\n\n AP chest radiograph was compared to .\n\n The patient was extubated in the meantime interval. The Swan-Ganz catheter\n was removed. Currently, the right internal jugular line tip is in the jugular\n vein, high at the level of the thoracic inlet. Cardiomediastinal silhouette\n is unremarkable. No right pneumothorax is seen. Questionable minimal left\n apical lucency is noted that might represent summation of shadows, but minimal\n pneumothorax cannot be excluded and should be followed on the subsequent\n studies.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1168339, "text": ", R. CSURG FA6A 6:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypotension ? mediastinal widening\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p cabg POD 3\n REASON FOR THIS EXAMINATION:\n hypotension ? mediastinal widening\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Stable cardiac and mediastinal silhouettes.\n\n 2. Right internal jugular catheter is in the high upper SVC just below the\n clavicles and could be advanced.\n\n 3. Small new left pleural effusion and associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2105-12-29 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1168994, "text": " 10:14 AM\n CHEST (PA & LAT) Clip # \n Reason: interval change\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with CABG\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CABG.\n\n FINDINGS: In comparison with the study of , there is little overall\n change. Stable cardiomediastinal silhouette in a patient with intact midline\n sternal wires. High position of the right IJ catheter is again seen. There\n may be some increase in the degree of left pleural effusion with associated\n compressive atelectasis. No evidence of vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-21 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1167773, "text": " 8:36 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with preop AVr, CABG\n REASON FOR THIS EXAMINATION:\n evaluate for acute process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preoperative evaluation for aortic valve replacement and CABG.\n\n COMPARISON: Chest CT, .\n\n PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette is moderately\n enlarged. The aorta is tortuous with diffuse calcifications identified.\n Pulmonary vascularity is normal and the lungs are clear. No pleural effusion\n or pneumothorax is seen. There is diffuse idiopathic skeletal hyperostosis.\n Multiple clips are seen in the left axilla.\n\n IMPRESSION: No acute cardiopulmonary abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2105-12-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1168338, "text": " 6:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: hypotension ? mediastinal widening\n Admitting Diagnosis: SHORTNESS OF BREATH;AORTIC STENOSIS\\LEFT HEART CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with s/p cabg POD 3\n REASON FOR THIS EXAMINATION:\n hypotension ? mediastinal widening\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MDAg FRI 11:38 AM\n PFI:\n\n 1. Stable cardiac and mediastinal silhouettes.\n\n 2. Right internal jugular catheter is in the high upper SVC just below the\n clavicles and could be advanced.\n\n 3. Small new left pleural effusion and associated atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG, POD 3with hypertension, evaluate for\n mediastinal widening.\n\n COMPARISON: Multiple radiographs dating back to , most recently\n .\n\n FINDINGS: A right internal jugular catheter projects over the high upper SVC\n just below the clavicles and could be advanced. Since , there has\n been interval development of a small left pleural effusion with associated\n atelectasis. The right lung is clear. There is no pulmonary venous congestion\n or pneumothorax. Cardiac and mediastinal silhouettes are unchanged from\n .\n\n IMPRESSION:\n 1. Stable cardiac and mediastinal silhouettes.\n 2. Right internal jugular catheter is in the high upper SVC and could be\n advanced.\n 3. New small left pleural effusion and associated atelectasis.\n\n" }, { "category": "Echo", "chartdate": "2105-12-25 00:00:00.000", "description": "Report", "row_id": 92284, "text": "PATIENT/TEST INFORMATION:\nIndication: hypotensive. Evaluate for tamponade.\nHeight: (in) 74\nWeight (lb): 330\nBSA (m2): 2.69 m2\nBP (mm Hg): 83/45\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Cannot assess LVEF.\n\nRIGHT VENTRICLE: Cannot assess RV systolic function.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - body habitus.\n\nConclusions:\nVery poor echo windows. Overall left ventricular systolic function cannot be\nreliably assessed. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2105-12-22 00:00:00.000", "description": "Report", "row_id": 92300, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for AVR, CABG\nStatus: Inpatient\nDate/Time: at 11:50\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Good (>20 cm/s) LAA ejection velocity. No thrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild-moderate regional LV systolic dysfunction. Moderately\ndepressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Complex (>4mm) atheroma in the aortic arch. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Severely thickened/deformed aortic\nvalve leaflets. Bioprosthetic aortic valve prosthesis (AVR). AVR leaflets move\nnormally. Severe AS (area 0.8-1.0cm2). Mild to moderate (+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mitral leaflets fail to fully\ncoapt. Moderate (2+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPRE-CPB:\nThere are three aortic valve leaflets. The aortic valve leaflets are severely\nthickened/deformed.\nThere is severe aortic valve stenosis (valve area 0.8-1.0cm2). Mild to\nmoderate (+) aortic regurgitation is seen.\n\nThe mitral valve leaflets are structurally normal. The mitral valve leaflets\ndo not fully coapt. Moderate (2+) mitral regurgitation is seen.\n\nThere is moderate regional left ventricular systolic dysfunction of the basal\nand mid-papillary inferior, inferoseptal and inferolateral segments. These\nwall segments also appear thinned. Overall left ventricular systolic function\nis moderately depressed (LVEF= 35-40 %).\n\nNo thrombus is seen in the left atrial appendage. No atrial septal defect is\nseen by 2D or color Doppler.\n\nRight ventricular chamber size and free wall motion are normal.\n\nThere are complex (>4mm) atheroma in the distal aortic arch. There are simple\natheroma in the descending thoracic aorta.\n\nPOST-CPB:\nA porcine bioprosthetic aortic valve prosthesis is present. The aortic valve\nprosthesis appears to be well seated and the leaflets appear to move normally.\nThere is no apparent paravalvular leak. The peak gradient across the aortic\nvalve is 15mmHg, the mean gradient is 9mmHg with a CO of 5.5.\n\nThe LV systolic function appears unchanged from pre-op. The regional wall\nmotion abnormalities are in the same distribution as pre-op, affecting the\ninferior, inferoseptal, and inferolateral walls. Estimated EF 35-40%.\n\nThere is moderate MR, unchanged from pre-op.\n\nRV systolic function remains normal. The protruding atheroma in the distal\narch remains unchanged. There is no evidence of dissection.\n\n\n" }, { "category": "Echo", "chartdate": "2105-12-17 00:00:00.000", "description": "Report", "row_id": 92301, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease\nHeight: (in) 74\nWeight (lb): 313\nBSA (m2): 2.63 m2\nBP (mm Hg): 127/77\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 15:53\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Definity\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Moderately\ndepressed LVEF. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal\ninferoseptal - hypo; mid inferoseptal - hypo; basal inferior - hypo; mid\ninferior - hypo; basal inferolateral - akinetic; mid inferolateral - akinetic;\nmid anterolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Mildy dilated aortic root. Focal calcifications in aortic root. Mildly\ndilated ascending aorta. Focal calcifications in ascending aorta.\n\nAORTIC VALVE: Aortic valve not well seen. Significant AS is present (not\nquantified) Mild (1+) 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. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Normal tricuspid\nvalve supporting structures. No TS. Mild [1+] TR. Indeterminate PA systolic\npressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is moderately depressed (LVEF= 35 %) secondary\nto hypokinesis of the inferior septum and inferior free wall, and akinesis of\nthe posterior wall. Right ventricular chamber size and free wall motion are\nnormal. The aortic root is mildly dilated at the sinus level. The ascending\naorta is mildly dilated. The aortic valve is not well seen. Significant aortic\nstenosis is present (not quantified). Mild (1+) aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild-to-moderate (+) mitral regurgitation is seen. The tricuspid\nvalve leaflets are mildly thickened. The pulmonary artery systolic pressure\ncould not be determined. There is no pericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2105-12-22 00:00:00.000", "description": "Report", "row_id": 257122, "text": "Sinus rhythm. Left axis deviation. Right bundle-branch block. Inferolateral\nwall myocardial infarction, most likely old. Left atrial abnormality. Diffuse\nST-T wave changes which are non-specific. Compared to the previous tracing\nof multiple described abnormalities persist. However, lateral\nST-T wave abnormality appears to be more prominent. Cannot rule out underlying\nmyocardial ischemia.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2105-12-23 00:00:00.000", "description": "Report", "row_id": 257123, "text": "Sinus tachycardia. Compared to tracing #1 heart rate is significantly faster.\nHowever, lateral ST-T wave changes have improved. Clinical correlation is\nsuggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2105-12-16 00:00:00.000", "description": "Report", "row_id": 257124, "text": "Sinus rhythm and occasional ventricular ectopy. Prior inferolateral myocardial\ninfarction. Right bundle-branch block. Left atrial abnormality. Non-specific\ninferior and lateral ST-T wave flattening. No previous tracing available for\ncomparison. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2130-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007768, "text": " 3:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement? NG placement? effusion?\n ______________________________________________________________________________\n FINAL ADDENDUM\n ADDENDUM: The endotracheal tube is low lying with the tip at the tracheal\n bifurcation. It should be pulled back approximately 3-4 cm to lie in\n appropriate position.\n\n These findings were discussed with Dr. at the time of the study.\n\n\n\n 3:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement? NG placement? effusion?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with GIB, NG tube, and intubation\n REASON FOR THIS EXAMINATION:\n tube placement? NG placement? effusion?\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: Gastrointestinal bleed, please evaluate NG tube placement.\n\n FINDINGS: A nasogastric tube courses through the mediastinum with tip and\n sideport overlying the gastric fundus. The lungs appear clear. The\n cardiomediastinal silhouette is within normal limits. The pulmonary\n vascularity is within normal limits. No effusion or pneumothorax is\n identified.\n\n IMPRESSION: Standard placement of nasogastric tube, without acute\n cardiopulmonary process identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2130-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1007789, "text": " 5:53 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 41 year old man with tube reposition to 22 cm at lip\n REASON FOR THIS EXAMINATION:\n ? tube placement\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portable AP chest radiograph.\n\n INDICATION: 41-year-old male with endotracheal tube repositioning.\n\n FINDINGS: The endotracheal tube is in acceptable position, approximately 4 cm\n from the carina. Nasogastric tube remains in good position. The\n cardiomediastinal silhouette is within normal limits. The lungs are clear.\n\n IMPRESSION: Acceptable positioning of lines and tubes.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2130-03-25 00:00:00.000", "description": "Report", "row_id": 1673135, "text": "Respiratory Care\nPt was assessed at begining of shift, and he was recieving adequate tidal volumes on PSV of . Pt was then changed to pressure support of 5 cmh20. Pt was still stable with Sp02/Exp Tv/RR all within normal range. Pt was then extubated as MD order. , pt had clear lung sounds, strong voice and SpO2 of greater than 95% on cool aerosol. Pt to be monitored by resp care.\n" }, { "category": "Nursing/other", "chartdate": "2130-03-25 00:00:00.000", "description": "Report", "row_id": 1673136, "text": "Nursing Note\nPlease see carevue for details\n\nNeuro: Alert and oriented x3. Cooperative with nursing care. c/o abdomenal pain - adequate relief observed with iv dilaudid. CIWA 13-14 while awake for tremor, h/a, nausea, diaphoresis, and mild anxiety - received ativan as ordered.\nCV: SR/ST. BP stable. +pp/csm. mag repleted. Hct stable overnight.\nResp: Intubated on admission. Was successfully extubated at 2100 (see resp note). Currently LSCTA, O2 sats >95% 2L NC.\nGI: Abd soft/nt/nd. +bs. OGT to lws on arrival - coffee ground drainage - d/c'd during extubation. mild nausea reported - zofran with + effect. No stool this shift.\nGU: Foley draining large amounts cyu.\nPlan: Monitor labs. Monitor vs. pain management. comfort and support.\n" }, { "category": "ECG", "chartdate": "2130-03-24 00:00:00.000", "description": "Report", "row_id": 217865, "text": "Sinus tachycardia. Non-specific ST-T wave abnormalities. No previous tracing\navailable for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2140-09-21 00:00:00.000", "description": "Report", "row_id": 1592090, "text": "***Admission note NPN TSICU 1900-0700\n40 YO unrestrained driver involved in MVA rollover at 35 MPH. Pt was ejected from car, yet ambulatory at scene. Positive for ETOH, cocaine, and opiates. Taken to OSH where films showed C2 and C4 fx. Head CT negative. Transfered to where halo traction was placed in OR. To TSICU for Q2/hr neuro assessment.\n\nNEURO: A&OX3, following commands. Moving all four extremities with good strength. Pupils 3mm, reacitve to light. TLS cleared. Halo traction intact. Morphine for generalized pain.\n\nCV: SR 60-70's with no ectopy. SBP 120-130's. Strong pedal pulses. TMAX 99.5. LR@85cc/hr.\n\nRESP: 3L NC with SATS 98-100%. No respiratory distress noted. LS clear.\n\nHEME: Pneumoboots intact. Heparin SC TID.\n\nGI: Abd soft, non distended. NPO. Positive BS.\n\nGU: Foley draining clear yellow urine. Adequate UO.\n\nSKIN: Pin care QD. Pin sites pink. Abrasion on shoulder, OTA, no drainage.\n\nSOCIAL: Sister into visit at beginning of shift, update given.\n\nPLAN: Continue with neuro checks Q2/hr. Possible transfer to floor today.\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 843823, "text": " 10:37 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Clip # \n Reason: please perform face cuts\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with ? L mzxilla\n REASON FOR THIS EXAMINATION:\n please perform face cuts\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 40 y/o man with questionable fracture of left maxilla.\n\n There are no priors for comparison.\n\n TECHNIQUE: Axial and coronal non-contrast images of the paranasal sinuses were\n obtained, with an overlying VTI headset device.\n\n There is diffuse mucosal thickening of the left maxillary, anterior ethmoid\n and mild mucosal thickening of the right maxillary sinus. The sphenoid sinuses\n are spared. There is no evidence of air fluid levels. Bilateral osteomeatal\n units appear obstructed. There is no evidence of fracture of the facial bones,\n or bony destruction. The cribiform plates are equal in height. The anterior\n clinoids are not pneumatized. The lamina papyracea is intact. The nasal septum\n deviates slightly to the right. The sphenoid sinus septum is midline.\n\n IMPRESSION: Mucosal soft tissue thickening of bilateral maxillary sinuses,\n left greater than right, and anterior ethmoid. No evidence of air fluid\n levels. Bilateral osteomeatal units appear obstructed. No evidence of facial\n bone fracture or bony destruction.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "P TRAUMA #2 (AP CXR & PELVIS PORT) PORT", "row_id": 843808, "text": " 9:37 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) PORT Clip # \n Reason: ? fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with C2 fx after rollover MVC\n REASON FOR THIS EXAMINATION:\n ? fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n AP VIEW OF THE CHEST: There is no evidence of pneumothorax on this supine\n view. There is no fracture or dislocation. The visualized portions of the\n lungs are clear. There is no mediastinal widening.\n\n AP PELVIS: There is no fracture or dislocation. The hips and SI joints are\n within normal limits.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "T-SPINE", "row_id": 843818, "text": " 10:00 AM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: r/o fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p MVC ejected\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma.\n\n SEVEN VIEWS OF THE LS AND THORACIC SPINE: The dens is not completely imaged.\n There is no loss of vertebral body height. The disc spaces are maintained.\n There is a Grade 1 retrolisthesis of L5 on S1. There is a mild scoliotic\n curvature of the thoracic spine convex to the right. The hips and sacroiliac\n joints are within normal limits. There are small anterior osteophytes at the\n L5 vertebral body.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-21 00:00:00.000", "description": "C-SPINE NON-TRAUMA 2-3 VIEWS", "row_id": 844004, "text": " 4:17 PM\n C-SPINE NON-TRAUMA VIEWS Clip # \n Reason: alignment: AP Lat, Open mouth odontoid\n Admitting Diagnosis: C2 FRACTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man with C2 fracture\n REASON FOR THIS EXAMINATION:\n alignment: AP Lat, Open mouth odontoid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: F/U fracture.\n\n Five views of the cervical spine done in halo are suboptimal due to overlying\n hardware and difficulty in positioning. There is a poorly assessed fracture\n apparently involving the base of the dens and apparently the adjacent C2\n vertebral body. Normal vertebral body alignment and the dens lies normally\n immediately behind the anterior arch of C1. The spine is visualized to the\n top of C7 in lateral projection. There is probable soft tissue swelling\n anterior to the proximal cervical spine.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "C-SPINE SGL 1 VIEW", "row_id": 843984, "text": " 2:53 PM\n C-SPINE SGL 1 VIEW; SPINAL FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: POSITION FOR HALO PLACEMENT\n Admitting Diagnosis: C2 FRACTURE\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Position for halo placement.\n\n FINDINGS: A single video-recorded image has been provided. It demonstrates a\n lateral view of the cervical spine. Image quality is suboptimal for detail\n evaluation. Apparently, the film was obtained in conjunction with a halo\n placement. No diagnostic films were provided.\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 843814, "text": " 9:49 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: eval fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p MVC with cspine fx on x-ray\n REASON FOR THIS EXAMINATION:\n eval fracture\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE C-SPINE WITHOUT CONTRAST.\n\n INDICATION: 40 year old man status post motor vehicle accident, with C-spine\n fracture on x-ray. Evaluate.\n\n There are no priors for comparison.\n\n TECHNIQUE: Axial non-contrast helical scanning of the cervical spine was\n performed without intravenous contrast. Sagittal and coronal reconstructions\n were obtained.\n\n FINDINGS: There is a type II fracture of the odontoid process, with a\n fracture extending through the C2 left vertebral body, left lateral mass, the\n left lamina and facet joints as well as the left foramen transversarium. There\n is minimal thickening of the soft tissues anterior to the fracture site.\n The remaining cervical vertebrae are in normal alignment, with no evidence of\n additional fracture or subluxation. CT is not able to provide any intrathecal\n detail. The visualized outline of the thecal sac is normal in appearance.\n\n IMPRESSION: Type II odontoid fracture, with fracture of the C2 left vertebral\n body, lateral mass, left lamina, and facet, as well as the left foramen\n transversarium.\n\n Dr. was telephoned with these findings at the time of observation\n at 11:30AM on .\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 843815, "text": " 9:50 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST; CT RECONSTRUCTION\n Reason: r/o solid organ injury\n Field of view: 36 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p MVC\n REASON FOR THIS EXAMINATION:\n r/o solid organ injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MAlb TUE 12:07 PM\n Small amounts of bibasilar atelactasis. No other abnormalities detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post MVC. Evaluate for solid organ injury.\n\n TECHNIQUE: MDCT-acquired contiguous axial images were obtained from the lung\n bases to the pubic symphysis. Multiplanar reconstruciton images were\n obtained.\n\n CONTRAST: 150 cc of IV Optiray contrast was administered due to the rapid\n rate of bolus injection required for this study.\n\n CT OF ABDOMEN WITH IV CONTRAST: No pleural effusions or pneumothorax is seen\n at the lung bases. Slight bibasilar atelectasis is noted. The liver, spleen,\n pancreas, kidneys, and adrenal glands are normal in appearance. The bowel is\n normal in appearance. No free fluid or free gas is seen. No retroperitoneal\n lymphadenopathy is seen.\n\n CT OF PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, bladder, and uterus\n are normal in appearance. No free fluid is seen. No pelvic lymphadenopathy\n is seen.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are identified. No\n fractures are identified.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions were obtained due to the\n rapid rate of bolus injection required for this study.\n\n IMPRESSION: Bibasilar atelectasis is noted. No other abnormalities are\n identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-09-20 00:00:00.000", "description": "L HAND (AP, LAT & OBLIQUE) LEFT", "row_id": 843824, "text": " 10:38 AM\n HAND (AP, LAT & OBLIQUE) LEFT Clip # \n Reason: r/o fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old man s/p MVC with swelling and pain over thenar eminance\n REASON FOR THIS EXAMINATION:\n r/o fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma with pain and swelling over the thenar eminence.\n\n THREE VIEWS OF THE LEFT HAND: There is no fracture, dislocation, or\n suspicious lytic or blastic lesion. The joint spaces are maintained. No\n radiopaque foreign body is demonstrated.\n\n IMPRESSION: Negative.\n\n" }, { "category": "ECG", "chartdate": "2140-09-20 00:00:00.000", "description": "Report", "row_id": 184769, "text": "Sinus rhythm, rate 54. The electrocardiogram is within normal limits. No\nprevious tracing available for comparison.\n\n" } ]

[ { "category": "Echo", "chartdate": "2193-03-09 00:00:00.000", "description": "Report", "row_id": 93890, "text": "PATIENT/TEST INFORMATION:\nIndication: Status-post left pneumonectomy. Chest pain. Hypotension. Left ventricular function.\nHeight: (in) 62\nWeight (lb): 122\nBSA (m2): 1.55 m2\nBP (mm Hg): 103/51\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 17:52\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD by 2D or color\nDoppler. Normal IVC diameter (<=2.1cm) with >50% decrease with sniff\n(estimated RA pressure (0-5 mmHg).\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV free wall thickness. Mildly dilated RV cavity.\nNormal RV systolic function.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild mitral annular calcification.\nPhysiologic MR (within normal limits).\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality as the patient was difficult to position. Suboptimal\nimage quality - body habitus. Emergency study performed by the cardiology\nfellow on call.\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 0-5 mmHg. Left\nventricular wall thickness, cavity size, and global systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. The right ventricular free wall\nthickness is normal. The right ventricular cavity is mildly dilated with\nnormal free wall contractility. The aortic valve leaflets (?#) appear\nstructurally normal with good leaflet excursion. There is no aortic valve\nstenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nstructurally normal. Physiologic/trivial mitral regurgitation is seen.\nModerate [2+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with\npreserved global systolic function. Dilated right ventricular cavity with\npreserved free wall motion. Pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-11 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1227854, "text": " 7:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: line placement\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hypovolemia\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n WET READ: MXAk MON 7:57 PM\n Left internal jugular central venous catheter with the tip at the junction of\n the brachiocephalic and superior vena cava. Otherwise, little change compared\n to prior study from the same day.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Line placement in a patient after pneumonectomy.\n\n COMPARISON: Multiple prior studies obtained the same day earlier.\n\n The left internal jugular line has been inserted with its tip at the level of\n superior mid SVC. No subsequent abnormalities developed after the replacement\n of the line.\n\n The mediastinum appears to be again in central position with more than\n expected right shift. The opacity in the left lower hemithorax appears to be\n unchanged associated with loculated air and left chest wall air as well. The\n findings might reflect accumulation of fluid in the left base of the\n hemithorax as previously suggested.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227712, "text": " 4:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess change\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pneumonectomy\n REASON FOR THIS EXAMINATION:\n assess change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 4:36 A.M. ON \n\n HISTORY: Pneumonectomy, assess progress.\n\n IMPRESSION: AP chest compared to through 12:\n\n Patient is rotated to the right, making assessment of mediastinal position\n unreliable, but there does appear to have been rightward shift with an\n increase in the volume of fluid in the air- and fluid-filled left\n pneumonectomy space. Subcutaneous emphysema in the left chest wall and neck\n is also increased. Right lung volume is lower with bronchovascular crowding\n has resolved. I have arranged for a repeat examination carefully positioned.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227757, "text": " 10:33 AM\n CHEST (PORTABLE AP); REPEAT, (REQUEST BY RADIOLOGIST) Clip # \n Reason: ASSES PT CONDITION\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 10:25 A.M., \n\n CLINICAL HISTORY: Assess condition following pneumonectomy.\n\n IMPRESSION: AP chest compared to , 4:20 a.m.:\n\n The extent of leftward mediastinal shift following left pneumonectomy has\n decreased, with an increase in solid components in the left pneumonectomy\n space, accompanied by increase in subcutaneous emphysema in the left chest\n wall and neck. Small right pleural effusion has increased.\n\n The heart is not enlarged. Dr. and I discussed these findings by\n telephone at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1228050, "text": " 4:55 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ? line position\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 F s/p Left pneumonectomy s/p left IJ placement\n REASON FOR THIS EXAMINATION:\n ? line position\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after pneumonectomy.\n\n AP radiograph of the chest was reviewed in comparison to prior study obtained\n .\n\n There is new right upper lobe opacity, highly concerning for aspiration or\n interval development of pneumonia. Left lower lung opacification with dense\n fluid has increased but with no substantial change in the position of the\n mediastinum. Loculated air bubbles in the left hemithorax and left chest wall\n are unchanged.\n\n Left internal jugular line tip is at the level of superior mid SVC.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227506, "text": " 6:35 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval CT placement\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p completion L pneumonectomy\n REASON FOR THIS EXAMINATION:\n eval CT placement\n ______________________________________________________________________________\n WET READ: GMSj FRI 9:50 PM\n Left chest tube terminating in apex of left chest cavity. No normal lung\n markings are visualized on left - findings c/w recent left complete\n pneumonectomy. Air within the left pleural space with significant volume loss\n and moderate leftward mediastinal shift. Well-aerated right lung. Feeding\n tube in stomach. Spinal epidural catheter noted. GSenapati \n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:22 P.M., \n\n HISTORY: Left completion pneumonectomy. Chest tube placed.\n\n IMPRESSION: AP chest compared to :\n\n Left apical pleural tube crosses the air-filled left pneumonectomy space.\n Surgical rib fracture and associated soft tissue suggest possible anastomotic\n intercostal flap augmentation. Mediastinum shifted only moderately into the\n left hemithorax. Right lung is clear, compensatorily overinflated.\n Nasogastric tube passes into the stomach and out of view. Epidural infusion\n catheter in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227528, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 F recurrent left adenocarcinoma s/p completion pneumonectomy\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:05 A.M., \n\n HISTORY: Left completion pneumonectomy.\n\n IMPRESSION: AP chest compared to , 6:22 p.m.:\n\n Extent of leftward mediastinal shift has not changed appreciably. Greater\n opacity in the base of the largely air filled left pneumonectomy space is\n probably fluid or organizing fibrin clot. Right lung is hyperinflated and\n clear. The heart is leftward shifted, but not enlarged. Apical pleural tube\n unchanged in position.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227569, "text": " 2:46 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: acute process?\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with chest pain and EKG changes. pt s/p pneumonectomy.\n REASON FOR THIS EXAMINATION:\n acute process?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:30 P.M., \n\n HISTORY: Chest pain and EKG changes after pneumonectomy.\n\n IMPRESSION: AP chest compared to , 5:05 a.m.:\n\n Small amount of organized fluid has begun to collect in the left pneumonectomy\n space after removal of the chest drain. Leftward mediastinal shift has been\n partially reversed as a result. Right lung is clear. No right pleural\n effusion or pneumothorax. Stomach is moderately distended with air. EKG\n changes might be explained by the rotation and translation of the cardiac\n silhouette.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1227615, "text": " 4:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute pulm process\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with s/p pneumonectomy with chest tube\n REASON FOR THIS EXAMINATION:\n acute pulm process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient after pneumonectomy.\n\n Portable AP radiograph of the chest was reviewed in comparison to .\n\n There is interval progression in accumulation of the effusion within the left\n hemithorax, expected after pneumonectomy. Overall, the appearance is expected\n for the postoperative stage. Subcutaneous air is noted on the left. The\n right lung is clear. The epidural catheter is projecting over the\n chest/spine, although the precise location of its tip cannot be seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1228427, "text": " 11:05 AM\n CHEST (PA & LAT) Clip # \n Reason: check interval change\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p left pneumonectomy\n REASON FOR THIS EXAMINATION:\n check interval change\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n COMPARISON: chest x-ray.\n\n FINDINGS: The patient is status post left pneumonectomy. Slight increase in\n amount of pleural fluid since the prior study, with major air-fluid level now\n at the left sixth rib level. Small loculations of gas in the mid and lower\n left hemithorax has slightly decreased as well, and subcutaneous emphysema has\n slightly decreased. Within the right lung, ground-glass and reticular\n opacities at the right upper lobe and more confluent opacity at the right base\n have slightly improved. Small right pleural effusion is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-03-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1228208, "text": " 8:51 AM\n CHEST (PA & LAT) Clip # \n Reason: eval lung expansion and edema\n Admitting Diagnosis: LUNG CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with L pneumonectomy\n REASON FOR THIS EXAMINATION:\n eval lung expansion and edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64-year-old female status post left pneumonectomy.\n\n COMPARISON: Multiple chest radiographs dating back to , most\n recent and CT chest .\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n FINDINGS: There is evidence of left pneumonectomy with increasing fluid in\n pleural space as expected with decrease in air component. Mediastinum is\n unchanged in position. Previously noted right upper lobe opacity has improved\n consistent with improving pneumonia. There is stable right lower lobe\n atelectasis and small pleural effusion. Stable mild multilevel degenerative\n changes of the thoracic spine are noted.\n\n IMPRESSION: Expected increase in fluid in left pleural space with decreasing\n air component. Improving right upper lobe pneumonia.\n\n" }, { "category": "ECG", "chartdate": "2193-03-10 00:00:00.000", "description": "Report", "row_id": 247965, "text": "Atrial fibrillation with a rapid ventricular response. Inferior and\nanterolateral ST-T wave changes which are non-specific. Probable left\nventricular hypertrophy. Compared to tracing #2 QRS voltage in the precordial\nleads is lower and atrial fibrillation is now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2193-03-09 00:00:00.000", "description": "Report", "row_id": 247966, "text": "Sinus rhythm. Short P-R interval without other signs of pre-excitation. Left\nventricular hypertrophy. Anterolateral T wave inversions may be due to left\nventricular hypertrophy but myocardial ischemia cannot be excluded. Clinical\ncorrelation is suggested. Compared to the previous tracing of the heart\nrate is faster and anterolateral T wave changes are new.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2193-03-04 00:00:00.000", "description": "Report", "row_id": 247967, "text": "Sinus bradycardia. Otherwise, tracing is within normal limits. No previous\ntracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2193-03-15 00:00:00.000", "description": "Report", "row_id": 247963, "text": "Accelerated junctional rhythm with delayed R wave transition. Compared to the\nprevious tracing of the junctional rhythm is new. Clinical correlation\nis suggested.\n\n" }, { "category": "ECG", "chartdate": "2193-03-10 00:00:00.000", "description": "Report", "row_id": 247964, "text": "Sinus rhythm with atrial premature beats. Compared to tracing #2 anterolateral\nST-T wave changes have resolved and the rhythm has reverted to sinus with\natrial premature beats. The Q-T interval is mildly prolonged.\nTRACING #3\n\n" } ]

[ { "category": "Echo", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 104887, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 90/60\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 10:20\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: The left ventricular cavity is mildly dilated. Overall left\nventricular systolic function is moderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter.\n\nAORTIC VALVE: The aortic valve leaflets are moderately thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen. The left ventricular inflow pattern suggests impaired\nrelaxation.\n\nTRICUSPID VALVE: Mild tricuspid [1+] regurgitation is seen.\n\nPERICARDIUM: There is no pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows.\n\nConclusions:\n1. The left ventricular cavity is mildly dilated. Overall left ventricular\nsystolic function is moderately depressed. Mid and distal septal, distal\nlateral and distal inferior akinesis, apical dyskinesis and probable anterior\nhypokinesis to akinesis are present.\n2. The aortic valve leaflets are moderately thickened. Mild (1+) aortic\nregurgitation is seen.\n3. The mitral valve leaflets are mildly thickened. Trivial mitral\nregurgitation is seen.\n\n\n" }, { "category": "ECG", "chartdate": "2101-03-20 00:00:00.000", "description": "Report", "row_id": 309890, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay. Extensive\nT wave inversions throughout the precordial leads as well as the lateral leads.\nThere are two millimeters of ST segment elevations in the anteroseptal leads as\nwell as one to two millimeters of ST segment depressions in the anterolateral\nleads. These findings are suggestive of an acute ischemic event/infarction.\nCompared to the previous tracing of the anterolateral ST segment\ndepression is significantly more pronounced. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-03-19 00:00:00.000", "description": "Report", "row_id": 309891, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay. Extensive\nT wave inversions throughout the precordial leads and in the lateral leads.\nAlso, two millimeters of ST segment elevation in the anteroseptal leads.\nFindings are suggestive of an acute ischemic event and/or myocardial\ninfarction. Clinical correlation is suggested. Compared to the previous tracing\nof the precordial T wave inversions are not as deep. Otherwise, no\nsignificant change.\n\n" }, { "category": "ECG", "chartdate": "2101-03-18 00:00:00.000", "description": "Report", "row_id": 309892, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction defect.\nExtensive deepm T wave inversions throughout the precordium, as well as two\nmillimeter ST segment elevation in the anteroseptal leads. Findings are highly\nsuggestive of an acute LAD ischemic event. Clinical correlation is suggested.\nCompared to the previous tracing of the precordial ST segment\nabnormalities are significantly more pronounced.\n\n" }, { "category": "ECG", "chartdate": "2101-03-21 00:00:00.000", "description": "Report", "row_id": 309889, "text": "Sinus rhythm. Left axis deviation. Intraventricular conduction delay. Extensive\nT wave inversions throughout the precordial leads as well as the lateral leads.\nThere are two millimeters of ST segment elevations anteroseptally as well as\none to two millimeters of ST segment depressions anterolaterally. These\nfindings are suggestive of an acute ischemic event/infarction. Compared to the\nprevious tracing of the anterolateral ST segment depressions and T wave\ninversions are slightly less pronounced. Otherwise, no significant change.\nClinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-03-16 00:00:00.000", "description": "Report", "row_id": 310112, "text": "Sinus rhythm. Left atrial abnormality. Left axis deviation. Intraventricular\nconduction delay. Anteroseptal myocardial infarction with ST-T wave\nconfiguration making for age indeterminate - possibly acute or recent process.\nLeft ventricular hypertrophy. Since the previous tracing of right\nbundle-branch block configuration and precordial leads are not present and\nthere are further precordial ST-T wave changes.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2101-03-16 00:00:00.000", "description": "Report", "row_id": 310113, "text": "Baseline artifact. Sinus rhythm. Since the previous tracing of ,\nprobably no significant change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2101-03-16 00:00:00.000", "description": "Report", "row_id": 310114, "text": "Sinus rhythm. Since the previous tracing of right precordial and\nlateral ST-T wave changes are slightly less prominent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2101-03-16 00:00:00.000", "description": "Report", "row_id": 310115, "text": "Sinus tachycardia. Consider left atrial abnormality. Left axis deviation.\nIntraventricular conduction delay. Question atypical right bundle-branch block.\nQS configuration in leads V1-V3 raises consideration of anteroseptal myocardial\ninfarction with accompanying ST-T waves making for age indeterminate - possibly\nacute. Left ventricular hypertrophy with lateral ST-T wave abnormalities - the\nlatter may be due to left ventricular hypertrophy but may be due, in part, to\nischemia. Since the previous tracing of further intraventricular\nconduction delay, right bundle-branch block and possible anteroseptal\ninfarction and further ST-T wave changes are all present.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 310111, "text": "Sinus rhythm. Left atrial abnormality. Left axis deviation. Intraventricular\nconduction delay. Anteroseptal myocardial infarction with ST-T wave\nconfiguration suggesting acute - recent process. Probable left ventricular\nhypertrophy. Since the previous tracing of further ST-T wave changes in\nthe precordial and inferior leads are present.\nTRACING #5\n\n" }, { "category": "Nursing/other", "chartdate": "2101-03-18 00:00:00.000", "description": "Report", "row_id": 1415061, "text": "CCU NSG NOTE: R/I MI/ D/C SUMMARY UPDATE\nO: CV: HR 65-70 NSR with frequent pacs. Pt conts on lopressor and is tolerating it. BP 98-115/50-60 with captopril increased to 12.5 and tolerated it. He received SQ heparin and was changed to lovenox which will start tonight and he is also to start coumadin. Lovenox will be d/c once coumadin theraputic. Groin dry with no ooze or hematoma. All pulses palpable. Rehab begun and pt OOB to chair. Tlerated well with no change in VS.\nRESP: Pt continues to have BBR. 02 sat 94-97% on RA.\nRENAL: Pt received 10mg IV lasix this am with only fair response. Pt now ~300cc neg for the day.\nGI: Pt eating and drinking without problem. NO BM\nENDO: FS elevated to 218 at noon and he received 4u reg insulin.\nSOCIAL: As pt speaks little English a family member is usually with him to help translate. Pt continue to require frequent rests, but is moving well.\nPLAN: Coumadinize.\n Work with family post MI teaching and meds.\n Increase activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 1415056, "text": "CCU Nursing Admission Note 1900-0700: AMI, S/P Stent\nHPI: 84 year old primarily Russian speaking man was admitted to ED with acute onset SSCP/pressure while standing at the bus stop with no radiation to back, arm, or jaw. Soon after became SOB and began coughing up bloody frothy mucous. On ED eval pt found to be in respiratory distress, CXR (+) for pulmonary edema, EKG with ST elevations and new RBBB. VS HR: 114, BP: 170/114, RR 30 and 90%/100% NRB. Pt then started on Nitro at 20mcgs, Heparin at 800u/hr, Lasix 20mg x 2 and sent to CL.\n\nPMH:\nDM, diet controlled\nOA\nS/P hernia\n\nALLERGIES: NKDA\n\nCATH revealing 90% mid thrombotic LAD lesion and 40% mid RCA. Stent intervention to LAD with \"good results.\" Opening pressures RA:5, RV:38/-2, PA:27/8, PCWP:7, AO:94/56, MVo2: 66%, CO/CI:2.85/1.80. Heparin dc'd on arrival to Cath, Nitro weaned during procedure, Integrillin started at 1900 and Plavix given. Right venous and arterial sheath left in place for ACT 380. Transferred to CCU for ovrnoc monitoring.\n\nID: Low grade temp, Tm 99.1 Ax. WBC on admission 11.6. No current issues.\n\nNEURO: Pleasant primarily russian speaking male who speaks very little english. Family and cardiac fellow translating for pt otherwise alert and oriented times three, MAE's and obeying and following commands.\n\nCV: Arrival from Cath Lab with 6FR arterial and venous sheaths in place with constant ooze, no hematoma note noted. Pulses distal easily palpable bilateral. Team and fellow aware. HCT 47 and now 40, will continue to monitor. Repeat ACT at 2200, 299 and 2400, 224. NSR with rare PAC's and PVC's, HR 70's to 80's. SBP 90's to 100's. Nitro restarted at 20mcg for CP, EKG repeated with no changes. CP possibly trasient from procedure considering c/o since CL. Nitro increased to 33mcg with good effect and weaned off at MN for pain free. CK on admission 318 and now possibly peaking at 1086. MB 12 and now 144. Troponin < 2.0 on admission and repeated w/ seconded CK. K repleted for K of 3.4 w/ 40 PO KCL. Integrillin at 2mcg(10ml's) times 18hr and to dc at 1300 and 1/2NS at 100cc/hr times 1L.\n\nRESP: LS with some expiratory wheezes above with some crackles at the bases. Breathing unlabored. RR 20-24, O2 Sats 96-98%. No Lasix given this shift.\n\nGU/GI: Condom cath intact draining clear yellow urine with adequate urine outputs. Abd soft with normoactive BS's. Taking sip of water with pills without difficulty and ordered for cardiac diet. No BM this shift.\n\nENDO: FS at 2200 282, rx with 6u Regular AM FS pending.\n\nHEME: HCT 40 at 2100 with AM HCT pending. T+C on hold in BB.\n\nSOCIAL: Married with three children who are all very supportive. Daughter and wife staying in waiting area, in and out during night. Wife currently at BS.\n\nPLAN:\nContinue to monitor right groin for bleeding and hematoma, will check ACT level this AM with Labs.\nContinue to monitor HCT's and CK's.\nContinue to follow LYTES.\nContinue to monitor respiratory status.\nPossible transfer to floor this AM.\n" }, { "category": "Nursing/other", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 1415057, "text": "CCU Nursing Note Addedum 1900-0700\nPMH:\n ECHO showing LVEF 55%\n\n" }, { "category": "Nursing/other", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 1415058, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: BP 91-114/50-65 HR 60-70's no VEA on captopril 6.25 TID and lopressor 12.5 . has low grade chest pain 0-1. EKG taken this am with same level of CP and had no changes. no SOB.\n\nResp: 2l np rr 16-20, lungs clear.\n\nGI: hypoactive BS, abd soft,non tender. eating small amounts\n\nGU: condom cath ,currently positive by 300cc,BUN/CREAT 29/0.7\n\nID: afebrile\n\nneuro: speaks primarily Russian,alert and oriented x3\n\naccess: two peripheral lines\n\nSocial: wife and adult children in most of day\n" }, { "category": "Nursing/other", "chartdate": "2101-03-17 00:00:00.000", "description": "Report", "row_id": 1415059, "text": "CCU NPN ADDENDUM:\n\nGU/VOLUME: given 10mg lasix at 7pm. goal 500cc negative.\n" }, { "category": "Nursing/other", "chartdate": "2101-03-18 00:00:00.000", "description": "Report", "row_id": 1415060, "text": "CCU Nursing Note 1900-0700: AMI, S/P Stent\nID: Afebrile: No issues.\n\nNEURO: Alert and oriented times three, MAE's, obeying and following commands and turning and repositioning self in bed. Wife at bedside for support.\n\nCV: NSR/SB, HR 50-70's, SBP 90-100's. MAP > 60. Tolerating beta blocker and ACE-I fair. At 0330 this AM did hve 16 beat run of SVT, pt asleep during event at BP stable post. No c/o of CP or SOB .\n\nRESP: LS's clear with fine crackles at bases. RR 20's. O2Sats 97%/> on 2L/NC. Last recieved Lasix on .\n\nGU/GI: Condom cath off last night, voiding in urinal w/o difficulty. Abd soft with normoactive BS's, no BM this shift. Tolerating PO's and cardiac diet fair\n\nENDO: FS at bedtime 187 treated w/ 2uR given. AM FS pending.\n\nSOCIAL: Wife at bedside for comfort.\n\nPLAN:\nTransfer to floor\n\n" } ]

[ { "category": "Radiology", "chartdate": "2136-10-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 773669, "text": " 2:56 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval if increased bleeding.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with h/o CVA on left side, new SDH s/p craniotomy. Currently\n has decreased finger movement on right.\n REASON FOR THIS EXAMINATION:\n eval if increased bleeding.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 year old female with history of CVA on the left side and\n subdural hemorrhage status post craniotomy. Evaluate for increased bleeding.\n\n TECHNIQUE: Axial CT images of the head without contrast were obtained.\n\n The study is compared with the prior exam of .\n\n FINDINGS: This study is somewhat limited due to patient motion. There has\n been interval removal of the right-sided dural drainage catheter. The\n previously described right-sided subdural hemorrhage appears smaller in size\n without evidence of new bleeding. Smaller quantities of subdural gas are\n seen. There is no change in the degree of contralateral shift of normally\n midline structures or the effacement of adjacent right cerebral convexity\n sulci. The size of the ventricles are stable in appearance.\n\n IMPRESSION: Interval removal of right-sided subdural drainage catheter with\n decrease interval in size of right subdural hemorrhage, with no evidence of\n new bleed or change in mass effect.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-19 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 773094, "text": " 8:11 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for acute processes\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of rt sided cva with hemiplegia- possible new facial\n droop also s/p fall\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute processes\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 year old woman with history of right sided CVA and hemiplesia\n with possible new facial droop s/p fall.\n\n TECHNIQUE: Multiple axial noncontrast images were obtained from the head.\n\n FINDINGS: There is a large right sided extra-axial collection. The extra-axial\n collection extends from the temporal all the way back to the occipital lobes.\n Its largest extent is seen in the frontal lobe where it measures approximately\n 2.4 cm in depth. Within the extra-axial collection there is hyperdense area of\n a clot which could represent a subacute on chronic bleed. There is marked to\n midline shift. The midline structures are deviated to the left by\n approximately .9 cm. There is compression of the right ventricle. The left\n ventricle is entrapped ??? and dilated. The basal cisterns are open. There\n are no depressed skull fractures seen. There is hyperdense material seen\n bilaterally behind the maxillary sinuses in the region of the pterygopalatine\n fossa. This should be correlated with the patient's surgical history. The\n visualized paranasal sinuses are well aerated. There are no depressed\n fractures seen.\n\n IMPRESSION:\n\n 1. There is a significant right sided extra-axial collection which is causing\n significant subfalcian herniation.\n 2. Sub-acute intercranial hemorrhage.\n\n Ordering physician was informed of these results at 9:30,\n .\n\n" }, { "category": "Radiology", "chartdate": "2136-10-19 00:00:00.000", "description": "R HIP UNILAT MIN 2 VIEWS RIGHT", "row_id": 773064, "text": " 12:24 PM\n HIP UNILAT MIN 2 VIEWS RIGHT Clip # \n Reason: please evalute for hip/pelvis fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman s/p fall with hip pain.\n REASON FOR THIS EXAMINATION:\n please evalute for hip/pelvis fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 year old woman status post fall with painful right hip.\n\n There are no acute fractures, dislocations, or subluxations seen. Both hips\n are seated. There is vascular calcifications and calcified fibroids seen. The\n visualized bowel gas is nondilated and nonobstructed. Degenerative changes\n seen in the lower lumbar spine.\n\n IMPRESSION: No fracture.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773584, "text": " 1:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess placement of R SC multi-lumen central venous catheter\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n\n REASON FOR THIS EXAMINATION:\n Assess placement of R SC multi-lumen central venous catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 64 year old woman with subdural hematoma and new right subclavian\n central venous catheter.\n\n CHEST XRAY PORTABLE AP: Comparison is made to film taken two hours previously.\n There is a right subclavian venous catheter with tip in the mid superior vena\n cava. The endotracheal tube is visualized with tip 2.7 cm from the carina.\n Nasogastric tube is seen which passes below the level of the diaphragm. Film\n is otherwise limited secondary to motion artifact. The left lower lung field\n is also not visualized on the film. There is likely no significant change from\n film two hours previously.\n\n IMPRESSION: Right subclavian line with tip in mid superior vena cava. No\n pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 773187, "text": " 8:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u s/p evacuation of subdural hematoma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of rt sided cva with hemiplegia- possible new\n facial droop also s/p fall\n REASON FOR THIS EXAMINATION:\n f/u s/p evacuation of subdural hematoma\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right sided CVA with hemiplegia, s/p evacuation of subdural\n hematoma. ? new facial droop.\n\n COMPARISON: (preop).\n\n TECHNIQUE: Contiguous axial images of the head were obtained without IV\n contrast.\n\n HEAD CT WITHOUT IV CONTRAST: The patient is s/p right frontoparietal\n craniotomy, evacuation of large right sided extra-axial fluid collection with\n hemorrhagic component, and placement of drainage catheter. Residual\n hemorrhagic products and gas are seen in the right frontoparietal subdural\n region. There is decrease in the extent of shift to the left involving the\n normally midline structures with partial decompression of lateral ventricles.\n No intra-axial hemorrhage or major territorial infarct are seen. /white\n matter differentiation is preserved.\n\n IMPRESSION: S/P right frontoparietal craniotomy and evacuation of large\n subdural HEMATOMA, with decrease in the extent of midline shift and effacent\n of lateral ventricles. Residual blood and gas are seen in the right\n frontoparietal subdural region.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2136-10-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 773258, "text": " 8:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: check post-op SDH drainage.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of rt sided cva, new left SDH s/p craniotomy\n drainage .\n REASON FOR THIS EXAMINATION:\n check post-op SDH drainage.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n NONCONTRAST HEAD CT SCAN.\n\n HISTORY: Right sided stroke. New left subdural hematoma. Status post\n craniotomy.\n\n TECHNIQUE: Noncontrast head ct scan.\n\n FINDINGS: Comparison with the previuos day's CT scan redemonstrates the\n moderately large right frontal convexity subdural hemorrhage which contains,\n at least in part, high density material consistent with recent hemorrhage.\n There is a subdural drainage catheter seen within this collection as well as a\n small quantity of subdural gas. These latter findings appear stable in\n appearance. Subdural hemorrhage continues to cause effacement of the\n contiguous right cerebral convexity sulci and a moderate degree of\n contralateral shift of normally midline structures. There has been no\n alteration in ventricular size. No new extracranial abnormalities have\n developed in the one day interval between scans.\n\n CONCLUSION: Negligible regression of moderately large right cerebral convexity\n subdural hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773300, "text": " 2:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R scv line placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n\n REASON FOR THIS EXAMINATION:\n s/p R scv line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n History of subdural hematoma and CV line placement. To evaluate for\n pneumothorax.\n\n Right subclavian CV line is in distal SVC. Endotracheal tube is 3 cm above\n carina. NG tube is in stomach. No pneumothorax. Linear atelectases are\n present in both mid zones.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773510, "text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pneumonia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n\n REASON FOR THIS EXAMINATION:\n r/o pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subdural hematoma. Rule out pneumonia.\n\n FINDINGS: A single AP semiupright view. Comparison study dated . The\n endotracheal tube and the right subclavian central line remain in satisfactory\n positions. The heart and pulmonary vessels are unremarkable. Some minor\n linear atelectasis is noted at the left lung base. Otherwise the lungs now\n appear clear. No infiltrates or effusions can be identified. The pulmonary\n vessels are unremarkable.\n\n IMPRESSION: Apart from slight left ventricular enlargement of the heart the\n appearance of the chest are unremarkable. Lines in good position.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773575, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p Right central line placement - Subclavian\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n\n REASON FOR THIS EXAMINATION:\n s/p Right central line placement - Subclavian\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Line placement.\n\n COMPARISON: \n\n SINGLE VIEW CHEST: The ETT is 1.9 cm above the carina. There is a right\n subclavian central venous catheter with tip at the cavoatrial junction. No\n pneumothorax. The tip of the NG tube is in the stomach. No CHF or pleural\n effusion is seen. The degree of atelectasis at the left base is slightly\n improved.\n\n IMPRESSION: Right subclavian central venous catheter tip at the cavoatrial\n junction. No PTX.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-10-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773757, "text": " 5:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post-intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n\n REASON FOR THIS EXAMINATION:\n post-intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subdural hematoma post intubation.\n\n Reference exam - \n\n FINDINGS: The ET tube tip is in good location with the tip 4 cm above the\n carina. The right subclavian line has been removed. There is patchy\n increased opacity at the left base consistent with volume loss with or without\n consolidation. There is increased patchy opacity in the right lower lobe that\n may represent an infiltrate or volume loss. Similar there is streaky\n increased opacity in the right upper lung.\n\n IMPRESSION: Increased patchy opacity in the left lower lobe, right lower lobe\n and right upper lobe that could represent volume loss with or without\n superimposed infiltrate.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-10-19 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 773098, "text": " 9:42 PM\n CHEST (PA & LAT) Clip # \n Reason: Please evaluate for acute cardiiopulmonary processes. Thank\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of DM, HTN, CVA- admitted s/p fall\n REASON FOR THIS EXAMINATION:\n Please evaluate for acute cardiiopulmonary processes. Thank you.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 21:34\n\n INDICATION: Recent CVA. Hypertension.\n\n FINDINGS: The aorta is slightly tortuous and the aortic knob shows\n calcification. There is no infiltrate or effusion. The pulmonary vascular\n markings are normal and the cardiac and mediastinal contours appear within\n normal limits.\n\n IMPRESSION:\n\n 1. No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2136-10-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 773137, "text": " 11:48 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o re-accumulation of SDH patient decompensated after place\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of rt sided cva with hemiplegia- possible new facial\n droop also s/p fall\n REASON FOR THIS EXAMINATION:\n r/o re-accumulation of SDH patient decompensated after placement of bedside\n drain.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of right sided CVA with hemiplasia and possible new facial\n droop. S/P fall. Patient has a known subdural hematoma on the right with\n recent decompensation after placement of bedside drain.\n\n COMPARISON: Head CT from .\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There has been interval placement of a subdural drain and drain from\n the right frontal approach. There is new high attenuation material within the\n subdural collection which was not present one day previously. The greatest\n dimension of the subdural collection currently measures 2.5 cm. This is\n increased slightly from the prior study. Again, there is new acute blood\n within this collection as well as air. The blood tracks over the right\n cerebral hemisphere including the temporal and parietal lobes. There is\n significant shift of the midline structures and subfalcian herniation. The\n right frontal is nearly completely compressed. The right occipital \n is obliterated. There is dilation of the left ventricle, not significantly\n changed. There is no definite uncAL herniation. No intraventricular blood is\n present.\n\n No traumatic skull fractures are present. There is significant soft tissue\n swelling overlying the right frontal area. The orbits and paranasal sinuses\n are unchanged.\n\n IMPRESSION: S/P subdural drain placement with new acute hemorrhage within the\n subdural collection and slightly worsened subfalcian herniation to the right.\n\n These findings were relayed immediately to the neurosurgical staff caring for\n the patient. The patient is going to the operating room at this time.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 773173, "text": " 1:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O PULM EDEMA/CHF S/P DRAINAGE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with SUBDURAL HEMATOMA\n REASON FOR THIS EXAMINATION:\n R/O PULM EDEMA/CHF S/P DRAINAGE SUBDURAL HEMATOMA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: 1:46\n\n INDICATION: Drainage of subdural hematoma - now intubated.\n\n COMPARISON: at 21:34\n\n FINDINGS: Tip of the endotracheal tube is 5.1 cm above the carina. There is\n no pneumothorax. Diffuse coarsening of pulmonary vessels is noted consistent\n with an element of fluid overload. The pattern is not one of cardiogenic\n pulmonary edema as the heart size appears normal. There are no effusions.\n No focal consolidation.\n\n IMPRESSION: Fluid overload, a change vs. prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2136-11-08 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 774604, "text": " 2:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: decreased mental status, re-eval sdh\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman with hx of rt sided cva, new left SDH s/p craniotomy\n drainage .\n REASON FOR THIS EXAMINATION:\n decreased mental status, re-eval sdh\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: History of right sided CVA new left subdural status post\n craniotomy.\n\n Noncontrast head CT.\n\n Exam was compared to prior study of .\n\n There is reduction in size of the right sided subdural collection. There is\n some reduction in the density as well. There is slight reduction in the degree\n of right to left subfalcine herniation with the herniation measured at the\n posterior septum of being only 1-2 mm. There is some swelling of the right\n hemisphere.\n\n IMPRESSION: Reduction in size and mass effect secondary to right sided\n subdural hematoma since the prior study.\n\n" }, { "category": "Radiology", "chartdate": "2136-11-06 00:00:00.000", "description": "UNILAT UP EXT VEINS US", "row_id": 774413, "text": " 1:07 PM\n UNILAT UP EXT VEINS US Clip # \n Reason: SWELLING IN LT ARM\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old woman subdural s/p CVL with L arm swelling\n REASON FOR THIS EXAMINATION:\n r/o thrombosis of L subclavian vein\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Left arm swelling.\n\n DUPLEX FINDINGS: There is normal flow and spectral Doppler waveform in the\n left IJ, left subclavian, left axillary, left brachial and cephalic veins.\n There is normal compression of the brachial, cephalic and axillary veins on\n the left.\n\n CONCLUSION: No evidence of subclavian thrombosis on the left.\n\n" }, { "category": "Radiology", "chartdate": "2136-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1260456, "text": " 7:44 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ASSESS LINE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM.\n\n History of subdural hematoma with intubation and line placement.\n\n Endotracheal tube is at the carina with neck flexed and too low for optimal\n position. Left subclavian CV line is in proximal SVC. NG tube extends below\n diaphragm. No pneumothorax. The lungs are clear.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-06 00:00:00.000", "description": "Report", "row_id": 1356349, "text": "Nursing Addendum\n\nAt 6:30 pt looking uncomfortable, when asked if she hurt she said yes, asked to point where she pointed at her abd, chest, said yes to neck pain, did not answer to head pain. ABG was normal, EKG done intern to look at it, she was given 5 mg of MS04 and she looked more comfortable but when you woke her up she said that she was still in pain but it was difficult to asess where.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-07 00:00:00.000", "description": "Report", "row_id": 1356350, "text": "MICU NPN\nNeuro: pt alert, mouthing words, follows commands and anwering yes/no to some questions. MAE - left stronger than right. Pt intially denied pain then at 2am pt very restless BP up to 170s, c/o pain in back. Given MSO4 2mg with minimal effect. Pt given 5mg with good effect - restlessness resolved, pt denying pain, BP down to 130-140s\n\nRespiratory: lung sounds coarse throughout. Cont on 50% trach mask overnight with sats >95%. Suctioned q1-2for thick yellow secretions from trach. Cont to have copious oral secretions.\n\nCV: BP 130-170s HR 70s SR. K+ 3.5 Mg 1.5 Pt presently receiving KCL 40meq and MgSO4 2mg\n\nEndo: BS labile overnight 91-146. Insulin gtt titrated between 2-3u/hr to keep BS in 80-120 range.\n\nID. Tmax 99.8. Cont on Vanco.\n\nGI: cont on TF promote with fiber at goal rate 60cc/hr. Cont to pass soft stool.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-05 00:00:00.000", "description": "Report", "row_id": 1356344, "text": "NPN\n\nCV: Tolerating her BP meds, hypertensive during the trache and PEG but responded well to sedation.\n\nResp: Trached, she has been on IMV since noon in preparation for the trache, she remains on IMV 500x10, 5 PEEP. She conts to have a lg amount of secreations from her mouth, now bloody secreations from her ETT due to the trache incertion. LS clear after suctioning, not overbreathing the vent.\n\nGI: PEG placed, TF off at 8:30am, PEG placed at ~ 2pm, only essential meds down PEG, full use - ie TF can start tomorrow morning. She conts to have loose stool.\n\nGU: u/o 30-40cc/hr, cloudy - sent for c&s\n\nNeuro: Weak on the R, usually follows commands.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-05 00:00:00.000", "description": "Report", "row_id": 1356345, "text": "NPN Addendum\n\nPt's insulin gtt was turned off soon after her TF was shut off for the trache and PEG, it was turned back on when they were done with the proceedures, still the goal is 80-120. She has been started on D5 at 40cc/hr for maintance fluid. She remains sedated after the trache and PEG - she recieved 200mcg fent, 200 mg propofol, 10 vec, she has since received a total of 10mg of MS04 for pain this afternoon. She does respond to voice, she has not been following commands since her sedation was increased. Her family - daughter, sister, and husband have all called today asking how she is doing, a sister was in this morning. She was given one does of IV levoquin for the proceedure, the vanco conts, trough was sent prior to her noon dose.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-05 00:00:00.000", "description": "Report", "row_id": 1356346, "text": "Resp Care\nremains on vent support. s/p perc. trach #8.0. also bronched after procedure for mod amts bld tinged secretions. presently still now awake from sedation...on full support but will change to spont mode when awake. should be able to wean to trach mask tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-06 00:00:00.000", "description": "Report", "row_id": 1356347, "text": " to 0700 shift summary 0520\n\nPt has had quiet night. VS stable, periods of agitation with coughing and gagging. Copious oral secretions noted.\n\nN/ pt does not follow cammands but withdraws to pain and sometimes localizes. Pupils are equal and reactive. Mae, remains restrained. Nods head at and says yes that she is experiencing pain, unable to indicate where. Mso4 given IVP per PRN.\n\nCV/ NSR, few PVCs noted. Bp stable, rises interminently with coughing. Tmax 101. Dr aware, tylenol given. All extremities are warm with good pulses, little edema noted.\n\nPulm/ #8 perc trach WNL, no bleeding noted at site. Blood tinged secretions have lessened through out the night. Gags alot, with copious thick clear secretions with some old blood noted. Lungs are coarse through out all fields.\n\nGI/ PEG tube dressing dry and intact. Meds given only, will restart TF this am at 0800. Abdomen is soft and non tender. Small smear of brown stool noted with bath. Hypoactive BS noted.\n\nGU/ Foley draining adequate amounts of urine to gravity.\n\nSkin/ Dry and intact, no breakdown noted. Small red area noted to R abdomen.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-06 00:00:00.000", "description": "Report", "row_id": 1356348, "text": "NPN\n\nCV: BP higher today, 140-160, HR 70s SR, conts on her atenolol and clonidine, no changes were made in her doses.\n\nResp: Pt put on a trache mask, she has tolerated it well, ABG on 50% and RR 24 7.37/41/83/25/-1. LS coarse, strong cough, she has coughed up a lg amount of sputum during the day yellow and thick. She has had less oral secreations today, mainly they are clear.\n\nGI: Pt is on TF Impact with fiber at 60cc/hr. ABD soft and distended, stooling mod amounts of golden loose stool, OB neg.\n\nGU: u/o ~ 40-50cc/hr, no diuretics were given.\n\nNeuro: Alert, follows commands on and off, given 2 bags of FFP for a INR of 1.6, coags sent at 4:30pm. Her L side remains stronger than her R, she will make purposful movements when her hands are unrestrained. L arm noted to be painful with movement and to be larger than her R, an US was done to r/o a clot.\n\nEndo: Conts on an insulin gtt, gtt curently at 4.5 U/hr to maintain a FS of 80-120.\n\nID: T max 100.3 PO, vanco trough was 8.1 after 24 hrs, frequency was changed to q18hrs.\n\nSoc: Sister and husband were in today. Seen by , they said that she would be a good canidate for their rehab, they need her to be off the insulin gtt and to apply for medicare.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-28 00:00:00.000", "description": "Report", "row_id": 1356334, "text": "Neuro: Propofol d/c'd this am at 0730 and had not required any sedation since. She may have Ativan/MS04. Generally she is lethargic, but opens her eyes to stim. Occ she follows commands by squeezing w/ her left hand. Occ she moves other extrems spont, but rarely. Withdraws all extrems to painful stim. Pupils 3mm/brisk.\n\nCardiac: Stable. HR=60-80's, nsr, no ectopy. BP=110-150s/60s. +periph pulses, extrems cool, + edema. T=99.8 rectal.\n\nResp: Currently on CPAP/PS at 5/15 w/ 02sat=98-99%. ABG was adequated on PS=20. Vt=370-480. Lungs coarse, suctioning tan/bloody secretions via ETT and cloudy/bloody secretions via mouth. RR=13-20.\n\nGI: +BS, no BM - rectal bag in place. TF at 60cc/hr w/ 25-30cc resid.\n\nGU: foley cath, amber urine\n\nSkin: Head incisions intact - staples/sutures intact.\n\nIVs: 2 periph IVs, NS at KVO. Insulin and propofol gtts d/c'd this am. IV Dilantin changed to po.\n\nPlan: Continue w/ slow resp wean. Check fingersticks QID. Medicate for comfort PRN.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-29 00:00:00.000", "description": "Report", "row_id": 1356335, "text": "NPN\n\nNeuro status improved from yesterday for me, given lasix for pos fluid status.\n\nCV: BP much better controled with her regular meds\n\nResp: Much more secreations today than yesterday, from both her ETT and her mouth. VTs ~ 300, min vent 4-8 L, requiring sx ~ q1 hr\n\nGI: TF cont, tol well, stool - soft brown in FIC\n\nGU: ~ 1 L pos at 2300, given 20 mg of IV lasix with good effect.\n\nNeuro: More alert today than yesterday, following commands more consistantly, moving all extremities now, L stronger than R.\n\nEndo: Back on an insulin gtt, up to 5 u/hr to off. TF need to be shut off around her dilantin so she can absorb it and this decreases her insulin requirements\n" }, { "category": "Nursing/other", "chartdate": "2136-10-29 00:00:00.000", "description": "Report", "row_id": 1356336, "text": "\n7Ato 7P shift summary\n\nPt had very stable day. Sutures were removed from head, tegram applied to some areas, no oozing noted. Continued Insulin gtt with ranging from 1 unit to 4 units/hr, to keep FS 80 to 120. NSICU team wants pt 2L negative today. Lasix gtt was started and is up to 4mg/hr, currently as of 1800 pt is just over 1L neg. with good urine output. Had periods of agitation, were she was wiggling so much she loosened her ETT tape (retaped today), was given 2mg Ativan with good effect. go for Trach and Peg tomorrow, or if improving may wait another day to see if she will be extubatable.\n\nN/ As mentioned above required PRN doses of ativan for agitiation, otherwise, alert and following commands. R sided weakness from previous stroke. Mae. Pupils are equal and brisk. Only pain she acknowledged was with coughing in her chest.\n\nCV/ NSR in the 70's , BP stable on PO antihypertensives. Temp up to 100 today. Same IV lines, Insulin gtt currently at 3 units/hr and Lasix currently at 4 mg/hr. All extremites are warm with good pulses.\n\nPulm/ Remains on Ps15Peep5 fio2 40%. Good ABG today. Lungs are coarse through out, SPo2 has been >95% all day. Sxning freq for thick clear sputum, last sxn was noted to be blood tinged, continue to monitor. Copious clear oral secretions noted. <ay trach in the next few days if not able to extubate.\n\nGI/ Abdomen is large, soft, non tender. Positive BS, has rectal bag with thick brown stool noted. Promote with fiber continues at 60 cc/hr. Nutrition was consulted today about stopping tf for admin of PO dilantin, stated that research shows you don't have to hold TF, just need to flush the tube well before and after the administration of Dilantin.\n\nGU/ Lasix gtt at 4mg/hr, good out put. Want pt 2L neg today, currently just over 1L neg. New foley placed today and started on fluconazole for UTI.\n\nSkin/ Head insicions weel approx , with no oozing. Skin is warn and dry with no breakdown noted. had bath today.\n\nPlan/ wean vent as tolerated. need Trach and PEG in next day or 2 if not avle to extubate.\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-29 00:00:00.000", "description": "Report", "row_id": 1356337, "text": "Resp care\npt maintained on psv mode today with ps 15/5/40%. vt low in the 200's with low Ve...however stable abg d/t met alkalosis. sxned intially for whitish/clear...then yellow/bld tinged. no cuff leak this morning on rounds..cuff requires only 2.5 cc's to seal. c/w airway mgmt.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-30 00:00:00.000", "description": "Report", "row_id": 1356338, "text": "NPN\n\nCV: VSS, becomes hypertensive with aggitation. HR stable, SR, tolerating her CV meds.\n\nPulm: She conts to have a huge amount of secreations from her mouth and mod to lg amounts from her ETT - thick yellow to blood tinged. LS coarse - cleared after suctioning. No changes were made on the vent\n\nGI: Loose stool, tol TF\n\nGU: Conts to have a good u/o on the lasix gtt, she was 1700 neg at MN\n\nNeuro: Not consistantly following commands, will have purposeful movements R side remains weaker than L. She was aggitated at 4 am and given ativan with good effect.\n\nEndo: Conts on an insulin gtt to maintain a BS 80-120.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-30 00:00:00.000", "description": "Report", "row_id": 1356339, "text": "Resp Care\nremains ett/vent support. c/w no cuff leak with only 2 cc's to seal cuff. suctioned frequently bld tinged secretions. sl agitated. vent status stable on ps 12/5/40%.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 1356320, "text": "NURSING PROGRESS NOTE 0700-1500\nNEURO--PROPOFOL OFF. FOLLOWS COMMANDS AND ATTEMPTING TO MOUTH WORDS. ASKED TO HOLD UP 2 FINGERS AND SHE DID CORRECTLY. NODS HEAD TO SIMPLE QUESTIONS. MAE SPONT AND TO COMMAND. NO SEIZURE ACTIVITY OBSERVED.\nRESTLESS BUT RESPONDS TO VERBAL STIMULATION. PEARL AT 3-4 MM.\n\nCARDIAC--AT ONSET OF SHIFT, PT WITH RATE 160'S. AFIB NOTED. SBP DECREASED FROM 140'S TO 90-100. GIVEN TOTAL OF 10MG IV LOPRESSOR WITHOUT RESULTS. HO PUSHED TOTAL OF 250MCG IV ESMOLOL. CARDIOVERTED WITH 100 J AND CONVERTED TO NSR BUT DID NOT STAY. CARDIOVERTED WITH 200 J AND CONVERTED TO NSR AND REMAINS THERE. STARTED ON ESMOLOL GTT AT 100 MCG/KG/MIN. REMAINS IN SR WITH FREQUENT APC'S. K+REPLETED.\n\nRESP--ATTEMTPING TO WEAN. REMAINS RESTLESS. +COUGH. -GAG. ABG'S PENDING ON IPS . SPONT RESP 20-28. COPIOUS AMTS OF THICK TAN BLOOD TINGED SPUTUM. SX Q30-60 MIN. LUNGS COARSE IN UPPER LOBES AND DECREASED IN BASES. NO WHEEZE HEARD.\n\nGI--TOLERATING TF AT 50 CC HR BUT ON HOLD PENDING EXTUBATION. NO STOOL ABD SOFT AND DISTENDED.\n\nGU--UO>30 CC HR OF CONCENTRATED URINE.\n\nENDO--REMAINS ON INSULIN GTT NOW AT 6U HR. BS 228. RECHECKING Q1HR.\n\nSKIN--HEAD INCISION CLEAN AND DRY WITH STAPLES INTACT. BUTTOCKS WITHOUT BREAKDOWN. SKIN CARE GIVEN.\n\nCOPING--FAMILY IN AT BEDSIDE. THEY HAVE LEFT FOR THE DAY. HUSBAND WAS PRESENT. PER DAUGHTER, PRIOR TO ADMISSION, PT HAS PERIODS OF APNEA WHEN SHE IS SLEEPING AND WAKES HERSELF UP WITH SNORING.\n\nA--RESTLESS BUT RESPONSIVE\n\nP--CON'T PULM TOILET. ATTEMPT TO WEAN TO EXTUBATE. RESTART TUBE FEEDS. ASPIRATION PRECAUTIONS.\n\nPAIN--NODDED HEAD YES\" TO PAIN. GIVEN 1 PERCOCET WITHOUT RELIEF.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 1356321, "text": "ADDENDUM TO NOTE.\nPROPOFOL PLACED BACK AT 10 MCG/KG/MIN ON AT 1415 FOR AGITATION AND RESTLESSNESS.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 1356322, "text": "MICU NSG 3P-7P\nPT FOR TEMP SPIKE. CONTS ON ESMOLOL GTT WITH GOOD BP HR CONTROL. INSULIN GTT OFF AT 5PM FOR FS 75, 1 AMP D50 GIVEN. PROPOFOL GTT OFF FOR 10MIN FOR NEURO ASSESSMENT. PT INCONSISTENTLY RESPONDS TO COMMANDS, NO SZ ACTIVITY NOTED, GOOD COUGH AND GAG. PLACED BACK ON IMV 10 500 40% PEEP 5 DUE TO LOW TV'S.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-25 00:00:00.000", "description": "Report", "row_id": 1356323, "text": "cns- pt kept sedated with propofol gtt. peerl with gtt lightened, will rouse easily with stim, locates, and occ follows simple commands.\n+cough, no gag. dilantin coverage continues. no szr noted.\n\ncv- sr with pacs/pvcs. vss. on esmolol gtt for rate control. insulin gtt for bg control. abx coverage continues.\n\nresp- see resp notes/flowsheet for details. freq sxn for tan/yellow sputum with occ bloody tinge. copious oral secretions. lungs coarse.\nmostly following vent, though overbreaths when propofol gtt lightened.\n\ngi- tf stopped at mn for large residuals; not resterted as yet for same. abd obese. bt+ ngt in place.\n\ngu- min uop-lasix 20mg iv given x2 with small diureses. yellow with sediment.\n\nmsi- scd's in place, turned q2hrs. family updated.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-25 00:00:00.000", "description": "Report", "row_id": 1356324, "text": "potassium being repleted, needing mag repletion as well.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-25 00:00:00.000", "description": "Report", "row_id": 1356325, "text": "Nursing Progress Note.\n\nRESP: Pt received on MV/SIMV mode c the following vent settings; 10-40-500-5.0. Pt c PAP's in the mid 20/low 30 range, sats in the high 90's. 04:00 ABG values WNL. Pt c fairly copious amounts of white thin secretions turning into thicker/tannish sec throughout the shift. LS were more coarse in upper lobes this AM, become slightly clearer over shift, bases have remained mildly diminished. No wheezing appreciated. The pt Propofol was weaned down to facilitate a CPAP/PS (18/5) trail c mixed results -- ABG values were good @ 11:00 (7.40-50-108) but the pt was highly agitated and quite uncomfortable. Per team, IV Propofol sedation titrated back up for comfort and the pt was returned to her resting SIMV settings. 15:00 ABG values are as follows; 7.42-47-95. Of note, the pt has had large quantities of oral secretions today.\n\nCV: Pt received on an IV Esmolol gtt @ 100mcg/kg/min via TLC. NSR all day c occ PAC's. No Afib or SVT today. 99.8 Tmax @ 15:00 noted. K, Mg both repleted per sliding scales, these labs have been re-drawn and the results are currently pending. INR = 1.5 c AM labs, team aware and pt subsequently transfused two units of FFP prophylactically to minimize risk of bleeding(no evidence of bleeding @ this time). No adv rxn was evident during FFP admin. Per team, R SC TLC was d/c'ed today and replaced c a quad-lumen venous catheter to facilitate TPN therapy. QLC placement confirmed by CXR. Old TLC cath tip sent for C&S analysis.\n\nDM: FS in the 81-175 range today, titrating IV Regular Insulin gtt to keept FS in the 80-120 range. The pt is currently receiving 2units/hr of Regular Insulin per QLC.\n\nMS: Pt currently receiving 40mcg/kg/min IV Propofol c good pt comfort noted. Pt easily arouses to verbal/tactile stimulation, follows commands (squeeze my hand) and nods head appropriately to simple yes/no questions. Off sedation the pt becomes agitated quite easily and experiences freq coughing spells. UE restrained to primarily protect ETT. AM Dilantin level = 18, per team the pt was bolused c an additional 500mg IV Dilantin @ 14:00 to minimize risk of seizures. No overt evidence of sz evident today thus far. PERRL. Strong LUE/LLE strength noted. Moving RUE weakly, infreq moves RLE.\n\nGI: Full strength Promote c Fiber tube feeding restarted @ 30ml/hr via OGT this am. Minimal residuals noted thus far, will calibrate rate up as tol to achieve the goal of 60ml/hr. No BM thus far today. Abd is obese, distended, soft, c + BS appreciated.\n\nDERM: Sutures on head are C/D/I. New R SC QLC in place is also C/D/I.\n\nFAMILY: The pt's dtr has called and freq visited today, kept up-to-date c POC/pt status. The pt is a full code.\n\nOTHER: Please see CareVue for additional pt care data/comments.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-27 00:00:00.000", "description": "Report", "row_id": 1356332, "text": "Pt weaned from SIMV to CPAP 5,5PSV .40FI02 at 0915. Tolwell. Pt remained on CPAP throughout the shift with good spont breathing trial on 40% ,0/0. Pt extubated at 1530. Pt suctioned large amount of clear watery secretions. Pre extubation ABG (see carevue). Pt immediately became , breathing increasingly labored, pt on 100% shovel mask 02 sats low 90s decreasing. pt sx,MD notified, Anesthesia notified. Pt emergently reintubated by anesthesia, 02 sat pre intubation on 100% ambu decreased to 53%. Pt difficult intubation due to upper arway /vocal chord swelling. Post intubation 02 sat 100% on ambu . pt placed on 7200 ventilator. SIMV 10, VT 500, 100%, 5 peep. FI02 decreased to .40 at 1800\n" }, { "category": "Nursing/other", "chartdate": "2136-10-28 00:00:00.000", "description": "Report", "row_id": 1356333, "text": "NPN\n\nCV: Hypertensive to the 190s, aggitated, given 37.5 mg of lopressor (Propofol cont) with little effect, 2 mg of ativan given she eventually settled down, requried an additional 2 mg of ativan later on in the night with good effect. She was on atenolol 50mg and clonidine 0.1 mg at home, she may need additional lopressor to meet her BP needs and or add clonidine and change to atenolol.\n\nNeuro: Pt on Propofol and prn ativan, aggitated on evening, given 2 mg of ativan x2 with good effect. She is not following commands consistatly, she usually will open her eyes to verbal command, she sometimes moves her L arm/hand to command, her extremity movement is usually to deep painful stimuli, she does not move her R hand/arm. When her L arm is out of the restraint it moves towards the ETT, her legs will occationally move on the bed without any painful stimuli. The HO is aware of her inconsistancy and no movement in her R arm/hand. Dilantin is 26 this am.\n\nResp: Pt was on changed to PS but her min vent was < 3 L so put on IMV 500x10, 5 PEEP, 40%, SATs high 90s, ABG ok. LS coarse, cleared with sx, mod to sm amount of thick blood tinged sputum, lots of secreations in her mouth.\n\nEndo: Remains on an insulin gtt has gone between units/hr, presently on 4.5.\n\nGI: Conts on TF at goal, low residuals, no BM, good BS.\n\nGU: Good u/o but still ~ 600cc pos at MN, no lasix was given.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-23 00:00:00.000", "description": "Report", "row_id": 1356317, "text": "Neuro: Sedated on propofol but when lightened opens eyes spontaneously and to command. MAE. Right side appears weaker than left related to old CVA. PEARL. At 1400 witnessed pt to have focal seizure involving her right arm only for approx 3 minutes. Team called and 2 mg ativan IV administered. No further seizure activity noted. VSS during this event. Dilantin level 32 (high).\n\nCV: Currently off of nipride and BP < 160 and > 120. Mid afternoon noted PAC's and PVC's on monitor. Neurosurg in and aware of finding.\n\nResp: Unable to extubate today related to BP earlier in the day.\nPt agitated when lightened off of propofol with increased BP. Purposeful moovements to self extubate attempted. L/S-clear with thin secretions. FIO2 decreased to 40%. See CareVue for ABG's.\n\nGI/GU: + bowel sounds. NGT being used for po meds and clamped.\nApproached neurosurg about tube feedings and decision to be made\nabout initiating TF. None ordered at present. Foley draining dark concentrated sediment urine. No BM.\n\nEndo: Insulin gtt started related to high FSBS. Q1H FSBS maintained.\nSee CareVue for gtt/FSBS data.\n\nHeme: Received 2 U FFP for INR 1.4. Q8H coags ordered.\n\nID: Remains on vanco. Max temp 101.2 po.\n\nPlan: Maintain frequent neuro checks, support hemodynamics as needed,\nreplace lytes prn, monitor plt and INR Q8H and administer FFP/platelets as needed, FSBS, hold 8PM dilantin dose and recheck dilantin level in AM, repeat head CT in am and support pt and family.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-11-08 00:00:00.000", "description": "Report", "row_id": 1356353, "text": "Please refer to nsg tx note for full review of systems.\n In brief, pt ready for tx to floor when she was found to be more difficult to arouse than previously. Pupils 3m/reactive, FS in 200's. NSURG resident paged--eval pt at bedside. CT obained--no changes from previous scans per resident. Pt eventually woke up and returned to baseline without intervention. ? dilantin involvment--level at 0400=25.\n Pt continues to clear secretions independently--mod amts thin white sputum.\n TF continue at 60 cc/hr--FS at 1800=229. Covered with 15 u NPH and 6 u regular per SS. Pt stooled several times today, colase held. Abd benign.\n Pts tx to floor on hold with ? MS pt is re-called out to floor and awaiting bed assignment.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-08 00:00:00.000", "description": "Report", "row_id": 1356354, "text": "NPN 7p-11p:\n Pt spiked temp to 101 rectal.. Dr. notified, as well as neuro MD.. blood cx x 1 sent, urine and sputum specs sent as well. pt med with tylenol.. pt fidgety early in shift.. rr mid 20's, constant sputum production.. yellow tinged, but also frothy/white.. sats 100% csm 50%.. LS bibasilar rales.. fluid balance 600cc's + today, 1L + each day past 2 days.. DR. notified.. pt med with 20mg lasix iv.. await effect.. sleeping now on R side. bm x 2.. smearing on pad.. needs spec sent when able. neuro status unchanged. alert and responsive. cont to require significant ssi on increased dose nph.. dose increased to 20unph . will give additional 5unph wht 12 am fsbs, then start 20 u nph at 6am.\n A/P: await bed on floor.. follow fluid balance, follow fsbs on increased dose nph.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-09 00:00:00.000", "description": "Report", "row_id": 1356355, "text": "Nursing Note: 12mn - 7am\nPt slept x3 hrs then awake restless, fidgeting, follows some commands, move all ext, no c/o of pain.\n\nResp- requires freq suctioning, despite her coughing up at times, suctioned for thick whitish secretions. Rhonchourous bs bil.\n\nCV- hr 70s - 80s sr, no ectopy, bp stable. lIJ tlc intact, all ports patent. She wa sdiures with lasix 20mg iv, responded well.\n\nGI- +bs, abd soft, soft yellow stool x1, continue on impact with fiber at 60cc/o via gt, minimal residual.\n\nGU- foley to cd, voiding cl yellow urine.\n\nENDO- fsbs 155, sarted on nph 20u sc this am.\n\n Pt spiked temp on evenings, pan cx, now started on levofloxacin for UTI.\n\nSkin- warm, dry and intact.\n\nSocial- no family contact overnight.\n\n Pt is called out to the floor, transfer note written, await bed placement.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-23 00:00:00.000", "description": "Report", "row_id": 1356318, "text": "Respiratory Care Note:\n Patient remains intubated and sedated on 20-30mcg/Kg/hr propofol. BS with occassional scatterd rhonchi esp RUL. Suctioned for small -med amounts of med thick yellowish secretions. Patient on SIMV and PS settings noted in carevue. FIO2 weaned to 40% today with good ABG results. Nipride is off and patient is maintaining adequate BP. She awakens slightly at times. No further seizure activity noted. Plan to maintain present level of support at this time.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 1356319, "text": "cns- rousing pt q2hrs to assess neuro status-unchanged. peerl. opens eyes to command/voice mostly. mae. no szr activityl noted. remains on propofol gtt at this time. given percocet 2 tabs x2 for pain control.\n\ncv- sr with occ pac/pvc. vss, though sbp occ somewhat high with turning/sxn. nipride gtt remains off. regular insulin gtt at 2u/hr.q2hr bg. see flowsheet for details.\n\nresp- see notes/flowsheet for details. lungs clear/coarse. sxn several times for mod amts tan/yellow sputum. copious oral secretion.\n\ngi- tol tf well via ngt with min residuals. cont at 40cc/hr. abd obese, bt+\n\ngu- amber to yellow uop with sediment. minimal amts.\n\nmsi- turned q2hrs, scd boots on. daughter updated early last noc. weaning this am?\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-20 00:00:00.000", "description": "Report", "row_id": 1356312, "text": "Nursing Note\nPt was in MICU this am for subdural drain placement. First drain inserted by neurosurg after premedicated w/Fentanyl 100mg and versed 3mg total. Pt very sedated, but maintained good sats, vs remained stable. Drain appeared clotted, so new one retrieved, and second drain reinserted at approx 10 am. At that time, pt was aaox3, MAE's and approx 100 cc old and fresh blood was drained. (Pt was given Fentanyl 50mcg, and versed 1mg.) She remained stable, on low dose iv ntg for b/p control, 2l nc with sats 97-99%, and was watching tv and dozing.\nAt approx 11:20 am, b/p and hr dramatically increased, pt stated she \"feel very sweaty\" She was diaphorhtic, sbp was over 200 and hr 130's. She appeared to be seizing, with larger hematoma over drain incision site. Neuro team called stat, ntg incr. and nrbm placed. She became unresponsive, apnea >20 secs, and was then intubated by anesthesia. Med team assisted at bs. Rt fem tlc attempted, but not successful. IV Nipride started, NS bolus 500 cc given for o flow b/p. B/P and hr very labile, requiring freq titration. Dr. at bs, pt then transported for emergent ct. Showed \"fresh bleeding\", was then taken to OR . Initial assessment as per careview. Dtr is here, and has been updated by MD's regarding progress.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-20 00:00:00.000", "description": "Report", "row_id": 1356313, "text": "Nursing note cont\nPt also recieved 2u FFP enroute to CT/OR or for incr INR. She remains in PACU at this time.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-22 00:00:00.000", "description": "Report", "row_id": 1356314, "text": "Resp. Care Note\nPt readm to MICU from PACU. Required intubation after second seizure, apnea and poor PaO2. Pt tubed with 8.0 ETT secured at 22cm lip. Placed on 7200 with initial settings SIMV 600x 12x 100% peep 5 psv 5. ABG 7.39/39/349. FiO2 decreased to 50%. Cont to support ventilation, follow ABG's.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-22 00:00:00.000", "description": "Report", "row_id": 1356315, "text": "PMICU Nursing Progress Note 10a-7p\n PT transferred this am from PACU for cont monitoring following R frontal craniotomy yesterday. While in PACU this am, pt taken to CT for a head scan, no further blding detected. Upon arrival to MICU, pt expereinced acute mental status changes and started to have sm focal seizures last for 30-40 seconds, pt unresponsive during these epsiodes. HO alerted and came to assess pt, she then received a 500 mg of Dilantin. Over the next hour, pt cont to have small seizures, w/ increasingly diminished mental status following each seizure. PT also became increasingly hypertensive and was started on a nitroglycerin gtt per HO orders. Around 1200 pm, pt started to seize more intensely. The seizing lasted from 3 to 4 min, she b/c hypertensive into the 200's, desaturated to the low 90's and had jerking facial movements. , pt became apenic and was unable to protect airway. She had a triple lumen central line placed in RIJ and was intubated by neuro team. Placement of all lines confirmed w/ chest xray per team. Since that time she has been stable, BP controlled w/ nipride gtt and sedated on Propofol.\n\nCurrent ROS-\n\n Pt arousable to voice and stimuli, not following commands. Sedated on 18 mcg/kg/min of Propofol. PERRLA, bsk. MAE. Recieved 1 gm of dilantin today, level following 27, HO aware. Goal level btw 20-30. EEG this afternoon, please follow up on results w/ team. Cont q hr neuro checks. Subdural drain removed by neuro team today. Site sutured and in dry and intact. All other suture lines open to air and intact.\n PT intubated on SIMV TV 500x10x50%fio2x5peep. Last ABG (w/ rate of 12) 7.45/30/146/21/-1. ABG folowing decrease in rate pending. Sats 96%. LS coarse in upper lobes, slightly diminished bases. Suctioned 2x for sm, thick white secretions.\nCV- HR 70's, Current SBP 136/59 on 2 mcg/kg/min of Nipride. Please follow trends on CareVue and titrate Nipride to attain SBP <160. Nitroglycerin gtt dc'd, prior to initiation of Nipride gtt. Repleted w/ 2 gm of mag sulfate this afternoon. Also recieved 2 Units of FFP for INR of 1.5, goal INR is 1.3. Plan to send recheck coags in 1hr.\nGI- Abd soft and slightly distended, hypoactive BS. No BM. Currently pt is NPO, team plans to start TF tomorrow. Cont to follow BG, both sliding scale and fixed insulin orders in\nGU- Adequate u/o, foley patent. cont to follow output.\nID- Cont on IVAB. low grade temps today,cont to follow.\nSocial- Daughter called this evening and given update on status by nsg. NSICU resident called and notified that daughter would like to be updated by team, he recommended having neuro contact her. Please notify them tomorrow am.\nPlan- Cont supportive medical care and close monitoring of neuro status. Follow up on all labs w/ team/\n" }, { "category": "Nursing/other", "chartdate": "2136-10-27 00:00:00.000", "description": "Report", "row_id": 1356330, "text": "rn progress note\n 4am\nneuro: propofol at 10mcg/ at beginning of shift. pt alert turns head to name calling. follow commands inconsistently. squeezes with left hand good grip. weak attemtp to squeeze with right hand. perrla. at c-line out pt rec ativan prn as previously ordered. propofol off. img atvian efffective pt lethargic not as responsive following dosong. pt can becmes increasingly restless. thrashing head back and forth moving around bed, biting ett tube. no seizure activity noted. dilantin level at 1700 29 md aware.\ncad vss hr70-80 sr, b/p sys teens to 140's. rest of 12.5mg of lopressor dosing from 1600 given at due to inc of b/p to 150-160's. next dose of lopressor given at 2am = 25mg as ordered.\nresp: no vent changes made. ls coarse suctioned numerous times for thick whiteish to yellowy secretions also moderate amts of oral secretions. abg pending.\ngi: tf cont at 60cc. no bm +flatus\ngu; uo 30-40cc/hr pt 1100cc positive at 12am. no lasix given over night.\nendo: bs 160 on eves 200's after 12amins gtt at 4u/hr\naccess: c line slipped out. 2 20guage peri. started.\nplans: ?need to replace cline, cont q1 bs for insulin gtt, labs pend. , lasix dosing on days\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-27 00:00:00.000", "description": "Report", "row_id": 1356331, "text": "ALTERED NEURO STATUS\nD: PT RESTLESS IN BED REQUIRING DOSES OF ATIVAN. PT OPENS EYES WHEN ASKED TO AND MOVING EXTREMTIES IN BED BUT NOT CONSISTENTLY SQUEEZING MY HAND ON COMMAND. L HAND GRASP BETTER THAN R. PUPILS EQUALLY REACTIVE TO LIGHT. ONCE PT REINTUBATED SHE WAS THEN STARTED ON PROPOFOL GTT AT 30MCG/KG/MIN.\n\nRESP: PT PLACED ON 40CPAP WITH 5 PEEP AND IPS OF AND TOLERATED WELL. ABG =7.38/52/82/32/3 AND O2 SATS>98%. IPS THEN DECREASED TO O AND PEEP OF 0 AND TOLERATED WELL WITH RR IN 20'S SO DECISION MADE TO EXTUBATE P AT APPROXIMATELY 1530. ONCE PT WAS EXTUBATED SHE WAS NOTED TO BE AND PT WAS WITH 100% AMBU MASK. PT REINTUBATED BY ANESTHESIA WITH #7 ETT WHICH IS SECURED AT 22 CM AND VENT SETTINGS PRESENTLY 40%/500/IMV10 WITH 5 PEEP AND O2 SATS>98%. COARSE BS BIL AND ETT SUCTIONED Q 3 HRS FOR THICK WHITE TO PALE YELLOW SPUTUM.WITH PT BEING INTUBATED IT WAS NOTED THAT HER VOCAL CORDS WERE VERY SWOLLEN. PT NOW SEDATED ON PROPOFOL GTT AT 30MCG/KG.MIN WITH GD EFFECT.\n\nCV: PT NOW ON 25 MG LOPRESSOR VIA NGT AND SBP 116-188. K+ 3.7 AND WAS NOT REPLACED. WILL FOLLOW ELECTROLYTES AS THEY ARE ORDERED.\n\nGI: RECEIVING PROMODE WITH FIBER TUBE FDGS AT HER GOAL RATE OF 60CC'S/HR WITH MINIMAL RESIDUALS. INCONTINENT OF LG AMT OF LOOSE BROWN STOOL X2 AND NOW HAS FIB IN PLACE. WILL CONTINUE TO CHECK NGT RESIDUALS.\n\nRENAL: BUN=25 AND CREAT=.8. FOLEY IN PLACE WITH ADEQUATE AMTS OF URINE.\n\nIV ACCESS: PT HAS 2 PIV'S BUT SHE REQUIRE CL PLACEMENT.\n\nSOCIAL: PT REMAINS A FULL CODE AND HER DAUGHTER WAS IN TODAY AND WAS UPDATED.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-07 00:00:00.000", "description": "Report", "row_id": 1356351, "text": "altered resp status\nd: neuro: pt remains restless in bed. follows simple commands but not consistently. pupils equally reactive to light. r sided weakness continues. physical therapy consulted and will continue to follow on daily basis.\n\nresp: remains trached and tolerating 50% trach collar with o2 sats> 97%. coarse bs bil. c&r thick yellow sputum and occasionally suctioning trach in addition. has copious oral secretions . mrsa precautions continue. receiving 1 gm vanco q 18 hrs as tol.\n\n\ncv: k+ and mg replaced as ordered. hr 60-70's nsr with occas pac's. sbp 130-158. will conitnue to follow electrolytes as ordered.\n\ngi: pt receiving tube fdgs of impact with fiber at goal rate of 60cc's/hr via peg. incontinent of mod amt golden colored soft stool which is guaic neg. abd benign on exam. insulin gtt d/c'd at 1530 and now started on 13 u nph insulin sc and will treat with reg sliding scale insulin. will conintue to follow blood sugars.\n\nrenal: bun and creat wnr. uo> 40cc's hr via foley cath. will follow i&o.\n\nid: max temp= 100.6 orally and wbc=8.3 continues on vanco for + mrsa.\n social: pt remains a full code. pt's daughter in to visit and was updated. if blood sugars controlled on sc insulin pt may be transfered to medical bed. presently being screened for rehab. pt remains a full code.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-08 00:00:00.000", "description": "Report", "row_id": 1356352, "text": "\n7P to 7A shift summary 0515\n\nPt had very stable night. No neuro changes noted. Hemodynamically stable, afebrile. Remains on trach collar and clearing own secretions. Tolerating TF and stooling.\n\nN/ Pt has received no sedation or pain meds on my shift. Shakes head\"no\" when asked if in pain. opens eyes spont, pupils are equal and brisk. Mae, foolows commands. Is very restless at times, only slept for about 4-5 hours last night.\n\nCV/ Afebrile, NSR with few PVCs noted. Bp stable , tolerating PO antihypertensives. All extremities are warm with weak palpable pulses. Has L SC TLC with KVO NS. Very hard to draw any blood from line. Several attempts made to draw blood peripherally. Only got enough blood from line for Chemistries and Hematolgy. Dr aware.\n\nPULM/ Remains on 50% trach collar, #8 perc trach. Spo2>97% all night. Lungs are coarse through out all fields. Clearing mod to copious thick yellow to clear secretions. Clear oral secretions noted.\n\nGI/ PEG tube intact with Impact with fiber infusing at 60cc/hr(goal). Abdomen is soft, distended and non tender. Positive BS, has stooled continously all night. Soft , thick light brown to yellow color, guaic neg.\n\nGU/ foley draining adequate amounts of clear yellow urine to gravity.\n\nSkin/ skin is dry and intact. Some reddness noted to perianal area with increased stooling, cream applied.\n\nPlan/ Labs pending. tranfer to floor and then to nursing home soon.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-23 00:00:00.000", "description": "Report", "row_id": 1356316, "text": "cns- pt on propofol gtt for sedation at thsi time; 24mcg/kg/min. peerl. withdraws from pain, opens eyes occ. to some pain stimuli.\n\ncv- sr. 100.7-tmax. on nipride gtt to keep sbp<160; currently at 2.2mcg/kg/min. k+ and mag repleted last noc. see flowsheet for details. 2units ffp and 1unit prbc given for high inr and low hct with good results.\n\nresp- see resp note/flowsheet for settings/details. lungs coarse upper, decreased lowers. sxn for small amts white/yellow sputum from ett. copious oral secretions. failed am ween, though still on propofol gtt at the time.\n\ngi- abt soft, round bt hypo. ngt to lcs-sm amts bilous drainage.\n\ngu- uop initially amber yellow, small amts. lasix given post ffp/rbc with good diuresis following. clear yellow uop.\n\nmsi- skin grossly intact. daughters updated; spoke with neuro pa.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-25 00:00:00.000", "description": "Report", "row_id": 1356326, "text": "Nursing Progress Note, Addendum:\n\nCV: Pt I&O's essentially even @ this time despite teams desire to achieve a net output of one to two liters. The pt had had a good/transient responce to 40mg IV Lasix times two today (last dose @ 11:00). Per Pharmacy, all IV meds will be as concentrated as possible. Team notified of I&O status @ 17:00, expect pt needs additional IV Lasix @ this time. Blood lab value of K = 3.3 noted @ 13:00, pt repleted c a total of 60MEQ KCL (both IV/PO). Repeat lytes/coag times drawn/sent @ 19:00, results currently pending.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-26 00:00:00.000", "description": "Report", "row_id": 1356327, "text": "Neuro: Pt currently on propofol for sedation, but when lightened up, pt will follow commands - L side stronger than R. Tracks w/ eyes, but doesn't attempt to communicate.\n\nCardiac: Stable - BP=130/60s. + edema in upper and lower extrems. HR=70-80s - NSR, no etopy noted.\n\nResp: SIMV = 10, 45%, p=5, 02sat=96-98%. Suctioning large amt thin white secretions via ETT and clear secretions from mouth. Lungs coarse bilat. Remains on propofol.\n\nGI; +BS, abd large,soft. No stool. On TPN as well as TF Promote w/ fiber currently at 50cc/hr. Last resid = 50cc.\n\nGU; foley cath, clear yellow urine. Received lasix 40mg earlier tonight. I/O just about even this morning.\n\nPain: Remains on propofol gtt at 30 mcg, No other disomfort\n\nSkin-Head sutures intact, no drainage from site.\n\nAntibx - T=98.9 On vanco and zosyn\n\nIVs Rsubcl quad lumen, L rad aline. Insulin gtt currently at 8 units/hr for last BS=222. See flowsheet for all BS/gtt rates. Propofol @ 30 mcg, TPN, NS @ KVO, Esmolol at 100 mcg.\n\nLabs: MG, K, Phos within limits, no need for repletion this am. Dilantin level=23.5 INR=1.4\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-20 00:00:00.000", "description": "Report", "row_id": 1356309, "text": "pmicu nsg admission note 3a-7a\n\n\n pt is a 64 yob woman w/an extensive pmh most notable for a cva w/residual right-sided weakness. she has presented to the hospital many times s/p falling at home and returned again yesterday afternoon after falling while using the commode at home. she initially presented a&ox3 in the ew but became progressively more lethargic by the time she was admitted to the floor. she had a head ct ~11pm last noc which revealed a significant right-sided subderal bleed. she was transferred to the micu for closer neuro and hemodynamic monitoring. neurosurg also plans to place a ventriculostomy this morning.\n\npmh: past h/o etoh abuse w/dt's; htn; s/p cva w/residual right-sided weakness; iddm; uti's; depression; sz disorder; hepatitis c; thrombocytopenia; tendonitis.\n\nallergies: pcn-> unknown\n\nreview of systems\n\nrespiratory-> pt arrived on 2l o2 via cannula w/sats >96%. lung exam w/diminished bs bibasilarly. denies c/o sob.\n\ncardiac-> goal has been to maintain sbp <160; an a-line was placed ~6am for closer hemodynamic monitoring while the pt is receiving iv ntg. she is receiving a considerable amt of ntg w/sbp's now runnining 140-160's range. the pt also arrived to the micu w/new bradycardia hr 40-60's, sb to sr w/o ectopy.\n\nneuro-> pt is clearly more lethargic but easily arousable and still oriented x3. her speech is garbled but the pt claims this is her baseline. she does have some slight right-sided weakness which is also her baseline. perrl @3mm. plan for a bolt placement this am.\n\ngi-> abd is soft, nontender w/+bs. no bm overnoc. she has been npo.\n\ngu-> foley was placed on arrival to the micu. output has been ~10-15cc/hr and she was started on maintainence fluids.\n\nendo-> nph to be held this am. she received 2u insulin per the riss at 6am.\n\naccess-> #22 in the left arm and #18 in the right wrist.\n\nsocial-> pt has repeatedly refused rehab in the past despite her multiple admits for falls at home. she has 2 dtrs and a husband who is also in rehab. she will need a social work consult.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-20 00:00:00.000", "description": "Report", "row_id": 1356310, "text": "Acute change in mental status. 20-30 sec periods apnea. Int #7.5 ETT 21@lip. Equal bilateral BS. Going to CT Scan\n" }, { "category": "Nursing/other", "chartdate": "2136-10-20 00:00:00.000", "description": "Report", "row_id": 1356311, "text": "nursing note\n\nPt's dtr is waiting for pt to arrive from or. Gave her pt's u/l dentures, and 5 gold hoop earrings. See note later for days' events.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-26 00:00:00.000", "description": "Report", "row_id": 1356328, "text": "Neuro/Resp\nD: pt tracking eyes to voice, nodding appropriately to closed ended questions. denies pain. following commands ie/ tongue protrusion which is midline. strog 4+ grasp of left hand. (+) movement on bed of lower extremities. minimal withdrawal of RUE. bil extremity cool to touch and edematous. eyes 3mm PERL. simv of 10 without PS. overbreathing ~ 8 times per minute with observed TV of <100 ml. PCO2 60. BS course ant with increased production requiring q 1 hour suction. gluc per carevue\nA: CT Scan scheduled awaiting availability of vent\nPropofol decreased with goal to off but increased for travel\nPS added to vent\nInsulin gtt titrated\nTPN off\nTF increased\nR:pt neuro appearing to improve, daughter states improvement but acknowledges decrease movement in RUE compared to her functioning level @ home. awaiting CT scan. ABG to be repeated after travel and return of propofol to pre-procedure dose. still awaiting orders from covering team but with MD re:d/c TPN and wean propofol.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-26 00:00:00.000", "description": "Report", "row_id": 1356329, "text": "ADDENDUM. TRAVELLED FOR HEAD CT AT 15 45 RESULTS PENDIING REQUIRED PROPOFOL FOR PROCEDURE.\n LOPRESSOR GIVEN ON RETURN ESMOLOL INFUSION OFF HR 70-80 BP 152/54\nT/F RESTARTED AT 60MLS INSULIN AT 2 UNITS BS 136\nALL LABS PENDINNG. ABG SENT\n CONTINUES TO REQUIRE SUCTIONING Q1HR\n\n" }, { "category": "Nursing/other", "chartdate": "2136-10-30 00:00:00.000", "description": "Report", "row_id": 1356340, "text": "NEURO: PT OPENS TO VOICE AND FOLLOWS SIMPLE COMMANDS. PURPOSEFUL MOVEMENT OF EXTREMITES X4 R SIDE WEAKER THAN L SECONDARY TO CVA. +PERRLA NOTED. COUGH/GAG INTACT. ANXIOUS AT AND ATIVAN GIVEN WITH +EFFECT.\nCV: MONITOR SHOWS NSR. PT BECOMES HYPERTENSIVE WITH AGITATIONWITH SBP 170'S. MEDICATED WITH PRN ATIVAN/MS04 WITH +EFFECT. L RADIAL A-LINE WITH GOOD WAVEFORM AND ACC TO CUFF PRESSURES.\nRESP: LS BRONCHIAL RLL. SXN Q1-2 HR THICK BLOOD TINGED SECRETIONS. COPIOUS AMTS OF CLEAR ORAL SECTETIONS. PS WEANED TO 12 AND TOLERATED WELL, OTHERWISE NO CHANGES. RR 14-26 WITH TV'S 320-580.\nGI: ABD SOFT AND DISTENDED. TF'S WITH MINIMAL RESIDUALS. INC BROWN FORMED STOOL X3 HEME-.\nGU: FOLEY INTACT AND PATENT DRAINING LIGHT YELLOW URINE WITH SEDIMENTATION NOTED. LASIX GTT REMAING S@ 3MG/HR.\nSKIN: SUPERFICIAL OPEN AREA NOTED ON BUTTOCK OTHERWISE INTACT.\nHEME: K REPLETED AS ORDERED.\nENDO: REMAINS ON FINGERSTICKS Q1HR. INSULIN GTT OFF AND PT STARTED ON NPH WITH RISS Q6HR.\nPSY-SOC: FAMILY IN TO VISIT AND UPDATED ON STATUS AND PLAN OF CARE. ?PEG/TRACH SINCE COPIOUS AMTS OF SECRETIONS AND UNABLE TO WEAN AT THIS TIME.\nPAIN: PT C/O PAIN ALL OVER AND MEDICATED WITH MSO4 WITH +EFFECT.\n" }, { "category": "Nursing/other", "chartdate": "2136-10-31 00:00:00.000", "description": "Report", "row_id": 1356341, "text": "NPN\n\nCV: , dampened, she becomes hypertensive with aggitation - ativan and MS04 have worked well.\n\nResp: She conts to have a huge amount of secreations form her mouth and her ETT, she would greatly benefit from a trache - if the secreations cont with the ETT in place she will certainly get a pneumonia.\n\nGI: She conts to rec TF at 60cc/hr, tol well.\n\nGU: Good u/o, she conts on a lasix gtt at 3mg/hr, she is 630cc neg since MN.\n\nNeuro: Even though she has rec more ativan and MS04 recently she is more responsive than she has been. She has been more aggitated but is also following commands on a consistant bases, her R side conts to be weaker than her L but she is moving it much than she did even yesterday, both of her hands will head towards the ETT when she is out of the restraints.\n\nEndo: Her BS cont to be high, her NPH is too low for her insulin requiremints.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-01 00:00:00.000", "description": "Report", "row_id": 1356342, "text": "NPN\n\nCV: , tolerating CV meds, a line is often dampened, dressing changed.\n\nPulm: Pt conts to have huge amounts of secreations from her mouth, and a lg amount from her ETT - thick yellow blood tinged. She was on - PS/PEEP, her rate was in the low 30s, VT cont to drop, went as low as 150-190, she was put back on , rates decreased to the teens. ABG 7.40/62/118/39/11.\n\nGI: Conts on TF, her NGT came untaped and the tube came out ~ 6 inches - put back in and placement checked.\n" }, { "category": "Nursing/other", "chartdate": "2136-11-01 00:00:00.000", "description": "Report", "row_id": 1356343, "text": "NPN Cont\n\nGI: Tol TF, rate at 60cc. low residuals, no stool\n\nGU: Lasix remains off, given diamox with mod results.\n\nNeuro: Conts to follow commands on a regular basis, R side remains weaker than her R.\n\nID: T max 102.0 R, pan clx.\n\nEndo: Conts on an insulin gtt, off ofr a few hrs when she was in the 80s, she is presently on 5 U an hr.\n" }, { "category": "ECG", "chartdate": "2136-11-06 00:00:00.000", "description": "Report", "row_id": 118449, "text": "Sinus rhythm\nDiffuse nonspecific T wave changes\nSince previous tracing of : modest further T wave changes seen\n\n" }, { "category": "ECG", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 118450, "text": "Sinus rhythm\nPoor R wave progression - probable normal variant\nModest inferolateral T wave changes are nonspecific\nSince previous tracing same date: atrial fibrillation absent and ST-T wave\nchanges decreased\n\n\n" }, { "category": "ECG", "chartdate": "2136-10-24 00:00:00.000", "description": "Report", "row_id": 118451, "text": "Atrial fibrillation with uncontrolled ventricular response\nDiffuse ST-T changes may be due to myocardial ischemia - clinical correlation\nis suggested\nSince previous tracing of : rapid atrial fibrillation and flutter ST-T\nwave changes present\n\n" }, { "category": "ECG", "chartdate": "2136-10-19 00:00:00.000", "description": "Report", "row_id": 117588, "text": "Sinus rhythm. Low amplitude T waves in leads II and V5-V6 and inverted T waves\nin leads, aVF and V3-V4 are all non-specific. Compared to the previous tracing\nof T wave abnormalities are more pronounced.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 518012, "text": "Valve repair (all valves)\n Assessment:\n POD #1 from MV repair. VSS. Min-adequate HUO this am.\n Action:\n OOB to chair on previous shift. Had first consult with PT this am,\n ambulated x2 today. Ate 100% of breakfast & lunch. Started ivp lasix\n and PO Lopressor this am. CTs dc\nd & post removal CXR obtained. PIV\n access obtained. Pt delined. PO Dilaudid and ivp toradol admin for pain\n regimine.\n Response:\n Stable and following csurg pathway. Mod diuresis after IVP Lasix. Pain\n well controlled per patient- last dilaudid 4mg 1600, last ivp toradol\n 1600.\n Plan:\n Transfer to 6 when bed is available. Continue to progress per\n csurg pathway. Continue to assess pain and administer meds prn.\n" }, { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 518014, "text": "Valve repair (all valves)\n Assessment:\n POD #1 from MV repair. VSS. Min-adequate HUO this am.\n Action:\n OOB to chair on previous shift. Had first consult with PT this am,\n ambulated x2 today. Ate 100% of breakfast & lunch. Started ivp lasix\n and PO Lopressor this am. CTs dc\nd & post removal CXR obtained. PIV\n access obtained. Pt delined. PO Dilaudid and ivp toradol admin for pain\n regimine.\n Response:\n Stable and following csurg pathway. Mod diuresis after IVP Lasix. Pain\n well controlled per patient- last dilaudid 4mg 1600, last ivp toradol\n 1600.\n Plan:\n Transfer to 6 when bed is available. Continue to progress per\n csurg pathway. Continue to assess pain and administer meds prn.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n MITRAL INSUFFICIENCY MITRAL VALVE REPLACEMENT /SDA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 90.7 kg\n Daily weight:\n 95.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PM history: facial fracture,left tkr,esophageal stricture s/p\n dilitation,lumbar disc disease,cervical disc fusion,anxiety,known mv\n prolapse now with flail leaflet & dilated lv with global mod.-severe\n hk.\n Surgery / Procedure and date: mv repair-p2 resection & 34 mm\n annuloplasty ring. required additional sedation-20 mg ativan,a750 mcgs\n fentanyl. pre T->ef 35-40&,dilated lv.,4+ mr.returned to cpb x 1 for\n air. off on epi & neo for tone/global hk ef 30-35%\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:107\n D:52\n Temperature:\n 98.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 95 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 932 mL\n 24h total out:\n 1,390 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 2 mA\n Temporary atrial stimulation setting:\n 4 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1 mV\n Temporary ventricular stimulation threshold :\n 8 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:24 AM\n Potassium:\n 3.8 mEq/L\n 08:03 AM\n Chloride:\n 106 mEq/L\n 02:24 AM\n CO2:\n 28 mEq/L\n 02:24 AM\n BUN:\n 13 mg/dL\n 02:24 AM\n Creatinine:\n 0.8 mg/dL\n 02:24 AM\n Glucose:\n 104 mg/dL\n 08:03 AM\n Hematocrit:\n 31.6 %\n 02:24 AM\n Finger Stick Glucose:\n 122\n 12:00 PM\n Additional pertinent labs:\n 2 units sc reg insulin for noon blood sugar.\n Lines / Tubes / Drains:\n foley cath , 20g piv , 16g piv , A/V epicardial pacing wires.\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cell phone\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: 0\n Transferred from: cvicu 798\n Transferred to: 605\n Date of Transfer: \n Time of Transfer: TBD\n" }, { "category": "Physician ", "chartdate": "2169-02-01 00:00:00.000", "description": "ICU Note - CVI", "row_id": 517976, "text": "CVICU\n HPI:\n HD2 POD 1-MVring (#34 ring)\n Ejection Fraction:40\n Hemoglobin A1c:5.1\n Pre-Op Weight:199.96 lbs 90.7 kgs\n Baseline Creatinine:0.9\n Events:\n CT out\n Rec'd from OR-> extubated, doing well.\n PMHx:\n PMH:Anxiety,Esophageal dilatation,Lumbar disc disease\n Mild Benign prostatic hypertrophy\n PSH:Repair right facial fracture,Ant. cerv. disectomy/fusion,Left\n TKR,Vasectmoy\n : Lorazepam 0.5mg \n Current medications:\n Allergies: NKDA\n 1. Acetaminophen 2. Aspirin EC 3. CefazoLIN 4. Docusate Sodium 5.\n Furosemide 6. HYDROmorphone (Dilaudid) 7.Insulin 8. Ketorolac 9.\n Metoclopramide 10. Metoprolol Tartrate 11. Milk of Magnesia 12.\n Ranitidine\n 24 Hour Events:\n OR RECEIVED - At 11:01 AM\n INVASIVE VENTILATION - START 11:01 AM\n NASAL SWAB - At 11:02 AM\n ARTERIAL LINE - START 11:39 AM\n PA CATHETER - START 11:40 AM\n CORDIS/INTRODUCER - START 11:40 AM\n EKG - At 12:11 PM\n INVASIVE VENTILATION - STOP 02:06 PM\n EXTUBATION - At 03:13 PM\n PA CATHETER - STOP 09:07 PM\n Post operative day:\n POD#1 - mv repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:15 AM\n Other ICU medications:\n Insulin - Regular - 12:21 PM\n Sodium Bicarbonate 8.4% (Amp) - 12:42 PM\n Ranitidine (Prophylaxis) - 02:39 PM\n Morphine Sulfate - 05:08 PM\n Hydromorphone (Dilaudid) - 05:40 PM\n Furosemide (Lasix) - 10:00 AM\n Flowsheet Data as of 12:26 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 36.4\nC (97.6\n HR: 78 (78 - 104) bpm\n BP: 114/65(76) {95/52(63) - 114/65(76)} mmHg\n RR: 13 (11 - 28) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 90.7 kg\n Height: 72 Inch\n CVP: 9 (5 - 13) mmHg\n PAP: (23 mmHg) / (12 mmHg)\n CO/CI (Thermodilution): (8.31 L/min) / (3.9 L/min/m2)\n SVR: 568 dynes*sec/cm5\n SV: 81 mL\n SVI: 38 mL/m2\n Total In:\n 5,894 mL\n 592 mL\n PO:\n 420 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 5,474 mL\n 412 mL\n Blood products:\n Total out:\n 2,320 mL\n 885 mL\n Urine:\n 1,830 mL\n 705 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,574 mL\n -293 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 915 (915 - 915) mL\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n Plateau: 16 cmH2O\n SPO2: 95%\n ABG: 7.46/40/101/28/-1\n Ve: 14.7 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 142 K/uL\n 11.2 g/dL\n 104 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 137 mEq/L\n 31.6 %\n 9.2 K/uL\n [image002.jpg]\n 10:11 AM\n 10:16 AM\n 11:26 AM\n 11:43 AM\n 12:59 PM\n 03:07 PM\n 05:37 PM\n 10:16 PM\n 02:24 AM\n 08:03 AM\n WBC\n 20.8\n 18.6\n 9.2\n Hct\n 35\n 31.8\n 36.1\n 35.7\n 31.6\n Plt\n 200\n 184\n 142\n Creatinine\n 0.9\n 0.8\n TCO2\n 24\n 24\n 23\n 24\n Glucose\n 168\n 139\n 109\n 93\n 127\n 116\n 122\n 104\n Other labs: PT / PTT / INR:14.4/37.0/1.2, Fibrinogen:179.2 mg/dL,\n Lactic Acid:3.2 mmol/L, Mg:2.2 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS,\n IMPAIRED, GAIT, IMPAIRED, VALVE REPAIR (ALL VALVES), PAIN CONTROL\n (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Assessment:48yoM s/p MV repair(#34 ring),\n hemodynamically stable, progressing well post operatively.\n Neurologic: Neuro checks Q: 8 hr, Pain well controlled on Toradol and\n dilaudid.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Hemodynamically stable,\n SR 80's-90's. Lopressor started today, titrate up as tolerated to HR\n 60's. Epicardial wires to remain in today.\n Pulmonary: IS, Discontinue chest tube(s), Brething comfortably on 2L\n nc, wean O2 to off with goal sats> 95%. OOB to chair, ambulate with\n assistance. Encourage cough and deep breathing.\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated , Tolerating cardiac, heart\n healthy diet.\n Renal: Foley, Lasix started this morning. Diuresing well, goal fluid\n balance -1L. Bun 13 Cr 0.8, continue to trend daily.\n Hematology: Stable post op anemia, platelets low at 142, continue to\n trend with CBC daily.\n Endocrine: RISS, Lantus (R), Transitioned off insulin gtt overnight\n with Lantus 10 units. BS well controlled in 120's with RISS coverage\n required once. Goal BS < 150.\n Infectious Disease: Afebrile, WBC 9.2. No active ID issues.\n Lines / Tubes / Drains: Foley, Chest tube - mediastinal, Pacing wires,\n D/C chest tube this morning, d/c foley tonight.\n Wounds: Dry dressings\n Imaging: CXR today, after chest tube removal\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition: encourage oral intake/cardiac healthy diet\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n 16 Gauge - 11:40 AM\n 20 Gauge - 06:19 AM\n Prophylaxis:\n DVT: (ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 518044, "text": "Valve repair (all valves)\n Assessment:\n POD #1 from MV repair. VSS. Min-adequate HUO this am.\n Action:\n OOB to chair on previous shift. Had first consult with PT this am,\n ambulated x2 today. Ate 100% of breakfast & lunch. Started ivp lasix\n and PO Lopressor this am. CTs dc\nd & post removal CXR obtained. PIV\n access obtained. Pt delined. PO Dilaudid and ivp toradol admin for pain\n regimine.\n Response:\n Stable and following csurg pathway. Mod diuresis after IVP Lasix. Pain\n well controlled per patient- last dilaudid 4mg 1600, last ivp toradol\n 1600. PO Tylenol admin at 1700 for increase in temp and HR. PO\n Lopressor dosage increased as pt became tachy this afternoon. Pain well\n controlled per patient. Add\nl Lopressor admin at 1700 & 1800 (total\n 25mg). NP denied add\nl ivf.\n Plan:\n Transfer to 6 when bed is available. Continue to progress per\n csurg pathway. Continue to assess pain and administer meds prn.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n MITRAL INSUFFICIENCY MITRAL VALVE REPLACEMENT /SDA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 90.7 kg\n Daily weight:\n 95.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PM history: facial fracture,left tkr,esophageal stricture s/p\n dilitation,lumbar disc disease,cervical disc fusion,anxiety,known mv\n prolapse now with flail leaflet & dilated lv with global mod.-severe\n hk.\n Surgery / Procedure and date: mv repair-p2 resection & 34 mm\n annuloplasty ring. required additional sedation-20 mg ativan,a750 mcgs\n fentanyl. pre T->ef 35-40&,dilated lv.,4+ mr.returned to cpb x 1 for\n air. off on epi & neo for tone/global hk ef 30-35%\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:81\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 106 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 992 mL\n 24h total out:\n 1360 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 2 mA\n Temporary atrial stimulation setting:\n 4 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1 mV\n Temporary ventricular stimulation threshold :\n 8 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:24 AM\n Potassium:\n 3.8 mEq/L\n 08:03 AM\n Chloride:\n 106 mEq/L\n 02:24 AM\n CO2:\n 28 mEq/L\n 02:24 AM\n BUN:\n 13 mg/dL\n 02:24 AM\n Creatinine:\n 0.8 mg/dL\n 02:24 AM\n Glucose:\n 104 mg/dL\n 08:03 AM\n Hematocrit:\n 31.6 %\n 02:24 AM\n Finger Stick Glucose:\n 111\n 17:00 PM\n Additional pertinent labs:\n 2 units sc reg insulin for noon blood sugar.\n Lines / Tubes / Drains:\n foley cath , 20g piv , 18g piv , A/V epicardial pacing\n wires.\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cell phone\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: 0\n Transferred from: cvicu 798\n Transferred to: 605\n Date of Transfer: \n Time of Transfer: 1830\n" }, { "category": "Nursing", "chartdate": "2169-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517809, "text": "Mitral valve repair\n Nsr/st withoccasional multifocal pvc\ns that improved after kcl &\n magnesium.transiently a paced post reversals,pacer presently aai mode\n with appropriate sensing.\n" }, { "category": "Nursing", "chartdate": "2169-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517814, "text": "Mitral valve repair\n Nsr/st with occasional multifocal pvc\ns that improved after kcl &\n magnesium.transiently a paced post reversals,pacer presently aai mode\n with appropriate sensing.hyperdynamic hemodynamics with brisk huo,low\n filling pressures with mixed acidosis treated with volume,nahco3-. Epi\n weaned to off,neo titrated as recorded with continued excellent\n cardiac parameters ,bp & improved glucose control. Extubated without\n incident,cooperative with deep breathing & sternal splinting. Pain\n difficult to manage despite escalating morphine & Toradol. Discussed\n with team,changed to dilaudid will continue to evaluate.family updated\n by physician via phone,no other family contact.\n" }, { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 517967, "text": "Valve repair (all valves)\n Assessment:\n POD #1 from MV repair. VSS. Min-adequate HUO.\n Action:\n OOB to chair on previous shift. Had first consult with PT this am,\n ambulated. Ate 100% of breakfast. Started ivp lasix and PO Lopressor\n this am. CTs dc\nd & post removal CXR obtained. PIV access obtained. Pt\n delined. PO Dilaudid and ivp toradol admin for pain regimine.\n Response:\n Stable and following csurg pathway. Pain well controlled per patient.\n Plan:\n Transfer to 6 when bed is available. Continue to progress per\n csurg pathway. Continue to assess pain and administer meds prn.\n" }, { "category": "Rehab Services", "chartdate": "2169-02-01 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 517954, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: MV repair / 424.0\n Reason of referral: Eval and treat\n History of Present Illness / Subjective Complaint: 48 y.o. male admit\n for planned mitral valve repair on . CPBT time 67 min and XCT 47\n min. Pt extubated and swan ganz removed.\n Past Medical / Surgical History: Mitral valve prolapse, esophageal\n stricture s/p dilation, facial fx s/p repair, anterior cervical\n fusion, L TKA 2 years ago.\n Medications: NTG, magnesium, ranitidine, dilaudid, insulin\n Radiology: CXR with moderate atelectasis\n Labs:\n 31.6\n 11.2\n 142\n 9.2\n [image002.jpg]\n Activity Orders: As tolerated; per cardiac surgery protocol\n Social / Occupational History: Works full time as prison guard. Lives\n with his elderly grandmother who is fairly independent, drives\n Living Environment: Lives in house with several stairs to enter\n Prior Functional Status / Activity Level: Independent, works full time,\n drives, active.\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3, pleasant,\n cooperative, follows all commands. Motivated to return to prior level\n of fxn.\n Hemodynamic Response NBP\n Aerobic Capacity NBP\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine (reclined in chair)\n 87bpm\n 102/61mmHg\n 16\n 95%on 2 L NC\n Rest\n 87bpm\n 102/61mmHg\n 16\n 95% on 2 L NC\n Sit\n 87bpm\n 93/61mmHg\n 13\n 99% on 2 L NC\n Activity\n 103bpm\n 127/76mmHg\n 18\n 2 L NC\n Stand\n 105bpm\n 113/55mmHg\n Recovery\n 93bpm\n 105/63mmHg\n 97% on 2 L NC\n Total distance walked: 300'\n Minutes: 5min\n Pulmonary Status: Breath sounds CTA but slightly diminished at bases,\n cough with splinting fairly strong nonproductive, breathiing with ease\n and NAD throughout session. Able to independently state protocol for\n IS and able to achieve 100mL consistently.\n Integumentary / Vascular: 1 central line, 2 PIV, 1 pleural chest tube\n to suction, foly catheter, sternal incision CDI. Skin warm to touch in\n extremities.\n Sensory Integrity: Intact to light touch throughout, no c/o numbness\n tingling.\n Pain / Limiting Symptoms: 0/10 pain at surgical site. Pt reports he\n had pain earlier but took pain meds. Also c/o L knee pain earlier\n today and asking what it could be from.\n Posture: , pt found seated up in chair in reclined position\n Range of Motion\n Muscle Performance\n B LE ROM , B UE \n grossly assessed to be during fxn'l activities.\n Motor Function: Coordination intact. Receptive to teaching and asking\n valid questions re medical condition.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt ambulated on level surfaces pushing w/c with\n portable monitor and chest tube to water seal x 300' around unit while\n speaking with various staff members. Good cadence and step length, no\n LOB, CGA. Cues for pursed lip breathing given and pt with good return\n .\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n T\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: Good/Good- static dynamic standing balance.\n Education / Communication: Issued cardiac surgery booklet and cardiac\n rehab handout and went over precautions and activity guidelines. Also\n ed re PT and recommendations. Ed possible cause of knee pain and\n that pt should perform LAQ several reps in the morning before\n mobilization. Pt verbalized understanding. Communicated with nurse re\n pt status and progress with PT.\n Intervention: Education, endurance, mobility\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Transfers, Impaired\n 4.\n Gait, Impaired\n Clinical impression / Prognosis: 48 y.o. male p/w above impairments a/w\n cardiac pump dysfxn. Pt experiencing knee pain as well which is likely\n related to his TKA done several years ago and anticipate that with\n morning ROM that pain should dissipate. Pt did really well on POD#1\n and was able to ambulate 300'. In addition he demonstrates motivation\n to return to prior level of fxn and so anticipate with 1-2 more PT\n sessions that he will be able to return to home from \n Goals\n Time frame: 1-2 sessions\n 1.\n Ambulate x 500' on RA without AD with Spo2 greater than 93% and\n appropriate hemodynamic response independent\n 2.\n Ascend/descend 1 FOS with 1 HR with good hemodynamic response and\n independent\n 3.\n All bed mobility and transfers independent\n 4.\n Able to good understanding of cardiac surgery precautions during\n all fxn'l mobility without verbal cues.\n 5.\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: session\n Increase ambulation distance/endurance\n Work on pacing\n Initiate home exercise program\n Assess/clear on stairs\n Increase independence with fxn'l mobility\n Education\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 518037, "text": "Valve repair (all valves)\n Assessment:\n POD #1 from MV repair. VSS. Min-adequate HUO this am.\n Action:\n OOB to chair on previous shift. Had first consult with PT this am,\n ambulated x2 today. Ate 100% of breakfast & lunch. Started ivp lasix\n and PO Lopressor this am. CTs dc\nd & post removal CXR obtained. PIV\n access obtained. Pt delined. PO Dilaudid and ivp toradol admin for pain\n regimine.\n Response:\n Stable and following csurg pathway. Mod diuresis after IVP Lasix. Pain\n well controlled per patient- last dilaudid 4mg 1600, last ivp toradol\n 1600. PO Tylenol admin at 1700 for increase in temp and HR. PO\n Lopressor dosage increased as pt became tachy this afternoon. Add\n Lopressor admin at 1700. NP denied add\nl ivf.\n Plan:\n Transfer to 6 when bed is available. Continue to progress per\n csurg pathway. Continue to assess pain and administer meds prn.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n MITRAL INSUFFICIENCY MITRAL VALVE REPLACEMENT /SDA\n Code status:\n Full code\n Height:\n 72 Inch\n Admission weight:\n 90.7 kg\n Daily weight:\n 95.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PM history: facial fracture,left tkr,esophageal stricture s/p\n dilitation,lumbar disc disease,cervical disc fusion,anxiety,known mv\n prolapse now with flail leaflet & dilated lv with global mod.-severe\n hk.\n Surgery / Procedure and date: mv repair-p2 resection & 34 mm\n annuloplasty ring. required additional sedation-20 mg ativan,a750 mcgs\n fentanyl. pre T->ef 35-40&,dilated lv.,4+ mr.returned to cpb x 1 for\n air. off on epi & neo for tone/global hk ef 30-35%\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:106\n D:81\n Temperature:\n 99.5\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 106 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 992 mL\n 24h total out:\n 1235 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 60 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 2 mA\n Temporary atrial stimulation setting:\n 4 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 1 mV\n Temporary ventricular stimulation threshold :\n 8 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:24 AM\n Potassium:\n 3.8 mEq/L\n 08:03 AM\n Chloride:\n 106 mEq/L\n 02:24 AM\n CO2:\n 28 mEq/L\n 02:24 AM\n BUN:\n 13 mg/dL\n 02:24 AM\n Creatinine:\n 0.8 mg/dL\n 02:24 AM\n Glucose:\n 104 mg/dL\n 08:03 AM\n Hematocrit:\n 31.6 %\n 02:24 AM\n Finger Stick Glucose:\n 111\n 17:00 PM\n Additional pertinent labs:\n 2 units sc reg insulin for noon blood sugar.\n Lines / Tubes / Drains:\n foley cath , 20g piv , 16g piv , A/V epicardial pacing wires.\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: cell phone\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: 0\n Jewelry: 0\n Transferred from: cvicu 798\n Transferred to: 605\n Date of Transfer: \n Time of Transfer: 1745\n" }, { "category": "Nursing", "chartdate": "2169-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 517866, "text": "POD #1\n Valve repair (MItral valve)\n Assessment:\n Pt A&Ox3, MAE, pleasant. HR NSR-ST, no ectpy noted this shift. LSCA, on\n insulin gtt. UOP adequate. Chest Tubes draining thin serous fluid, skin\n intact, Afebrile. Pulses palpable. A and V wires\n Action:\n Insulin gtt monitored QH, titrated per c- protocol\n Turned per protocol\n PA catheter discontinued due to ectopy for previous shift\n 1L LR given for hypotension\n On 3L NS sats 96%\n Wires not checked due to increased HR- remains in AAI backup from\n previous shift\n Lytes monitored and repleated\n Pt had episode of nausea, given reglan\n Response:\n Pt slept most of shift\n Conversive with staff, assists with care are able\n Insulin gtt transitioned off per protocol\n Heart rate decreased to 80\ns and sbp up to 100\ns after fluid bolus\n O2 decreased to 2L NC, sats remain 95-96%\n Nausea resolved after reglan\n Plan:\n Continue to advance per pathway, transfer to 6 in AM\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt complaining of incisional pain on assessment\n Action:\n Ketalorac given IV\n Dilaudid PO\n Repositioned\n Response:\n Pain improved with ketalorac and Dilaudid\n Pt complaining of headache, treated with 650 tylenol- pt reports\n resolution of headache after tylenol\n Plan:\n Continue ketalorac Q6H, Dilaudid for breakthrough pain\n" }, { "category": "Physician ", "chartdate": "2169-02-01 00:00:00.000", "description": "ICU Note", "row_id": 517986, "text": "TITLE:\n CVICU\n HPI:\n HD2 POD 1-MVring (#34 ring)\n Ejection Fraction:40\n Hemoglobin A1c:5.1\n Pre-Op Weight:199.96 lbs 90.7 kgs\n Baseline Creatinine:0.9\n Events:\n CT out\n Rec'd from OR-> extubated, doing well.\n PMHx:\n PMH:Anxiety,Esophageal dilatation,Lumbar disc disease\n Mild Benign prostatic hypertrophy\n PSH:Repair right facial fracture,Ant. cerv. disectomy/fusion,Left\n TKR,Vasectmoy\n : Lorazepam 0.5mg \n Current medications:\n Allergies: NKDA\n 1. Acetaminophen 2. Aspirin EC 3. CefazoLIN 4. Docusate Sodium 5.\n Furosemide 6. HYDROmorphone (Dilaudid) 7.Insulin 8. Ketorolac 9.\n Metoclopramide 10. Metoprolol Tartrate 11. Milk of Magnesia 12.\n Ranitidine\n 24 Hour Events:\n OR RECEIVED - At 11:01 AM\n INVASIVE VENTILATION - START 11:01 AM\n NASAL SWAB - At 11:02 AM\n ARTERIAL LINE - START 11:39 AM\n PA CATHETER - START 11:40 AM\n CORDIS/INTRODUCER - START 11:40 AM\n EKG - At 12:11 PM\n INVASIVE VENTILATION - STOP 02:06 PM\n EXTUBATION - At 03:13 PM\n PA CATHETER - STOP 09:07 PM\n Post operative day:\n POD#1 - mv repair\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 06:15 AM\n Other ICU medications:\n Insulin - Regular - 12:21 PM\n Sodium Bicarbonate 8.4% (Amp) - 12:42 PM\n Ranitidine (Prophylaxis) - 02:39 PM\n Morphine Sulfate - 05:08 PM\n Hydromorphone (Dilaudid) - 05:40 PM\n Furosemide (Lasix) - 10:00 AM\n Flowsheet Data as of 12:26 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 36.4\nC (97.6\n HR: 78 (78 - 104) bpm\n BP: 114/65(76) {95/52(63) - 114/65(76)} mmHg\n RR: 13 (11 - 28) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 95.3 kg (admission): 90.7 kg\n Height: 72 Inch\n CVP: 9 (5 - 13) mmHg\n PAP: (23 mmHg) / (12 mmHg)\n CO/CI (Thermodilution): (8.31 L/min) / (3.9 L/min/m2)\n SVR: 568 dynes*sec/cm5\n SV: 81 mL\n SVI: 38 mL/m2\n Total In:\n 5,894 mL\n 592 mL\n PO:\n 420 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 5,474 mL\n 412 mL\n Blood products:\n Total out:\n 2,320 mL\n 885 mL\n Urine:\n 1,830 mL\n 705 mL\n NG:\n 110 mL\n Stool:\n Drains:\n Balance:\n 3,574 mL\n -293 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 915 (915 - 915) mL\n RR (Set): 16\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 100%\n PIP: 11 cmH2O\n Plateau: 16 cmH2O\n SPO2: 95%\n ABG: 7.46/40/101/28/-1\n Ve: 14.7 L/min\n PaO2 / FiO2: 253\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 142 K/uL\n 11.2 g/dL\n 104 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 106 mEq/L\n 137 mEq/L\n 31.6 %\n 9.2 K/uL\n [image002.jpg]\n 10:11 AM\n 10:16 AM\n 11:26 AM\n 11:43 AM\n 12:59 PM\n 03:07 PM\n 05:37 PM\n 10:16 PM\n 02:24 AM\n 08:03 AM\n WBC\n 20.8\n 18.6\n 9.2\n Hct\n 35\n 31.8\n 36.1\n 35.7\n 31.6\n Plt\n 200\n 184\n 142\n Creatinine\n 0.9\n 0.8\n TCO2\n 24\n 24\n 23\n 24\n Glucose\n 168\n 139\n 109\n 93\n 127\n 116\n 122\n 104\n Other labs: PT / PTT / INR:14.4/37.0/1.2, Fibrinogen:179.2 mg/dL,\n Lactic Acid:3.2 mmol/L, Mg:2.2 mg/dL\n Assessment and Plan\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, KNOWLEDGE, IMPAIRED, TRANSFERS,\n IMPAIRED, GAIT, IMPAIRED, VALVE REPAIR (ALL VALVES), PAIN CONTROL\n (ACUTE PAIN, CHRONIC PAIN)\n Assessment and Plan: Assessment:48yoM s/p MV repair(#34 ring),\n hemodynamically stable, progressing well post operatively.\n Neurologic: Neuro checks Q: 8 hr, Pain well controlled on Toradol and\n dilaudid.\n Cardiovascular: Aspirin, Beta-blocker, Statins, Hemodynamically stable,\n SR 80's-90's. Lopressor started today, titrate up as tolerated to HR\n 60's. Epicardial wires to remain in today.\n Pulmonary: IS, Discontinue chest tube(s), Brething comfortably on 2L\n nc, wean O2 to off with goal sats> 95%. OOB to chair, ambulate with\n assistance. Encourage cough and deep breathing.\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated , Tolerating cardiac, heart\n healthy diet.\n Renal: Foley, Lasix started this morning. Diuresing well, goal fluid\n balance -1L. Bun 13 Cr 0.8, continue to trend daily.\n Hematology: Stable post op anemia, platelets low at 142, continue to\n trend with CBC daily.\n Endocrine: RISS, Lantus (R), Transitioned off insulin gtt overnight\n with Lantus 10 units. BS well controlled in 120's with RISS coverage\n required once. Goal BS < 150.\n Infectious Disease: Afebrile, WBC 9.2. No active ID issues.\n Lines / Tubes / Drains: Foley, Chest tube - mediastinal, Pacing wires,\n D/C chest tube this morning, d/c foley tonight.\n Wounds: Dry dressings\n Imaging: CXR today, after chest tube removal\n Consults: CT surgery, P.T.\n ICU Care\n Nutrition: encourage oral intake/cardiac healthy diet\n Glycemic Control: Regular insulin sliding scale, Lantus (R) protocol\n Lines:\n 16 Gauge - 11:40 AM\n 20 Gauge - 06:19 AM\n Prophylaxis:\n DVT: (ambulate today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Communication: Patient discussed on interdisciplinary rounds , ICU\n consent signed:\n Code status: Full code\n Disposition: Transfer to floor Time spent 32 min Dx- Post-op Resp\n Insuff\n" }, { "category": "Echo", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 88300, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for Mitral valve repair. Left ventricular function. Mitral valve disease. Mitral valve prolapse. Preoperative assessment. Prosthetic valve function. Right ventricular function. Shortness of breath. Valvular heart disease.\nHeight: (in) 72\nWeight (lb): 200\nBSA (m2): 2.13 m2\nBP (mm Hg): 123/67\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 08:52\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Mildly\ndepressed LVEF. [Intrinsic LV systolic function likely depressed given the\nseverity of valvular regurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Moderately dilated aortic sinus. Normal ascending aorta diameter.\nNormal descending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Elongated mitral valve leaflets. Moderate/severe MVP. Partial\nmitral leaflet flail. MR vena contracta is >=0.7cm Severe (4+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was 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\n\nNo atrial septal defect is seen by 2D or color Doppler. There is mild\nsymmetric left ventricular hypertrophy. The left ventricular cavity is\nmoderately dilated. Overall left ventricular systolic function is mildly\ndepressed (LVEF= 40 %). [Intrinsic left ventricular systolic function is\nlikely more depressed given the severity of valvular regurgitation.] Right\nventricular chamber size and free wall motion are normal. The aortic root is\nmoderately dilated at the sinus level. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are elongated. There is moderate/severe mitral valve\nprolapse. There is partial mitral leaflet flail. The mitral regurgitation vena\ncontracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. There is no\npericardial effusion. Dr. was notified in person of the results on\n at 820am.\n\nPost bypass\n\nPatient is in sinus rhythm and receiving an infusion of phenylephrine and\nepinephrine. Biventricular systolic function is unchanged. Annuloplasty ring\nseen in the mitral position. Leaflets move well and the annuloplasty ring\nappears well seated. Trivial central mitral regurgitation present. Mean\ngradient across the mitral valve is 4 mm Hg. Aorta appears intact post\ndecannulation.\n\n\n" }, { "category": "ECG", "chartdate": "2169-01-31 00:00:00.000", "description": "Report", "row_id": 232262, "text": "Sinus rhythm with borderline sinus tachycardia. There may be modest inferior\nlead ST-T wave changes but unstable baseline in those leads makes assessment\ndifficult. Since the previous tracing of modest inferior lead ST-T wave\nchanges are suggested but unstable baseline in those leads makes comparison\ndifficult.\n\n" }, { "category": "Radiology", "chartdate": "2169-01-31 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1120620, "text": " 2:30 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with s/p MV Repair - please call if there is\n concern with findings\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post mitral valve repair.\n\n COMPARISON: Preoperative chest x-ray from .\n\n FINDINGS: Status post mitral valve repair. The newly inserted endotracheal\n tube projects 4.5 cm above the carina with its tip. The nasogastric tube\n shows a normal and unremarkable course. The Swan-Ganz catheter, inserted over\n the right internal jugular vein is also unremarkable. Normal position of\n pleural and mediastinal drains. No evidence of pneumothorax. No evidence of\n pneumoperitoneum. Moderate retrocardiac atelectasis. No pulmonary edema, no\n pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2169-02-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1120760, "text": " 10:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man s/p chest tube removal. Please at \n with abnormalities.\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man status post chest tube removal. Rule out\n pneumothorax.\n\n COMPARISON: Portable chest radiograph .\n\n TECHNIQUE: Portable AP chest radiograph.\n\n FINDINGS: Since , support lines and tubes have been removed.\n Sternotomy wires are midline and intact. The patient is status post mitral\n valve repair. Stable cardiomegaly is unchanged from . Mediastinal\n and hilar contours are unchanged since . Bilateral lower lung\n volumes with improved moderate left lower lobe and stable small right lower\n lobe atelectasis. No focal consolidation, pleural effusion, pneumothorax or\n pulmonary edema.\n\n IMPRESSION:\n 1. Improved moderate left lower lobe and stable small right lower lobe\n atelectasis since .\n 2. No pneumothorax or pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2169-02-03 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1121089, "text": " 9:54 AM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage\n Admitting Diagnosis: MITRAL INSUFFICIENCY\\MITRAL VALVE REPLACEMENT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old man with MV ring\n REASON FOR THIS EXAMINATION:\n interval chnage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 48-year-old man with mitral valve ring. Evaluate for interval\n change.\n\n COMPARISON: Portable AP chest radiograph, .\n\n TECHNIQUE: PA and lateral chest radiograph.\n\n FINDINGS: Patient is status post mitral valve repair. Sternotomy wires are\n midline and intact. Mild cardiomegaly is stable. Mediastinal and hilar\n contours are unchanged since . Both lung volumes are low\n with unchanged moderate left lower lobe atelectasis. Increased opacity at the\n right lung base since , likely represent basal atelectasis,\n however, aspiration, pneumonia or layering of pleural effusion cannot be\n completely excluded. Trace bilateral pleural effusions. noted. No\n pneumothorax.\n\n IMPRESSION:\n 1. Lateral view would be helpful to characterize new right basilar\n atelectasis, small layering pleural effusion or aspiration pneumonia. Improved\n moderate left lower lobe atelectasis.\n\n" } ]

[ { "category": "Echo", "chartdate": "2184-06-14 00:00:00.000", "description": "Report", "row_id": 96468, "text": "PATIENT/TEST INFORMATION:\nIndication: Endocarditis. Murmur. Fever.\nHeight: (in) 62\nWeight (lb): 272\nBSA (m2): 2.18 m2\nBP (mm Hg): 126/72\nHR (bpm): 94\nStatus: Inpatient\nDate/Time: at 15:02\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. TDI E/e' >15, suggesting PCWP>18mmHg. No\nresting 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.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and global\nsystolic function (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). Right\nventricular chamber size and free wall motion are normal. The diameters of\naorta at the sinus, ascending and arch levels are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic 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 no pericardial\neffusion.\n\nIMPRESSION: Suboptimal image quality. Mild symmetric left ventricular\nhypertrophy with preserved global biventricular systolic function. No valvular\npathology or pathologic flow identified. Increased PCWP.\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": "2184-06-22 00:00:00.000", "description": "Report", "row_id": 264123, "text": "Sinus rhythm\nDelayed R wave progression with late precordial QRS transition\nProlonged Q-Tc interval\nModest low amplitude T wave changes\nFindings are nonspecific but clinical correlation is suggested for possible in\npart metabolic/drug effect\nSince previous tracing of , probably no significant change but baseline\nartifact on previous tracing makes comparison difficult\n\n" }, { "category": "ECG", "chartdate": "2184-06-18 00:00:00.000", "description": "Report", "row_id": 264124, "text": "Significant baseline artifact in several leads. Normal sinus rhythm. Diffuse\nnon-specific T wave changes. Compared to the previous tracing of these\nnon-specific T wave changes are new and are most prominent in leads I and aVL.\nT wave inversions in these leads with flattening in the lateral precordial\nleads. These are non-specific changes but may be related to ischemia.\n\n" }, { "category": "Radiology", "chartdate": "2184-06-18 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1084639, "text": " 1:23 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evidence for infectious source such as abscess\n Admitting Diagnosis: FEBRILE NEUTROPENIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with factor VIIIi inhibitor initially presented with\n neutropenic fever. Currently not neutropenic and on nafcillin, but spiking\n feveres the past 2 mornings.\n REASON FOR THIS EXAMINATION:\n Evidence for infectious source such as abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Factor VIII-I inhibitor with neutropenic fever, currently not\n neutropenic and on nafcillin, but spiking fevers the past two mornings,\n evaluate for infectious source such as abscess.\n\n COMPARISON: .\n\n TECHNIQUE: Axial MDCT images were obtained from the lung apices to the pubic\n symphysis after the intravenous administration of Optiray. Coronal and\n sagittal reformatted images are provided.\n\n CONTRAST: Oral and intravenous nonionic contrast.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: Since the previous examination,\n diffuse ground-glass opacities throughout the lungs are more marked, and there\n is mosaic attenuation throughout the lungs suggestive of either airtrapping,\n as in the case of expiratory phase of imaging, or patchy involvement by\n ground- glass opacity due to infectious or inflammatory process. The nodular\n density in the left lower lobe which was present on the previous examination\n has decreased in size, although a linear density remains (2:19) that is\n approximately 2 x 8 mm and does not appear mass like. There remains plate-\n like atelectasis in the lingula. A 2 mm right upper lobe nodule (2:23) is\n unchanged. In the right lower lobe, a couple of ground-glass nodules which\n were previously present are no longer clearly visualized. Mediastinal, hilar\n and axillary lymph nodes do not meet CT criteria for pathologic enlargement. A\n right hilar node measures 9 mm in transaxial diameter. Coronary artery\n calcifications again noted. A trace pericardial fluid is present, likely\n physiologic, but slightly increased from previous CT.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen and bilateral\n adrenal glands appear unremarkable. The gallbladder is distended and contains\n multiple layering gallstones, but there is no evidence of abnormal gallbladder\n wall thickening or pericholecystic fluid that is detectable by CT. There is\n no intra- or extra-hepatic biliary ductal dilation. The pancreas appears\n unremarkable. There is no hydronephrosis, and no renal masses are identified.\n Numerous retroperitoneal lymph nodes do not meet CT criteria for pathologic\n enlargement.\n\n (Over)\n\n 1:23 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evidence for infectious source such as abscess\n Admitting Diagnosis: FEBRILE NEUTROPENIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is no free air or free fluid within the abdomen. The appendix contains\n a focus of density at its base, which could represent inspissated material or\n an appendicolith and which was present at the time of the previous CT, but is\n otherwise air-filled, normal in caliber and appearance. The large and small\n bowel loops are normal in caliber and contour. There is no evidence of intra-\n abdominal abscess.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder, distal ureters,\n rectum and sigmoid colon appear unremarkable. By report in the clinical\n record, the patient has undergone hysterectomy. An 11 mm hypodensity adjacent\n to the vaginal cuff or possibly located in the right adnexa is unchanged from\n and contains internal fluid density. This could possibly\n represent an adnexal cyst or a portion of the vaginal cuff. No examinations\n more remote than are available for longer term comparison. There\n is no free fluid or free air in the pelvis. Bilateral inguinal lymph nodes do\n not meet CT criteria for pathologic enlargement. Numerous foci of density in\n the subcutaneous tissues anteriorly and in the buttocks may relate to\n injections. In the left buttock, a focus of stranding, spanning an area of 2.1\n x 3.7 cm, is slightly decreased in size from , at which time it measured\n approximately 3.5 x 5.4 cm. Note is made of enlargement in relative\n of the adductor musculature of the left hip (2:119), consistent\n with hematoma. This is new in the interval and only partially imaged.\n\n BONE WINDOWS: There is degenerative change of the thoracic spine with\n calcified material narrowing the spinal canal at T9-10, an unchanged finding.\n The canal and its contents are not fully evaluated on this examination which\n is targeted for evaluation of the abdomen and pelvis. No lesions worrisome\n for osseous metastases are identified.\n\n IMPRESSION:\n 1. Diffuse bilateral pulmonary ground-glass opacities and areas of probable\n air trapping, progressed from . The differential diagnosis\n includes infectious and inflammatory considerations or edema. However, it is\n noted that several nodular densities previously present have improved or\n resolved. Remaining tiny pulmonary nodules may be reassessed at next followup\n imaging.\n 2. No evidence of intra-abdominal or pelvic abscess.\n 3. Distended gallbladder containing multiple stones. While there are no CT\n features to suggest acute cholecystitis, if this is of clinical concern, then\n gallbladder ultrasound would be better suited for evaluation.\n 4. 11 mm cystic structure in the deep pelvis. By medical record, the patient\n has undergone hysterectomy, and therefore, this could represent a cyst in the\n adnexa or fluid in portion of vaginal cuff. If pelvic ultrasound has not been\n performed (none available on our system), then further evaluation with pelvic\n (Over)\n\n 1:23 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: Evidence for infectious source such as abscess\n Admitting Diagnosis: FEBRILE NEUTROPENIA\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n ultrasound is recommended.\n 5. Intramuscular hematoma in the left thigh and decreased size of a\n subcutaneous hematoma in the left buttock.\n 6. Degenerative change of the spine with posterior calcification narrowing\n the spinal canal at approximately T9-10, unchanged from .\n\n Results were discussed with Dr. on at 2:30 p.m.\n\n\n\n" }, { "category": "Physician ", "chartdate": "2184-06-09 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 579098, "text": "TITLE:\n Chief Complaint: fever\n HPI:\n Pt is a 63 year old female p/t of Dr. of oncology with hx of\n factor 8 defficeny to factor 8 inhibitor now presenting from rehab\n with fever and neutropenia. She had a recent prolonged hospital course\n at due to her coagulopathy and since then has been at the \n rehab. Her hosptial course was complicated by significant bleeding into\n her arms with line placement and spontanous bleeding, overall requiring\n 20 units of blood. Also was treated for a MSSA bacteremia. She was\n discharged with a PICC, which fell out appx 10 days prior to this\n hospitalization. She has been continued on steriods and daily cytoxan\n for her factor 8 inhibitor, and is s/p 2 treatements with Rituximab.\n Now over the last 4 days she states she has noticed a slight cough\n without sputum. This AM she was noted to have chills and rigors and a\n temperature of 102 per records. She denies any GI sx, dysuria, other\n resp sx, sore throat, of rash. She last had a dose of pentamidine one\n month prior. Also has been having left leg swelling starting today. She\n was noted at the rehab to have a postive UA. Urine cx was pending. CXR\n was clear.\n .\n In the ER VS were T- 101.1, BP- 125/61, HR- 107, RR-22, O2 100%RA. She\n was given a dose of cefepime 2gIV. Blood cx were sent. Lactate was\n elevated at 4.7. PIV was started in left thumb. Also given 2L IVF NS,\n tylenol of 650mg, and humalog 35 units. Found to have neutropenia.\n Admitted to due to difficult access. Discusses with heme/onc.\n History obtained from Patient, Family / Medical records\n Allergies:\n Valium (Oral) (Diazepam)\n Unknown;\n Darvon (Oral) (Propoxyphene Hcl)\n Unknown;\n Scopolamine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:46 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Prednisone 60 mg daily\n Multivitamin 1 tab daily\n Vitamin D3 400 unit daily\n Simvastatin 40 mg daily\n Omeprazole 20mg before breakfast\n Acetaminophen 1g Q12H PO\n Clonidine 0.2mg Q8H PO\n Colace 100mg \n Cyclophosphamide 225mg daily\n Toprol XL 100 mg daily\n Torsemide 20 mg daily\n Trazodone 25 mg qhs prn\n Calcium Carbonate 500 mg tid\n Senna 2 tabs daily PO\n Sorbitol 70% 30ml PO PRN constipation\n Bisacodyl 10mg PR PRN constipation\n Amlodipine 10 mg daily\n Bacitracin oint Daily to skin tear on left arm\n Zofran 4 mg IV q8h prn\n Lantus 36 units qam\n Eucerin cream daily\n Insulin Aspart SSI (see order)\n Lantus 34 units at breakfast\n Zofran 8 mg tab prior to cyclophosphamide\n Past medical history:\n Family history:\n Social History:\n - Acquired Factor VIII Inhibitor, on steriods, cytoxan, and rituximab\n - DM type 2, on high dose insulin, followed by \n - Anemia, baseline Hct 24-26, as per HPI - Has been on Aranesp,\n Procrit for this in the past\n - Hypertension\n - Hyperlipidemia\n - Has had multiple surgeries on right knee; first was in \n - Recent h/o MSSA bacteremia \n non-contributory\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Recently residing at Rehab. Previously lived with\n daughter, previously independent, 10 year tobacco history but not\n smoking currently, no etoh or IVDU.\n Review of systems:\n Flowsheet Data as of 11:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 38\nC (100.4\n HR: 100 (95 - 114) bpm\n BP: 138/50(70) {115/35(59) - 168/151(155)} mmHg\n RR: 29 (21 - 39) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,517 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,277 mL\n Blood products:\n Total out:\n 0 mL\n 600 mL\n Urine:\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,917 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n PE: T 99 BP 161/63 HR 104 RR 27 O2 sat 100% 2L NC\n Gen - NAD, obese pleasant female, awake and alert\n HEENT - Clear OP, moist MM\n CV - tachy, slight systolic murmur at 2ICS\n Lungs - CTA B but difficult to assess due to body habitus\n Abd - soft, NT, ND, +BS, echymosis present on abd\n Ext - no c/c, +erythema on both lower extremities, edema 2+, warm\n Skin - multiple echymosis, warm\n Neuro - A&O x3, moving all extremities, except decreased mobility in\n right index fingers and thumb\n Labs / Radiology\n 125 K/uL\n 7.3 g/dL\n 1.6\n 36\n 25\n 99\n 3.1\n 138\n 23.0 %\n [image002.jpg]\n \n 2:33 A6/10/ 08:32 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 0.3\n Hct\n 23.0\n Plt\n 125\n Other labs: PT / PTT / INR:14/65/1.2, Lactic Acid:1.7 mmol/L\n Fluid analysis / Other labs: UA-\n WBC 135\n Bact few\n Lactate 4.7\n Imaging: CXR- no infiltrate\n Assessment and Plan\n 63 yo f with hx of acquired factor 8 inhibitor now with fever and\n neutropenia transfered from rehab.\n .\n #) Fever and Neutropenia: unclear source, with WBC of 0.3 and\n 63% neutrophils. Has slight cough without infiltrate on CXR. Pt is on\n chemo for factor 8 inhibtior and has been on chronic high dose\n steriods. Possible sources include recent long placement of PICC line,\n (however line fell out 10 days ago), pulmonary, skin (legs with\n possible cellulitis), or urinary. UA came back positive with WBC 135\n and few bacteria, so most likely has UTI. Concern for if pt becomes\n septic due to difficult IV access. Had complications in the past with\n line placement and bleeding. Lactate elevated at 4.7.\n - staring vanco\n - continuing cefepime\n - follow blood and urine cx here and at rehab\n - IV team to place PICC\n - trend lactate\n .\n #) Factor 8 Inhibitor: Has aquired inhibitor. Levels have been trending\n down over last several weeks. Followed by heme/onc. On cytoxan,\n steriods, and has been having weekly rituximab for 2 weeks.\n - hold cytoxan fer heme\n - heme recs\n - continue prednisone 60mg daily\n - check factor 8 inhibitor levels\n - protocol for if pt bleeds is to use activated factor 7 70-90ug/kg IV,\n and if bleeding presists will give second dose in hours. Will avoid\n bovine thrombin topical applications since they may worsen inhibtior\n levels\n .\n #) Acute on chronic renal failure: Cr up to 1.6, has hx of renal\n failure during prior addmission. be secondary to sepsis and low\n intravascular volume\n - will give IVF\n - monitor renal function\n - renally dose meds\n .\n #) Diabetes- followed by , on high dose SSI and lantus\n - continue aspart SSI from rehab and lantus 34 in AM\n .\n #) Hypertension\n - hold htn meds for today, restart in AM if stable\n .\n #) Hyperlipidemia\n - continue home statin\n .\n #) FEN/GI - Diabetic diet\n #) Ppx - auto anticoagulated\n #) Code - Full confirmed\n #) Communication - With pt and her Daughter.\n #) Dispo - ICU for tonight.\n ICU Care\n Nutrition:\n Comments: Diabetic\n Glycemic Control: Comments: lanuts and aspart ssi\n Lines:\n 20 Gauge - 03:29 PM\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2184-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579037, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology.\n Febrile at home T max 103, 101 at the ED, received Tylenol 650 mgs PO;\n stable vital signs but with a lactate of 4.7 received total of 2.5\n liters of NS bolus. Given 1 dose of cefepime at the ED.\n Febrile neutropenia with ? sepsis\n Assessment:\n T 99.9 upon ICU arrival, stable blood pressure; no complaints of any\n pain. O2 sats > 95% at 2 lpm via NC\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579253, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cyclosporine and prednisone for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97. U/O has remained over 100 cc/hr\n and clear. Lactic acid levels down to 1.7 from 4.7 in ED. U/A came\n back w/ few bacteria and WBC 135, so team is leaning towards UTI as\n source. Skin infection on lower legs is another possible source. BP\n stable in 150-170/50-60.\n Action: Admin Tylenol as ordered. Received Cefepime this am.\n Response\n Plan\n -cefepime at 0800\n -BS have been running high around 300\n -afebrile\n -lactate levels 1.7\n -BP stable around 150-170/50-60. received lopressor at 0500\n -hct 22 this am after 1 unit PRBCs\n" }, { "category": "General", "chartdate": "2184-06-09 00:00:00.000", "description": "Generic Note", "row_id": 579093, "text": "TITLE:\n I have seen and examined the patient with the resident and agree\n substanitally with the assessment and plan with the following\n modifications/emphasis:\n This is a 63 yo F with h/o high-titer acquired factor VIII inhibitor\n with large transfusion requirement due to recurrent bleeding/hematomas,\n DM II, and HTN with recent admission for work-up of acquired factor\n VIII inhibitor, anemia hematomas, and MSSA bacteremia who presents\n with fevers from rehab.\n .\n In the ED, Tm 101 HR 110, RR 18\n Labs notable for WBC 0.3 with 63% neutrophils and 3% bands, Hct 22.1,\n Cr 1.6, lactate 4.7, and ESR 110.\n T 99.9 BP 137/80 P 102 RR 30 SaO2: 100%\n Awake, alert, obese\n Chest: CTA bilaterally\n Abd: Soft NT ND\n Ext: bruising, swelling in right upper extremity, bilaterally lower\n extremities\n Glu: 198\n Lactate:4.7\n WBC: 0.3\n Hgb: 7.5\n Hct: 22%\n A:\n 1) Sepsis with evidence of hypo-perfusion:\n a. Will need access for fluids and antibiotics\n given high bleed\n risk, will pursue PICC Line placement now\n b. IVFs and repeat lactate\n c. Antibiotics (Cefepime/Vancomycin)\n d. Continue outpatient statin\n 2) Factor VIII inhibitor: Follow coags,\n 3) Hyperglycemia\n Critical Care: 30 minutes\n ------ Protected Section ------\n Addendum: The source of infection is unclear at this moment although\n bilateral erythema and warmth of lower extremities may represent\n cellulitis. Also, note that while pt BP within\nnormal\n range, she has\n not taken anti-hypertensives in over 24 hours and also has lactate of\n 4.7 so that is reason for concern of hypo-perfusion and relative\n hypotension.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:25 PM ------\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579251, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cyclosporine and prednisone for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97. U/O has remained over 100 cc/hr\n and clear. Lactic acid levels down to 1.7 from 4.7 in ED. U/A came\n back w/ few bacteria and WBC 135, so team is leaning towards UTI as\n source. Skin infection on lower legs is another possible source. BP\n stable in 150-170/50-60.\n Action: Admin Tylenol as ordered. Received Cefepime this am.\n Response\n Plan\n -cefepime at 0800\n -BS have been running high around 300\n -afebrile\n -lactate levels 1.7\n -BP stable around 150-170/50-60. received lopressor at 0500\n -hct 22 this am after 1 unit PRBCs\n" }, { "category": "General", "chartdate": "2184-06-09 00:00:00.000", "description": "Generic Note", "row_id": 579092, "text": "TITLE:\n I have seen and examined the patient with the resident and agree\n substanitally with the assessment and plan with the following\n modifications/emphasis:\n This is a 63 yo F with h/o high-titer acquired factor VIII inhibitor\n with large transfusion requirement due to recurrent bleeding/hematomas,\n DM II, and HTN with recent admission for work-up of acquired factor\n VIII inhibitor, anemia hematomas, and MSSA bacteremia who presents\n with fevers from rehab.\n .\n In the ED, Tm 101 HR 110, RR 18\n Labs notable for WBC 0.3 with 63% neutrophils and 3% bands, Hct 22.1,\n Cr 1.6, lactate 4.7, and ESR 110.\n T 99.9 BP 137/80 P 102 RR 30 SaO2: 100%\n Awake, alert, obese\n Chest: CTA bilaterally\n Abd: Soft NT ND\n Ext: bruising, swelling in right upper extremity, bilaterally lower\n extremities\n Glu: 198\n Lactate:4.7\n WBC: 0.3\n Hgb: 7.5\n Hct: 22%\n A:\n 1) Sepsis with evidence of hypo-perfusion:\n a. Will need access for fluids and antibiotics\n given high bleed\n risk, will pursue PICC Line placement now\n b. IVFs and repeat lactate\n c. Antibiotics (Cefepime/Vancomycin)\n d. Continue outpatient statin\n 2) Factor VIII inhibitor: Follow coags,\n 3) Hyperglycemia\n Critical Care: 30 minutes\n" }, { "category": "Nursing", "chartdate": "2184-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579131, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology. Presented to ED on w/ chills/rigors and\n fever to 102, Lactate was 4.7, noted to be neutropenic w/ pos UA.\n Admitted to M/SICU for further mgt.\n Overnight Events:\n Left brachial PICC line placed by IV RN at bedside,\n placement confirmed by CXR.\n Received 2L NS bolus.\n Received one unit PRBCs for HCT 23.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.4.\n Vitals stable, 02 sats >95% on 2L NC.\n Lactate down to 1.7 following IVF.\n Pt voiding, UO adequate.\n Pt 3.\n Action:\n Received Tylenol, IV abx as ordered.\n Blood cultures drawn.\n On neutropenic precautions.\n Response:\n Temp down to 98.2\n Vitals and resp status remains stable.\n Urine output adequate.\n Plan:\n Cont to monitor pts vitals and urine output.\n f/u w/ repeat HCT following blood transfusion and AM labs.\n f/u with pending blood cultures.\n - pt has multiple area\ns of bruising which pt states are not new and\n are r/t factor VIII deficiency.\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579237, "text": "TITLE:\n I have seen and examined the patient with the resident and agree\n substanitally with the assessment and plan with the following\n modifications/emphasis:\n This is a 63 yo F with h/o high-titer acquired factor VIII inhibitor\n with large transfusion requirement due to recurrent bleeding/hematomas,\n DM II, and HTN with recent admission for work-up of acquired factor\n VIII inhibitor, anemia hematomas, and MSSA bacteremia who presents\n with fevers from rehab.\n Overnight, had PICC line placed, received fluids, and antibiotics and\n is clearing her lactate.\n Temp 36.1 P 77 BP 149/52 RR 19 SaO2: 100%\n Awake, alert, obese\n Chest: CTA bilaterally\n Abd: Soft NT ND\n Ext: bruising, swelling in right upper extremity, bilaterally lower\n extremities\n A:\n 1) Sepsis: sources include urine or potentially skin (bilateral\n erythema of shins which has been improving)\n a. Excellent perfusion and hemodynamics, so no further\n resuscitation needed and can begin to re-introduce home BP meds slowly\n b. Continue antibiotics for now (Cefepime/Vancomycin) and can\n de-escalate when cultures return and continues to improve\n c. Continue outpatient statin\n 2) Factor VIII inhibitor: Follow coags,\n 3) Hyperglycemia: on insulin and managed by outpatient\n 4) Baseline Hypertension: Was\n Critical Care: 30 minutes\n ------ Protected Section ------\n Addendum: The source of infection is unclear at this moment although\n bilateral erythema and warmth of lower extremities may represent\n cellulitis. Also, note that while pt BP within\nnormal\n range, she has\n not taken anti-hypertensives in over 24 hours and also has lactate of\n 4.7 so that is reason for concern of hypo-perfusion and relative\n hypotension.\n" }, { "category": "Physician ", "chartdate": "2184-06-10 00:00:00.000", "description": "Progress Note", "row_id": 579238, "text": "TITLE: Progress Note\n 24 Hour Events:\n PICC LINE - START 08:00 PM\n BLOOD CULTURED - At 09:00 PM\n FEVER - 102.4\nF - 08:00 PM\n -PICC line placed by IV team\n -UA appears to have UTI\n -fever of 102 in afternoon, recultured\n -BP in 150s, metoprolol restarted\n Allergies:\n Valium (Oral) (Diazepam)\n Unknown;\n Darvon (Oral) (Propoxyphene Hcl)\n Unknown;\n Scopolamine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:46 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 36.5\nC (97.7\n HR: 77 (77 - 114) bpm\n BP: 166/64(85) {115/35(59) - 190/151(155)} mmHg\n RR: 17 (17 - 39) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,526 mL\n 355 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,286 mL\n 76 mL\n Blood products:\n 279 mL\n Total out:\n 600 mL\n 1,500 mL\n Urine:\n 600 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,926 mL\n -1,145 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n PE: T 99 BP 161/63 HR 104 RR 27 O2 sat 100% 2L NC\n Gen - NAD, obese pleasant female, awake and alert\n HEENT - Clear OP, moist MM\n CV - tachy, slight systolic murmur at 2ICS\n Lungs - CTA B but difficult to assess due to body habitus\n Abd - soft, NT, ND, +BS, echymosis present on abd\n Ext - no c/c, +erythema on both lower extremities, edema 2+, warm\n Skin - multiple echymosis, warm\n Neuro - A&O x3, moving all extremities, except decreased mobility in\n right index fingers and thumb\n Labs / Radiology\n 129 K/uL\n 7.8 g/dL\n 210 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 34 mg/dL\n 106 mEq/L\n 139 mEq/L\n 22.4 %\n 0.7 K/uL\n [image002.jpg]\n 08:32 PM\n 10:33 PM\n 03:45 AM\n WBC\n 0.3\n 0.7\n Hct\n 23.0\n 22.4\n Plt\n 125\n 129\n Cr\n 1.5\n 1.3\n Glucose\n 118\n 210\n Other labs: PT / PTT / INR:14.8/97.3/1.3, Differential-Neuts:86.0 %,\n Band:2.0 %, Lymph:2.0 %, Mono:10.0 %, Eos:0.0 %, Lactic Acid:1.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Gran-Ct: 616\n 6:52p\n _______________________________________________________________________\n Source: CVS\n Color\n Yellow\n Appear\n Hazy\n SpecGr\n 1.015\n pH\n 5.0\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Lg\n Bld\n Tr\n Nitr\n Neg\n Prot\n 30\n Glu\n Tr\n Ket\n Neg\n RBC\n 0\n WBC\n 135\n Bact\n Few\n Yeast\n None\n Epi\n 4\n Assessment and Plan\n 63 yo f with hx of acquired factor 8 inhibitor now with fever and\n neutropenia transfered from rehab.\n .\n #) Fever and Neutropenia: Neutropenia resolved with ANC 616. Source\n most likely urinary tract infection, Ua significantly positive. Blood\n culture and urine culture pending. Lactate improving.\n - continue vanc and cefepime until prelim cultures\n - follow blood and urine cx here and at rehab\n - d/c neutropenia pre-cautions\n - PICC line for access\n .\n #) Factor 8 Inhibitor: Has aquired inhibitor. Levels have been trending\n down over last several weeks. Followed by heme/onc. On cytoxan,\n steriods, and has been having weekly rituximab for 2 weeks. Patient has\n received total of 2 pRBC.\n - hold cytoxan per heme\n - heme recs\n - continue prednisone 60mg daily\n - check factor 8 inhibitor levels\n - protocol for if pt bleeds is to use activated factor 7 70-90ug/kg IV,\n and if bleeding presists will give second dose in hours. Will avoid\n bovine thrombin topical applications since they may worsen inhibtior\n levels\n .\n #) Acute on chronic renal failure: Back to baseline 1.3 with fluids,\n most likely pre-renal.\n - monitor renal function\n - renally dose meds\n .\n #) Diabetes- followed by , on high dose SSI and lantus\n - continue aspart SSI from rehab and lantus 34 in AM\n .\n #) Hypertension: re-start outpatient blood pressure medications. Hold\n toresomide for today until BP stable.\n .\n #) Hyperlipidemia\n - continue home statin\n .\n #) FEN/GI - Diabetic diet, no longer requires neutropenic diet\n #) Ppx - auto anticoagulated\n #) Code - Full confirmed\n #) Communication - With pt and her Daughter.\n #) \n transfer to floor today\n ICU Care\n Lines:\n 20 Gauge - 03:29 PM\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT: no hep sq\n Code status: Full code\n Disposition: transfer to floor\n" }, { "category": "Nursing", "chartdate": "2184-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579084, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology.\n Febrile at home T max 103, 101 at the ED, received Tylenol 650 mgs PO;\n stable vital signs but with a lactate of 4.7 received total of 2.5\n liters of NS bolus. Given 1 dose of cefepime at the ED.\n Febrile neutropenia with ? sepsis\n Assessment:\n T 99.9 upon ICU arrival, stable blood pressure; no complaints of any\n pain. O2 sats > 95% at 2 lpm via NC\n Action:\n Received cepefime 2 gms at ED and 2.5liters NS at Ed, waiting for team\n to place orders\n Response:\n Stable vital signs, febrile 101.8 at 1800, received Tylenol 650 mgs\n Plan:\n Waiting for team for plans\n K 3.1\n will receive 40 mEq of KCl\n Received 16 units of humalog for FS of 74\n UA culture sent, UO pungent odor and concentrated\n 300cc\n Poor IV access, has only guage 20 at R thumb. Plan for PICC at bedside\n or IR\n" }, { "category": "General", "chartdate": "2184-06-09 00:00:00.000", "description": "Generic Note", "row_id": 579073, "text": "TITLE:\n I have seen and examined the patient with the resident and agree\n substanitally with the assessment and plan with the following\n modifications/emphasis:\n This is a 63 yo F with h/o high-titer acquired factor VIII inhibitor\n with large transfusion requirement due to recurrent bleeding/hematomas,\n DM II, and HTN with recent admission for work-up of acquired factor\n VIII inhibitor, anemia hematomas, and MSSA bacteremia who presents\n with fevers from rehab.\n .\n In the ED, Tm 101.1, BP 125/..., HR 110, RR .... Labs notable for WBC\n 0.3 with 63% neutrophils and 3% bands, Hct 22.1 (baseline ...), Cr 1.6,\n lactate 4.7, and ESR 110.\n T 99.9 BP 137/80 P 102 RR 30 SaO2: 100%\n Awake, alert, obese\n Glu: 198\n Lactate:4.7\n WBC: 0.3\n Hgb: 7.5\n Hct: 22%\n A:\n 1) Sepsis:\n a. Will need access for fluids and antibiotics\n b. IVFs\n c. Antibiotics (Cefepime/Vancomycin)\n d. Continue outpatient statin\n 2) Factor VIII inhibitor\n 3) Hyperglycemia\n 4)\n" }, { "category": "Nursing", "chartdate": "2184-06-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579075, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology.\n Febrile at home T max 103, 101 at the ED, received Tylenol 650 mgs PO;\n stable vital signs but with a lactate of 4.7 received total of 2.5\n liters of NS bolus. Given 1 dose of cefepime at the ED.\n Febrile neutropenia with ? sepsis\n Assessment:\n T 99.9 upon ICU arrival, stable blood pressure; no complaints of any\n pain. O2 sats > 95% at 2 lpm via NC\n Action:\n Received cepefime 2 gms at ED and 2.5liters NS at Ed, waiting for team\n to place orders\n Response:\n Stable vital signs\n Plan:\n K 3.1\n will receive 40 mEq of KCl\n Tolerating\n" }, { "category": "Nursing", "chartdate": "2184-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579114, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology. Presented to ED on w/ chills/rigors and\n fever to 102, Lactate was 4.7, noted to be neutropenic w/ pos UA.\n Admitted to M/SICU for further mgt.\n Overnight Events:\n Left brachial PICC line placed by IV RN at bedside,\n placement confirmed by CXR.\n Received 2L NS bolus.\n Received one unit PRBCs.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.4.\n Vitals stable, 02 sats >95% on 2L NC.\n Lactate down to 1.7 following IVF.\n Pt voiding, UO adequate.\n Pt 3.\n Action:\n Received Tylenol, IV abx as ordered.\n Blood cultures drawn.\n On neutropenic precautions.\n Response:\n Temp down to 98.2\n Vitals and resp status remains stable.\n Plan:\n Cont to monitor pts vitals and urine output.\n" }, { "category": "Nursing", "chartdate": "2184-06-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 579120, "text": "63 year old female with history of DM, HTN, hyperlipidemia, anemia,\n MSSA and newly diagnosed factor VIII deficiency. She had a recent\n admission last where she stayed for about a month for acute\n blood loss secondary to the acquired factor VIII deficiency. She was\n treated with cyclosporine and prednisone for that, followed by\n heme-oncology. Presented to ED on w/ chills/rigors and\n fever to 102, Lactate was 4.7, noted to be neutropenic w/ pos UA.\n Admitted to M/SICU for further mgt.\n Overnight Events:\n Left brachial PICC line placed by IV RN at bedside,\n placement confirmed by CXR.\n Received 2L NS bolus.\n Received one unit PRBCs for HCT 23.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Tmax 102.4.\n Vitals stable, 02 sats >95% on 2L NC.\n Lactate down to 1.7 following IVF.\n Pt voiding, UO adequate.\n Pt 3.\n Action:\n Received Tylenol, IV abx as ordered.\n Blood cultures drawn.\n On neutropenic precautions.\n Response:\n Temp down to 98.2\n Vitals and resp status remains stable.\n Urine output adequate.\n Plan:\n Cont to monitor pts vitals and urine output.\n f/u w/ repeat HCT following blood transfusion and AM labs.\n f/u with pending blood cultures.\n" }, { "category": "Physician ", "chartdate": "2184-06-10 00:00:00.000", "description": "Progress Note", "row_id": 579191, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 08:00 PM\n BLOOD CULTURED - At 09:00 PM\n FEVER - 102.4\nF - 08:00 PM\n -PICC line placed by IV team\n -UA appears to have UTI\n -fever of 102 in afternoon, recultured\n -BP in 150s, metoprolol restarted\n Allergies:\n Valium (Oral) (Diazepam)\n Unknown;\n Darvon (Oral) (Propoxyphene Hcl)\n Unknown;\n Scopolamine\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 08:46 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.1\nC (102.4\n Tcurrent: 36.5\nC (97.7\n HR: 77 (77 - 114) bpm\n BP: 166/64(85) {115/35(59) - 190/151(155)} mmHg\n RR: 17 (17 - 39) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 62 Inch\n Total In:\n 2,526 mL\n 355 mL\n PO:\n 240 mL\n TF:\n IVF:\n 2,286 mL\n 76 mL\n Blood products:\n 279 mL\n Total out:\n 600 mL\n 1,500 mL\n Urine:\n 600 mL\n 1,500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,926 mL\n -1,145 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///23/\n Physical Examination\n PE: T 99 BP 161/63 HR 104 RR 27 O2 sat 100% 2L NC\n Gen - NAD, obese pleasant female, awake and alert\n HEENT - Clear OP, moist MM\n CV - tachy, slight systolic murmur at 2ICS\n Lungs - CTA B but difficult to assess due to body habitus\n Abd - soft, NT, ND, +BS, echymosis present on abd\n Ext - no c/c, +erythema on both lower extremities, edema 2+, warm\n Skin - multiple echymosis, warm\n Neuro - A&O x3, moving all extremities, except decreased mobility in\n right index fingers and thumb\n Labs / Radiology\n 129 K/uL\n 7.8 g/dL\n 210 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 34 mg/dL\n 106 mEq/L\n 139 mEq/L\n 22.4 %\n 0.7 K/uL\n [image002.jpg]\n 08:32 PM\n 10:33 PM\n 03:45 AM\n WBC\n 0.3\n 0.7\n Hct\n 23.0\n 22.4\n Plt\n 125\n 129\n Cr\n 1.5\n 1.3\n Glucose\n 118\n 210\n Other labs: PT / PTT / INR:14.8/97.3/1.3, Differential-Neuts:86.0 %,\n Band:2.0 %, Lymph:2.0 %, Mono:10.0 %, Eos:0.0 %, Lactic Acid:1.7\n mmol/L, Ca++:7.5 mg/dL, Mg++:1.9 mg/dL, PO4:3.9 mg/dL\n Gran-Ct: 616\n 6:52p\n _______________________________________________________________________\n Source: CVS\n Color\n Yellow\n Appear\n Hazy\n SpecGr\n 1.015\n pH\n 5.0\n Urobil\n Neg\n Bili\n Neg\n Leuk\n Lg\n Bld\n Tr\n Nitr\n Neg\n Prot\n 30\n Glu\n Tr\n Ket\n Neg\n RBC\n 0\n WBC\n 135\n Bact\n Few\n Yeast\n None\n Epi\n 4\n Assessment and Plan\n 63 yo f with hx of acquired factor 8 inhibitor now with fever and\n neutropenia transfered from rehab.\n .\n #) Fever and Neutropenia: unclear source, with WBC of 0.3 and\n 63% neutrophils. Has slight cough without infiltrate on CXR. Pt is on\n chemo for factor 8 inhibtior and has been on chronic high dose\n steriods. Possible sources include recent long placement of PICC line,\n (however line fell out 10 days ago), pulmonary, skin (legs with\n possible cellulitis), or urinary. UA came back positive with WBC 135\n and few bacteria, so most likely has UTI. Concern for if pt becomes\n septic due to difficult IV access. Had complications in the past with\n line placement and bleeding. Lactate elevated at 4.7.\n - staring vanco\n - continuing cefepime\n - follow blood and urine cx here and at rehab\n - IV team to place PICC\n - trend lactate\n .\n #) Factor 8 Inhibitor: Has aquired inhibitor. Levels have been trending\n down over last several weeks. Followed by heme/onc. On cytoxan,\n steriods, and has been having weekly rituximab for 2 weeks.\n - hold cytoxan fer heme\n - heme recs\n - continue prednisone 60mg daily\n - check factor 8 inhibitor levels\n - protocol for if pt bleeds is to use activated factor 7 70-90ug/kg IV,\n and if bleeding presists will give second dose in hours. Will avoid\n bovine thrombin topical applications since they may worsen inhibtior\n levels\n .\n #) Acute on chronic renal failure: Cr up to 1.6, has hx of renal\n failure during prior addmission. be secondary to sepsis and low\n intravascular volume\n - will give IVF\n - monitor renal function\n - renally dose meds\n .\n #) Diabetes- followed by , on high dose SSI and lantus\n - continue aspart SSI from rehab and lantus 34 in AM\n .\n #) Hypertension\n - hold htn meds for today, restart in AM if stable\n .\n #) Hyperlipidemia\n - continue home statin\n .\n #) FEN/GI - Diabetic diet\n #) Ppx - auto anticoagulated\n #) Code - Full confirmed\n #) Communication - With pt and her Daughter.\n #) Dispo - ICU for tonight.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:29 PM\n PICC Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579277, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely. With increasing sbp pt has now been restarted on\n colnidine and amlodipine\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management. Continue to follow hemodynamics closely\n and adjust out pt meds as needed\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579278, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely. With increasing sbp pt has now been restarted on\n colnidine and amlodipine\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management. Continue to follow hemodynamics closely\n and adjust out pt meds as needed\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n 15:05\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579279, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely. With increasing sbp pt has now been restarted on\n colnidine and amlodipine\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management. Continue to follow hemodynamics closely\n and adjust out pt meds as needed\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n 15:05\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , Student\n Nurse on: 15:06 ------\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579280, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely. With increasing sbp pt has now been restarted on\n colnidine and amlodipine\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management. Continue to follow hemodynamics closely\n and adjust out pt meds as needed\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n 15:05\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , Student\n Nurse on: 15:06 ------\n I agree with the above note.\n ------ Protected Section Addendum Entered By: , RN\n on: 15:07 ------\n" }, { "category": "General", "chartdate": "2184-06-10 00:00:00.000", "description": "Generic Note", "row_id": 579266, "text": "TITLE: Nursing Progress Note\n 63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely.\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management.\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n" }, { "category": "Radiology", "chartdate": "2184-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1084435, "text": " 12:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evidence of pneumonia\n Admitting Diagnosis: FEBRILE NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with factor VIIIi presented with neutropenia and fever.\n Spiked temp to 101.5 this AM.\n REASON FOR THIS EXAMINATION:\n Evidence of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever, to evaluate for pneumonia.\n\n FINDINGS: In comparison with study of , there are lower lung volumes that\n may be partially responsible for the enlarged transverse diameter of the\n heart. No vascular congestion or pleural effusion. Left PICC line again\n extends to the lower portion of the SVC.\n\n Specifically, no evidence of acute pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1083031, "text": " 11:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with fever, cough\n REASON FOR THIS EXAMINATION:\n assess for infiltrate\n ______________________________________________________________________________\n WET READ: EAGg WED 12:17 PM\n No acute abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 63-year-old female with fever and cough. Assess for\n infiltrate.\n\n COMPARISON: and CT torso of .\n\n UPRIGHT AP VIEW OF THE CHEST: The lungs are clear. There is no appreciable\n pleural effusion or pneumothorax. Mild cardiomegaly and elevation of the\n right hemidiaphragm are unchanged from . The mediastinal silhouette,\n hilar contours and pulmonary vasculature are unremarkable.\n\n" }, { "category": "Nursing", "chartdate": "2184-06-10 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 579286, "text": "63 yo female w/ ho DM, HTN, hyperlipidemia, anemia, MSSA, and newly\n diagnosed Factor VIII deficiency. She had a recent admission last\n where she stayed for about a month for acute blood loss\n secondary to acquired factor VIII deficiency. She was treated w/\n cytoxan, prednisone, and rituximab for that and followed by heme-onc.\n Presented to ED on w/ chills/rigors and fever to 102.\n Lactate was at 4.7, noted to be neutropenic w/ pos UA. Admitted to\n for further management.\n Fever (hyperthermia, pyrexia, fever of unknown origin)\n Assessment: Pt afebrile around 97 since fever broke during PM. BP\n stable in 150-170/50-60. U/O has remained over 100 cc/hr and clear.\n Lactic acid levels down to 1.7 from 4.7 in ED. Neutropenia self-\n resolved w/ ANC at 616. WBC is 0.7. U/A came back w/ few bacteria and\n WBC 135, so team is leaning towards UTI as source. Skin infection on\n lower legs is another possible source. Pt\ns cough is minimal and\n non-productive. Blood sugars are also running high in the low 300s,\n possibly due to infection?\n Action: Admin Tylenol as ordered. Received Cefepime this am. Vanco\n due . Monitoring U/O, hemodynamics, blood sugars, and respiratory\n status closely. With increasing sbp pt has now been restarted on\n colnidine and amlodipine\n Response: Pt remains afebrile and stable. Urine cultures pending.\n Plan: Continue to monitor bacteremia. Waiting for transfer to medical\n floor for further management. Continue to follow hemodynamics closely\n and adjust out pt meds as needed\n Factor VIII Inhibitor\n Assessment: Pt has significant resolving hematomas from previous\n acute. Hct was 22 this am after infusing w/ 1 unit PRBCs last night.\n Pt O2 sats remain around 100%. Has PICC in left brachial and 20 gauge\n in right hand for access.\n Action: Pt on 2 L O2 NC. Monitoring hct closely. Followed by\n heme-onc.\n Response: Pt is stable and awaiting transfer to floor.\n Plan: Continue to monitor for s/s of bleeding. Dressing not to be\n changed on PICC until tomorrow.\n 15:05\n ------ Protected Section ------\n ------ Protected Section Addendum Entered By: , Student\n Nurse on: 15:06 ------\n I agree with the above note.\n ------ Protected Section Addendum Entered By: , RN\n on: 15:07 ------\n Demographics\n Attending MD:\n W.\n Admit diagnosis:\n FEBRILE NEUTROPENIA\n Code status:\n Full code\n Height:\n 62 Inch\n Admission weight:\n 117.4 kg\n Daily weight:\n Allergies/Reactions:\n Valium (Oral) (Diazepam)\n Unknown;\n Darvon (Oral) (Propoxyphene Hcl)\n Unknown;\n Scopolamine\n Unknown;\n Precautions:\n PMH: Anemia, Diabetes - Insulin\n CV-PMH:\n Additional history: HTN, Hyperlipidemia, multiple surgery R knee,\n Acquired factor VIII deficiency, MSSA, pulmonary nodules\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:162\n D:57\n Temperature:\n 97.7\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 20 insp/min\n Heart Rate:\n 86 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 100% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 531 mL\n 24h total out:\n 2,300 mL\n Pertinent Lab Results:\n Sodium:\n 139 mEq/L\n 03:45 AM\n Potassium:\n 4.5 mEq/L\n 03:45 AM\n Chloride:\n 106 mEq/L\n 03:45 AM\n CO2:\n 23 mEq/L\n 03:45 AM\n BUN:\n 34 mg/dL\n 03:45 AM\n Creatinine:\n 1.3 mg/dL\n 03:45 AM\n Glucose:\n 210 mg/dL\n 03:45 AM\n Hematocrit:\n 22.4 %\n 03:45 AM\n Finger Stick Glucose:\n 322\n 11:00 AM\n Valuables / Signature\n Patient valuables: pt\ns valuables (cell phone, wallet) are stored in\n her purse.\n Other valuables: pillow, dentures in mouth\n Clothes: did not come w/ clothes\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: in purse\n Jewelry: on pt\n Transferred from: \n Transferred to: 1175\n Date & time of Transfer: at 15:30\n" }, { "category": "Radiology", "chartdate": "2184-06-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1083120, "text": " 8:01 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: 52 cm Picc placed in left cephalic vein, need Picc tip place\n Admitting Diagnosis: FEBRILE NEUTROPENIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 63 year old woman with new Picc\n REASON FOR THIS EXAMINATION:\n 52 cm Picc placed in left cephalic vein, need Picc tip placement\n ______________________________________________________________________________\n WET READ: AJy WED 9:12 PM\n left PICC terminates at cavoatrial junction. no other interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Assess PICC.\n\n Left PICC terminates at the cavoatrial junction. No pneumothorax. No other\n change compared to prior study performed nine hours earlier.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2121-05-07 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1128294, "text": " 4:37 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with fall elevated INR\n REASON FOR THIS EXAMINATION:\n eval for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 7:17 PM\n No acute cervical fx or malalignment.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old woman, status post fall with elevated INR. Evaluate for\n acute cervical fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast MDCT images were acquired from the skull base to the\n cervicothoracic junction. Multiplanar reformatted images were obtained for\n evaluation.\n\n FINDINGS: There is no acute cervical fracture or malalignment. Multilevel\n mild degenerative changes are noted with posterior osteophytes at C5-C6 and\n C6-C7, without significant narrowing of the central canal. The prevertebral\n soft tissues are normal. Mild biapical scarring is noted in the visualized\n lungs. The thyroid demonstrates small nodules bilaterally.\n\n IMPRESSION: No acute cervical fracture or malalignment. Multilevel\n degenerative changes. Small bilateral thyroid nodules which could be further\n evaluated on ultrasound if not previously and as clinically warranted.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-07 00:00:00.000", "description": "R HAND (AP, LAT & OBLIQUE) RIGHT", "row_id": 1128296, "text": " 5:07 PM\n HAND (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: eval for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with fall and tenderness over right 5th metacarpal\n REASON FOR THIS EXAMINATION:\n eval for fx\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Right hand, three views.\n\n CLINICAL INFORMATION: 87-year-old female with history of fall and tenderness\n over right fifth metacarpal, evaluate for fracture.\n\n COMPARISON: None.\n\n FINDINGS: AP, lateral, oblique views of the right hand were obtained. A true\n lateral view was not obtained. There is diffuse osteopenia. Osteoarthritic\n changes are seen at the first carpometacarpal joint with joint space\n narrowing, sclerosis and proliferative changes. There are also degenerative\n changes at the lunate-triquetral joint and the radiocarpal joint.\n Additionally, degenerative change is noted at the second MCP joint with\n proliferative change, soft tissue calcification, and joint space narrowing.\n No evidence of acute fracture or dislocation is seen.\n\n IMPRESSION: Degenerative changes, as above. No definite acute fracture or\n dislocation.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1128293, "text": " 4:36 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with fall elevated INR\n REASON FOR THIS EXAMINATION:\n eval for bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 7:19 PM\n No acute intracranial process. Old infarcts.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old woman, status post fall. With elevated INR, rule out\n for intracranial bleed.\n\n COMPARISON: Multiple prior head CTs with the latest on .\n\n TECHNIQUE: Non-contrast MDCT images were acquired through the brain.\n Multiplanar reformatted images were obtained for evaluation.\n\n FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or\n major vascular territorial infarct. The known encephalomalacia in the right\n posterior cerebral artery territory is unchanged. Old lacunar infarcts in the\n right putamen, left genu of internal capsule and posterior limb of the left\n internal capsules are all stable in appearance. Mild-to-moderate\n periventricular white matter hypodensities are compatible with chronic\n microvascular ischemic disease. The ventricles and sulci are otherwise\n unchanged and within normal limits. There is no shift of normally midline\n structures. There is mild ethmoidal mucosal thickening. The remaining\n paranasal sinuses and mastoid air cells are clear. No acute fracture is\n noted.\n\n IMPRESSION: No acute intracranial process. Unchanged encephalomalacia and\n lacunar infarcts. Chronic microvascular ischemic disease. Ethmoidal\n opacification.\n\n" }, { "category": "Radiology", "chartdate": "2121-05-07 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1128307, "text": " 6:07 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for traumatic injury\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 87 year old woman with fall gross rectal blood, oxygen sat 94%\n REASON FOR THIS EXAMINATION:\n eval for traumatic injury\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 7:24 PM\n 1. No acute traumatic injury.\n 2. Minimal loss of height at L3, likely chronic. Rec clinical correlations.\n 3. Marked DJD with scoliosis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 87-year-old woman, status post fall. Now gross rectal blood.\n Assess for traumatic injury.\n\n COMPARISON: Limited comparison from prior CT chest on .\n\n TECHNIQUE: MDCT images were acquired from the thoracic inlet to the pubic\n symphysis after administration of IV contrast. Multiplanar reformatted images\n were obtained for evaluation.\n\n CT CHEST WITH CONTRAST: There is biapical scarring. Atelectasis is noted in\n the anterior right upper lobe. The lungs are otherwise symmetrically expanded\n without pleural effusions or pneumothorax. There are no pulmonary masses or\n nodules suspicious for malignancy.\n\n The right atrium is enlarged. There is no pericardial effusion. The aorta is\n normal in course and caliber without acute pathology. Small mediastinal nodes\n are not pathologically enlarged. There is no hilar or axillary\n lymphadenopathy. In the subcutaneous tissue of the anterior left breast\n (S2:I28), there is a 2 cm subcutaneous lesion again seen. Correlation with\n mammogram continues to be recommended if not obtained since prior study. The\n multinodular thyroid is grossly unchanged.\n\n CT ABDOMEN WITH CONTRAST: A 3-mm hypodensity in the right hepatic lobe (2:57)\n is too small to be fully evaluated. The liver is otherwise normal without\n focal lesions. There is no intrahepatic or extrahepatic biliary ductal\n dilation. The gallbladder, spleen, and right kidney are normal. There is a\n large exophytic cyst in the lower pole of the left kidney measures 44 x 44 mm\n (2:78), compatible with a simple cyst. There are prompt excretion of IV\n contrast bilaterally into the collecting system. No hydronephrosis,\n hydroureter or evidence of renal stone is noted The pancreas is atrophic in\n appearance, with calcification along the splenic artery. No free fluid, air\n or lymphadenopathy is noted in the abdomen.\n\n CT PELVIS WITH CONTRAST: Diffuse colonic diverticulosis is again noted but\n without acute diverticulitis. There is no bowel obstruction. The urinary\n (Over)\n\n 6:07 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for traumatic injury\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bladder is normally distended without focal lesions. The right hip fixation\n screws cast streaking artifacts, limiting evaluation of adjacent structures.\n Calcified atherosclerotic plaques are moderate along the aorta and its major\n branches. The atrophic uterus is appropriate for age. There is no free\n fluid, air or lymphadenopathy in the pelvis.\n\n BONE WINDOW: There is a moderate loss of height of the L3 superior endplate,\n of uncertain chronicity. There is no other acute fracture or dislocation.\n Mild smooth S-shaped scoliosis is noted with multilevel degenerative changes.\n The patient is status post ORIF of the right hip with fixation screws, causing\n adjacent streak artifact.\n\n IMPRESSION:\n 1. Moderate compression of the L3 superior endplate, of uncertain chronicity.\n Recommend clinical correlation with site tenderness.\n 2. No evidence of acute visceral injury in the chest, abdomen, or pelvis.\n 3. 2-cm anterior left breast subcutaneous lesion, again seen. Correlation\n with mammogram continues to be recommended if not obtained since prior study.\n 5. Diverticulosis without diverticulitis.\n 6. Multinodular thyroid again seen. Continued follow-up per thyroid\n ultrasound () recommendation.\n\n" }, { "category": "ECG", "chartdate": "2121-05-09 00:00:00.000", "description": "Report", "row_id": 222627, "text": "Atrial fibrillation with a slow ventricular response. Right bundle-branch\nblock. Non-specific ST-T wave changes. Right axis deviation. Compared to the\nprevious tracing there is no significant chnage.\n\n" }, { "category": "ECG", "chartdate": "2121-05-08 00:00:00.000", "description": "Report", "row_id": 222628, "text": "Atrial fibrillation with ventricular premature beats. Right bundle-branch\nblock. Modest right axis deviation. ST-T wave changes may be primary but\nunstable baseline makes assessment difficult. Findings raise consideration\nof possible right ventricular overload but clinical correlation is suggested.\nSince the previous tracing of ventricular ectopy is now present.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2121-05-07 00:00:00.000", "description": "Report", "row_id": 222629, "text": "Atrial fibrillation. Right bundle-branch block. Modest right axis deviation.\nST-T wave changes may be primary and are non-specific. Findings raise\nconsideration of possible right ventricular overload. Clinical correlation is\nsuggested. Since the previous tracing of ventricular rate is faster.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628744, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management.\n Coagulopathy\n Assessment:\n Received pt in A-fib 70-90\ns with frequent PVC\ns. SBP 140\ns. Denying\n any CP, SOB, or chest tightness. Pedal pulses weak but palpable. Sp02\n high 80\ns on RA. Lungs clear, diminished at bases. Abdomen benign. Oral\n mucosa with dried blood, pt states all teeth are her original, they do\n not appear lose. Hematoma present on posterior occiput, skin intact.\n Right lower arm severely eccymotic. Alert and oriented to self and\n date, though she was in Rehab. Repeat labs on admission with\n INR 2.7 and a 4 point Hct drop.\n Action:\n EKG done showing Afib with frequent PVC, right bundle branch block, ST\n changes. Enzymes flat in ED. Placed on 3 L NC\nfoley placed after\n incontinent episode x2. CBC with coags drawn with morning labs.\n Response:\n Pt now alert and oriented to person, place, and time.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 628866, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management\n Coagulopathy\n Assessment:\n Pt\ns INR at 3 am was 2.4, at 10 am it was 1.7. She is in afib, she\n still has a bruise on her R lower arm and the back of her upper back\n Action:\n To be restarted on coumadin this afternoon\n Response:\n Plan:\n Follow her INR, she is a fall risk and lives at an \n facility.\n Of note, pt has phlebitis from an old IV, it had great blood draw and\n the red area somewhat matched where the tape and tegaderm was. The IV\n was pulled and IV will put in a new IV.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n LOWER GASTROINTESTINAL BLEED;SUPRATHERAPEUTIC INR\n Code status:\n DNR / DNI\n Height:\n Admission weight:\n 53.5 kg\n Daily weight:\n Allergies/Reactions:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\n Precautions:\n PMH:\n CV-PMH: Arrhythmias, CVA, Hypertension\n Additional history: afib (on coumadin); hypercholesterolemia; recurrent\n angioedema r/t ace inhibitors; eczema; hayfever; osteoarthritis;\n osteoporosis; right hip replacement; falls\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:135\n D:58\n Temperature:\n 100.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 17 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n AF (Atrial Fibrillation)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,250 mL\n 24h total out:\n 550 mL\n Pertinent Lab Results:\n Sodium:\n 143 mEq/L\n 03:41 AM\n Potassium:\n 3.6 mEq/L\n 03:41 AM\n Chloride:\n 106 mEq/L\n 03:41 AM\n CO2:\n 24 mEq/L\n 03:41 AM\n BUN:\n 20 mg/dL\n 03:41 AM\n Creatinine:\n 0.9 mg/dL\n 03:41 AM\n Glucose:\n 102 mg/dL\n 03:41 AM\n Hematocrit:\n 31.8 %\n 10:37 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from:\n Transferred to:\n Date & time of Transfer:\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628741, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management.\n Coagulopathy\n Assessment:\n Received pt in A-fib 70-90\ns with frequent PVC\ns. SBP 140\ns. Denying\n any CP, SOB, or chest tightness. Pedal pulses weak but palpable. Sp02\n high 80\ns on RA. Lungs clear, diminished at bases. Abdomen benign. Oral\n mucosa with dried blood, pt states all teeth are her original, they do\n not appear lose. Hematoma present on posterior occiput, skin intact.\n Right lower arm severely eccymotic. Repeat labs on admission with INR\n 2.7 and a 4 point Hct drop.\n Action:\n Placed on 3 L NC\nfoley placed after incontinent episode x2. CBC with\n coags drawn with morning labs.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628727, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management.\n Coagulopathy\n Assessment:\n Received pt in A-fib 70-90\ns with frequent PVC\ns. SBP 140\ns. Denying\n any CP, SOB, or chest tightness. Pedal pulses weak but palpable. Sp02\n high 80\ns on RA. Lungs clear, diminished at bases. Abdomen benign. Oral\n mucosa with dried blood, pt states all teeth are her original, they do\n not appear lose. Hematoma present on posterior occiput, skin intact.\n Right lower arm severely eccymotic.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 628731, "text": "Chief Complaint: Fall with hematoma to right side of head\n HPI:\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained two\n falls today while rehabbing at home with PT/OT/VNA. First fall was\n witnessed with no head trauma or LOC. Second fall was unwitnessed and\n caused hematoma to right side of head. Pt does not recall falling or\n events immediately preceding fall (she was using her cane). She denies\n diziness, lightheadedness or aura prior to event. No chest pain,\n palpitations. She was able to put the hand to prevent hitting her head.\n She did not feel very fatigued afterwards, there were no abnormal\n movments. She has rugs at home, but does not remember tripping. After\n falling, pt's next memory is of daughter taking her to her primary care\n doctor, where she was found ot have an elevated INR and administered 10\n mg of PO Vitamin K. Pt denies any changes to her medications including\n new antibiotics, changes in coumadin dosage, diet, or supplements. She\n denies any current alcohol or social event. She denies any fever,\n chills, diarrhea, nausea, vomit or other signs of infection. She takes\n her medications by herself and knows her coumadin dose (2.5), but is\n unable to mention other medications. She lives in an ,\n where they do not suppervise her in terms of her medications, but has a\n VNA. Pt was then transferred to ER for further care.\n .\n In the ER her initial VS were BP 131/53 mmHg, HR 83 BPM, RR 18,\n 97.7 F. On physical exam she was A&OX3, had an hematoma in the right\n occiput and lower lip laceration of 0.5 cm aproximately. She had\n C-collar and had gross blood in the rectal vault. She had labs that\n were significant for INR of 20.2 with PTT of 71.4, HCT of 37.7 at her\n baseline. She received 500 cc NS (?). She underwent CT scan of the head\n and c-spine without any abnormality and CT scan of abdomen and pelvis\n without acute pahtology. Patient was T&C and received 2 FFP units. Her\n VS were stable throught the ER course. She was admitted to the ICU for\n hemodynamic monitoring. GI was not called from the ER.\n .\n Pt was recently hospitalized at on for right facial and\n upper lip angioedema, as well as a recent fall. Pt's daughter reports\n she was confused and altered from her baseline mental status on day\n prior to admission. Angiogedema improved significantly with IV\n solumedrol and H1,H2 blockers. A brain MRI was obtained due to h/o\n altered mental status in setting of fall, and was notable for an acute\n left caudate head infarct. MRA of the neck demonstrated a 50% stenosis\n of the left proximal internal carotid artery and 50% stenosis in both\n vertebral arteries in the V2 segment. The TTE on was negative\n for mural thrombus or cardiac source, but etiology of stroke felt most\n likely cardioembolic in setting of subtherapeutic INR. Pt was\n discharged in stable condition to rehab. On , pt returned to\n ED with transient dizziness, R arm and face weakness. Head CT was\n negative for bleed, and neuro felt most her presentation was most\n likely due to recrudescence of prior caudate infarct in setting of mild\n dehydration.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Warfarin 2.5 PO Daily at 4 PM\n Prednisone 5 mg PO Every other day\n Metoprolol Succinate Sustained Release 25 mg PO Daily\n Amlodipine 10 mg PO Daily\n Simvastatin 20 mg PO Daily\n Famotidine 20 mg PO BID\n Fexofenadine 60 mg PO BID\n Camphor-Menthol 0.5-0.5 % Lotion Sig Appl Topical \n Past medical history:\n Family history:\n Social History:\n -Left Caudate Head infarct\n -Angioedema: pruritis and periorbital and lip/tongue edema,\n previously intubated in MICU (), etiology thought to be due to\n lisinospril, which was subsequenlty discontinued. Recurrence in \n requiring MICU admission, managed with IV steroids and H1/H2 blockers,\n no intubation required.\n -Atrial fibrillation on coumadin\n -Hypertension\n -Hyperlipidemia\n -Osteoporosis\n -Osteoarthritis\n -S/p right hip replacement\n -Eczema\n -Hayfever as a child\n -1st cousin with peanut allergy developed in his 80s.\n -No FH of asthma or eczema\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She lives by herself in an in 100 Center Stree\n in MA. She cooks for herslef often, has a VNA and home PT.\n Denies any current or past history of smoking or illegal substances.\n Drinks 1 cup of wine occasionaly. Uses a cane.\n Review of systems:\n Constitutional\n Resp Psych\n [x] Normal [x]\n Normal [x] Normal\n [] Fever [] Hemoptysis []\n Suicidal\n [] Sweats [] Wheezing\n [] Delusions\n [] Weightloss [] Cough []\n Depression\n [] Fatigue []\n SOB [] Other:\n [] Other: [] Other:\n Eyes Gastrointestinal\n Genitourinary\n [x] Normal [x]\n Normal [x] Normal\n [] Discharge [] Abdominal pain\n [] Dysuria\n [] Blurry Vision [] Diarrhea []\n Hematuria\n [] Double Vision [] Constipation [] Hx of UTIs\n [] Loss of Vision: [] Hematochezia [] Hx of STDs\n [] Other: [] Melena []\n Renal stones\n [] Nausea [] Dark urine\n [] Vomiting [] Cloudy urine\n [] Other [] Other\n Cardiovasc\n Endocrine Msk\n [x] Normal [x]\n Normal [x] Normal\n [] Fluttering [] Libido\n decreased [] Swollen joint\n [] Racing [] Low\n Energy [] Myalgias\n [] Bradycardia [] Thyroid disease\n [] Arthralgia\n [] HTN []\n Sweating [] Other\n [] Other: [] Excessive dry skin\n [] Changes in hair\n [] Other:\n ENT\n Skin Neurological\n [x] Normal [x]\n Normal [x] Normal\n [] Nosebleed []\n Petichiae [] Alertness\n []Gum Bleed [] Ecchymosis\n [] Numbness\n [] Pain in teeth [] Ulcers: [] Nl\n Sensation\n [] Nasal drainage [] Rash [] Weakness\n [] Dry mouth [] Other: []\n Forgetful\n [] Oral ulcers\n [] Headache\n []\n Other:\n [] Seizures\n [] Tingling\n Heme/Lymph\n [x] WNL\n [] History of anemia\n [] Easy bruising/bleeding\n [x] ALL OTHER SYSTEMS NEGATIVE EXCEPT AS NOTED ABOVE\n Flowsheet Data as of 02:19 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 84 (84 - 96) bpm\n BP: 117/55(70) {117/54(70) - 146/61(81)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 137 mL\n PO:\n TF:\n IVF:\n 137 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 137 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n VITAL SIGNS - Temp 98.5 F, BP 146/61 mmHg, HR 96 BPM, RR 16 X', O2-sat\n 91% RA\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 5/5\n throughout, sensation grossly intact throughout, DTRs 2+ and symmetric,\n cerebellar exam intact, steady gait\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 280 K/uL\n 11.7 g/dL\n 128 mg/dL\n 1.0 mg/dL\n 23 mg/dL\n 24 mEq/L\n 100 mEq/L\n 3.7 mEq/L\n 140 mEq/L\n 34.7 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A4/1/ 12:07 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.7\n Hct\n 34.7\n Plt\n 280\n Cr\n 1.0\n Glucose\n 128\n Other labs: PT / PTT / INR:27.6/35.2/2.7, Ca++:9.5 mg/dL, Mg++:1.6\n mg/dL, PO4:2.4 mg/dL\n INR: 20.2 --> 2.7\n Hct: 37.7 --> 34.7\n EKG: Irregularly irregular at ventricular rate of 85 bpm, rightward\n axis deviation, widened qrs at 160 msd interval with evidence of right\n bundle branch block, no ST/T wave changes.\n IMAGING:\n CT Head w/o contrast:\n No acute intracranial process. Old infarcts.\n CT Spine w/o contrast:\n No acute cervical fx or malalignment.\n CT abdomen and pelvis:\n 1. No acute traumatic injury.\n 2. Minimal loss of height at L3, likely chronic. Rec clinical\n correlations.\n 3. Marked DJD with scoliosis.\n Assessment and Plan\n COAGULOPATHYMrs. is an 87 yo F with chronic atrial\n fibrillation on coumadin, hypertension, hyperlipidemia, and recent left\n caudate lobe infarct who presents after unwitnessed fall and an INR of\n 20 and gross blood in rectal vault.\n .\n #. Elevated INR - Pt denies any change to her coumadin dosage, new\n medications, change in diet or supplements, so cause of her increased\n INR is unclear. Pt has already received 10 mg Vitamin K and 2 units of\n FFP, with repeat INR now 2.7 from 20.2. I would expect INR to respond\n to vitamin K in ~24 hours.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine\n .\n #. Chronic Atrial Fibrillation - Pt with CHADS2 score of 4, therefore\n is very high risk for stroke and MUST be anticogulated. The timing will\n be for the PCP to decide. She is currently rate-controlled with\n metoprolol.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Swith from simvastatin to atorvastatin according to SPARCL (NEJM\n )\n .\n #. FEN - Regular cardiac healthy diet. NPO until HCT stable.\n .\n #. Access - PIV with 18G and 20G.\n .\n #. PPx -\n -DVT ppx with pneumoboots and supratherapeutic INR\n -Bowel regimen colace/senna\n -Pain management with tylenol\n .\n #. Code - DNR/DNI\n .\n #. Dispo - ICU until HCT stable and then to floor\n , M.D., M.P.H.\n Internal Medicine PGY-2\n pager #\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:56 PM\n 18 Gauge - 11:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n ------ Protected Section ------\n I was physically present with the resident team on this date for\n discussion of the above history, exam, data and assessment and plan\n with which I agree. I independently examined the patient and would add\n the following comments.\n 87 yo female with chronic anticoagulation with coumadin who presents\n with elevated INR in the setting of multiple falls. This was\n identified at PCP office and patient to ED for further evaluation.\n In ED\npatient with unremarkable vital signs but with significant\n lacerations in lip and scalp hematoma.\n Exam\notherwise unremarkable except for blood on rectal exam.\n Labs-HCT-34.7, INR=2.7\n Head CT\nno intracranial blood\n ABD/Pelvis CT\nno retroperitoneal hematoma\n A/P-87 yo female with elevated INR in the setting of coumadin therapy\n who presents with multiple falls and localized hematoma without\n evidence of intracranial bleeding and with blood seen on rectal exam\n concerning for GI bleed but without systemic signs of brisk blood loss.\n 1)GI Bleed-\n -Follow HCT\n -NPO tonight\n -IV access in place\n -PPI\n -Follow up eval depending on trend in HCT and any evidence of further\n active bleeding\n 2)Coagulopathy-\n -FFP and Vitamin K given\n -Coumadin held\n -Follow INR\n Time-45 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 03:54 ------\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628726, "text": "87 year old female from admitted s/p fall x2 with INR\n >20. Pt sustained 2 falls at the today resulting in a\n posterior occipital hematoma. Pt\ns right arm was also noted to be\n eccymotic from her life line band being too tight. Head CT, C-Spine,\n and right hand/forearm x-ray all clear. Guiac (+) stool during rectal\n exam. 500 cc NS bolus and 2 bags of FFP given. Admitted to for\n further management.\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 628843, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management\n Coagulopathy\n Assessment:\n Pt\ns INR at 3 am was 2.4, at 10 am it was 1.7. She is in afib, she\n still has a bruise on her R lower arm and the back of her upper back\n Action:\n To be restarted on coumadin this afternoon\n Response:\n Plan:\n Follow her INR, she is a fall risk and lives at an \n facility.\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628755, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management.\n Coagulopathy\n Assessment:\n Received pt in A-fib 70-90\ns with frequent PVC\ns. SBP 140\ns. Denying\n any CP, SOB, or chest tightness. Pedal pulses weak but palpable. Sp02\n high 80\ns on RA. Lungs clear, diminished at bases. Abdomen benign. Oral\n mucosa with dried blood, pt states all teeth are her original, they do\n not appear lose. Hematoma present on posterior occiput, skin intact.\n Right lower arm severely eccymotic. Alert and oriented to self and\n date, though she was in Rehab. Pt with hx of left sided\n weakness but limited assessment in bed normal. Repeat labs on admission\n with INR 2.7 and a 4 point Hct drop.\n Action:\n EKG done showing Afib with frequent PVC, right bundle branch block, ST\n changes. Enzymes flat in ED. Placed on 3 L NC\nfoley placed after\n incontinent episode x2. CBC with coags drawn with morning labs. NS\n running @ 75 cc/hr\n Response:\n Pt now alert and oriented to person, place, and time. No active s/s\n bleeding\nIV site still oozing blood since admission. Hct stable at 33.\n INR now 2.4 without intervention since MICU admission. Sp02 96% on 3 L\n NC. SBP 120\ns, Afib in the 50-70\ns with some pauses. UO adequate.\n Plan:\n Hct q4h. Watch for s/s of bleeding. Blood products as needed.\n Pt\ns vagina with questionable folds and what appears to be wart like\n tissue. MD made aware\nordered RPR (STS) with social work consult.\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 628719, "text": "Chief Complaint: Fall with hematoma to right side of head\n HPI:\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained two\n falls today while rehabbing at home with PT/OT/VNA. First fall was\n witnessed with no head trauma or LOC. Second fall was unwitnessed and\n caused hematoma to right side of head. Pt does not recall falling or\n events immediately preceding fall (she was using her cane). She denies\n diziness, lightheadedness or aura prior to event. No chest pain,\n palpitations. She was able to put the hand to prevent hitting her head.\n She did not feel very fatigued afterwards, there were no abnormal\n movments. She has rugs at home, but does not remember tripping. After\n falling, pt's next memory is of daughter taking her to her primary care\n doctor, where she was found ot have an elevated INR and administered 10\n mg of PO Vitamin K. Pt denies any changes to her medications including\n new antibiotics, changes in coumadin dosage, diet, or supplements. She\n denies any current alcohol or social event. She denies any fever,\n chills, diarrhea, nausea, vomit or other signs of infection. She takes\n her medications by herself and knows her coumadin dose (2.5), but is\n unable to mention other medications. She lives in an ,\n where they do not suppervise her in terms of her medications, but has a\n VNA. Pt was then transferred to ER for further care.\n .\n In the ER her initial VS were BP 131/53 mmHg, HR 83 BPM, RR 18,\n 97.7 F. On physical exam she was A&OX3, had an hematoma in the right\n occiput and lower lip laceration of 0.5 cm aproximately. She had\n C-collar and had gross blood in the rectal vault. She had labs that\n were significant for INR of 20.2 with PTT of 71.4, HCT of 37.7 at her\n baseline. She received 500 cc NS (?). She underwent CT scan of the head\n and c-spine without any abnormality and CT scan of abdomen and pelvis\n without acute pahtology. Patient was T&C and received 2 FFP units. Her\n VS were stable throught the ER course. She was admitted to the ICU for\n hemodynamic monitoring. GI was not called from the ER.\n .\n Pt was recently hospitalized at on for right facial and\n upper lip angioedema, as well as a recent fall. Pt's daughter reports\n she was confused and altered from her baseline mental status on day\n prior to admission. Angiogedema improved significantly with IV\n solumedrol and H1,H2 blockers. A brain MRI was obtained due to h/o\n altered mental status in setting of fall, and was notable for an acute\n left caudate head infarct. MRA of the neck demonstrated a 50% stenosis\n of the left proximal internal carotid artery and 50% stenosis in both\n vertebral arteries in the V2 segment. The TTE on was negative\n for mural thrombus or cardiac source, but etiology of stroke felt most\n likely cardioembolic in setting of subtherapeutic INR. Pt was\n discharged in stable condition to rehab. On , pt returned to\n ED with transient dizziness, R arm and face weakness. Head CT was\n negative for bleed, and neuro felt most her presentation was most\n likely due to recrudescence of prior caudate infarct in setting of mild\n dehydration.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Warfarin 2.5 PO Daily at 4 PM\n Prednisone 5 mg PO Every other day\n Metoprolol Succinate Sustained Release 25 mg PO Daily\n Amlodipine 10 mg PO Daily\n Simvastatin 20 mg PO Daily\n Famotidine 20 mg PO BID\n Fexofenadine 60 mg PO BID\n Camphor-Menthol 0.5-0.5 % Lotion Sig Appl Topical \n Past medical history:\n Family history:\n Social History:\n -Left Caudate Head infarct\n -Angioedema: pruritis and periorbital and lip/tongue edema,\n previously intubated in MICU (), etiology thought to be due to\n lisinospril, which was subsequenlty discontinued. Recurrence in \n requiring MICU admission, managed with IV steroids and H1/H2 blockers,\n no intubation required.\n -Atrial fibrillation on coumadin\n -Hypertension\n -Hyperlipidemia\n -Osteoporosis\n -Osteoarthritis\n -S/p right hip replacement\n -Eczema\n -Hayfever as a child\n -1st cousin with peanut allergy developed in his 80s.\n -No FH of asthma or eczema\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: She lives by herself in an in 100 Center Stree\n in MA. She cooks for herslef often, has a VNA and home PT.\n Denies any current or past history of smoking or illegal substances.\n Drinks 1 cup of wine occasionaly. Uses a cane.\n Review of systems:\n Constitutional\n Resp Psych\n [x] Normal [x]\n Normal [x] Normal\n [] Fever [] Hemoptysis []\n Suicidal\n [] Sweats [] Wheezing\n [] Delusions\n [] Weightloss [] Cough []\n Depression\n [] Fatigue []\n SOB [] Other:\n [] Other: [] Other:\n Eyes Gastrointestinal\n Genitourinary\n [x] Normal [x]\n Normal [x] Normal\n [] Discharge [] Abdominal pain\n [] Dysuria\n [] Blurry Vision [] Diarrhea []\n Hematuria\n [] Double Vision [] Constipation [] Hx of UTIs\n [] Loss of Vision: [] Hematochezia [] Hx of STDs\n [] Other: [] Melena []\n Renal stones\n [] Nausea [] Dark urine\n [] Vomiting [] Cloudy urine\n [] Other [] Other\n Cardiovasc\n Endocrine Msk\n [x] Normal [x]\n Normal [x] Normal\n [] Fluttering [] Libido\n decreased [] Swollen joint\n [] Racing [] Low\n Energy [] Myalgias\n [] Bradycardia [] Thyroid disease\n [] Arthralgia\n [] HTN []\n Sweating [] Other\n [] Other: [] Excessive dry skin\n [] Changes in hair\n [] Other:\n ENT\n Skin Neurological\n [x] Normal [x]\n Normal [x] Normal\n [] Nosebleed []\n Petichiae [] Alertness\n []Gum Bleed [] Ecchymosis\n [] Numbness\n [] Pain in teeth [] Ulcers: [] Nl\n Sensation\n [] Nasal drainage [] Rash [] Weakness\n [] Dry mouth [] Other: []\n Forgetful\n [] Oral ulcers\n [] Headache\n []\n Other:\n [] Seizures\n [] Tingling\n Heme/Lymph\n [x] WNL\n [] History of anemia\n [] Easy bruising/bleeding\n [x] ALL OTHER SYSTEMS NEGATIVE EXCEPT AS NOTED ABOVE\n Flowsheet Data as of 02:19 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.5\n Tcurrent: 36.9\nC (98.5\n HR: 84 (84 - 96) bpm\n BP: 117/55(70) {117/54(70) - 146/61(81)} mmHg\n RR: 24 (16 - 24) insp/min\n SpO2: 97%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 137 mL\n PO:\n TF:\n IVF:\n 137 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 137 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: ///24/\n Physical Examination\n VITAL SIGNS - Temp 98.5 F, BP 146/61 mmHg, HR 96 BPM, RR 16 X', O2-sat\n 91% RA\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 5/5\n throughout, sensation grossly intact throughout, DTRs 2+ and symmetric,\n cerebellar exam intact, steady gait\n PULSES:\n Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+\n Labs / Radiology\n 280 K/uL\n 11.7 g/dL\n 128 mg/dL\n 1.0 mg/dL\n 23 mg/dL\n 24 mEq/L\n 100 mEq/L\n 3.7 mEq/L\n 140 mEq/L\n 34.7 %\n 9.7 K/uL\n [image002.jpg]\n \n 2:33 A4/1/ 12:07 AM\n \n 10:20 P\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 9.7\n Hct\n 34.7\n Plt\n 280\n Cr\n 1.0\n Glucose\n 128\n Other labs: PT / PTT / INR:27.6/35.2/2.7, Ca++:9.5 mg/dL, Mg++:1.6\n mg/dL, PO4:2.4 mg/dL\n INR: 20.2 --> 2.7\n Hct: 37.7 --> 34.7\n EKG: Irregularly irregular at ventricular rate of 85 bpm, rightward\n axis deviation, widened qrs at 160 msd interval with evidence of right\n bundle branch block, no ST/T wave changes.\n IMAGING:\n CT Head w/o contrast:\n No acute intracranial process. Old infarcts.\n CT Spine w/o contrast:\n No acute cervical fx or malalignment.\n CT abdomen and pelvis:\n 1. No acute traumatic injury.\n 2. Minimal loss of height at L3, likely chronic. Rec clinical\n correlations.\n 3. Marked DJD with scoliosis.\n Assessment and Plan\n COAGULOPATHYMrs. is an 87 yo F with chronic atrial\n fibrillation on coumadin, hypertension, hyperlipidemia, and recent left\n caudate lobe infarct who presents after unwitnessed fall and an INR of\n 20 and gross blood in rectal vault.\n .\n #. Elevated INR - Pt denies any change to her coumadin dosage, new\n medications, change in diet or supplements, so cause of her increased\n INR is unclear. Pt has already received 10 mg Vitamin K and 2 units of\n FFP, with repeat INR now 2.7 from 20.2. I would expect INR to respond\n to vitamin K in ~24 hours.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine\n .\n #. Chronic Atrial Fibrillation - Pt with CHADS2 score of 4, therefore\n is very high risk for stroke and MUST be anticogulated. The timing will\n be for the PCP to decide. She is currently rate-controlled with\n metoprolol.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Swith from simvastatin to atorvastatin according to SPARCL (NEJM\n )\n .\n #. FEN - Regular cardiac healthy diet. NPO until HCT stable.\n .\n #. Access - PIV with 18G and 20G.\n .\n #. PPx -\n -DVT ppx with pneumoboots and supratherapeutic INR\n -Bowel regimen colace/senna\n -Pain management with tylenol\n .\n #. Code - DNR/DNI\n .\n #. Dispo - ICU until HCT stable and then to floor\n , M.D., M.P.H.\n Internal Medicine PGY-2\n pager #\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 20 Gauge - 11:56 PM\n 18 Gauge - 11:57 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2121-05-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628704, "text": "87 year old female from admitted s/p fall with INR >20.\n Pt sustained a fall at the today resulting in a\n posterior occipital hematoma. Pt\ns right arm was also noted to be\n eccymotic from her life line band being too tight. Per pt and daughter,\n she never lost consciousness and remained neurological intact at home\n and in the ED. Head CT, C-Spine, and right hand/forearm x-ray all\n clear. Guiac (+) stool during rectal exam. 500 cc NS bolus and 2 bags\n of FFP given. Admitted to for further management.\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 628807, "text": "Chief Complaint: Supratherapeutic INR s/p fall\n 24 Hour Events:\n -10 mg Vitamin K and 2 units FFP received in ED, INR trended down from\n 20.2 to 2.7 to 2.4\n -Hct stable at 33.3, no transfusions required\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 59 (52 - 96) bpm\n BP: 147/48(71) {117/40(61) - 147/61(81)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 572 mL\n PO:\n TF:\n IVF:\n 572 mL\n Blood products:\n Total out:\n 0 mL\n 260 mL\n Urine:\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 312 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox2 ( Hospital, does not know year or month), CNs\n II-XII grossly intact, muscle strength 5/5 throughout, sensation\n grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam\n intact, steady gait\n Labs / Radiology\n 270 K/uL\n 11.1 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:07 AM\n 03:41 AM\n WBC\n 9.7\n 8.5\n Hct\n 34.7\n 33.3\n Plt\n 280\n 270\n Cr\n 1.0\n 0.9\n Glucose\n 128\n 102\n Other labs: PT / PTT / INR:25.1/33.7/2.4, ALT / AST:14/22,\n Fibrinogen:438 mg/dL, Albumin:3.7 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20 and gross blood in\n rectal vault.\n # elevated INR\n Patient denies any change in her warfarin dosage, new\n medications, or change in diet or supplements. Pt received 10 mg\n Vitamin K and 2 units of FFP, with repeat INR now 2.4 down from 20.2.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs, most recent Hct stable at 33.3\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine, most recent Cr 0.9\n .\n #. Chronic Atrial Fibrillation\n CHADS2 = 4. Currently rate\n controlled on metoprolol succinate.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Switch from simvastatin to atorvastatin according to SPARCL (NEJM\n )\n ..\n #. Contact - (daughter) \n ICU Care\n Nutrition: Regular cardiac healthy diet. NPO until Hct stable\n Glycemic Control:\n Lines:\n PIV 18 Gauge and 20 gauge\n Prophylaxis:\n DVT: Boots, supratherapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Floor pending stable HCT, trending down INR, hemodynamic\n stability\n" }, { "category": "Nursing", "chartdate": "2121-05-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 628770, "text": " is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20. Pt sustained a total\n of 2 falls at the yesterday resulting in a posterior\n occipital hematoma. Pt\ns right arm was also noted to be eccymotic from\n her life line band being too tight. Head CT, C-Spine, and right\n hand/forearm x-ray all clear. Guiac (+) stool during rectal exam. 500\n cc NS bolus and 2 bags of FFP given. Admitted to for further\n management.\n Coagulopathy\n Assessment:\n Received pt in A-fib 70-90\ns with frequent PVC\ns. SBP 140\ns. Denying\n any CP, SOB, or chest tightness. Pedal pulses weak but palpable. Sp02\n high 80\ns on RA. Lungs clear, diminished at bases. Abdomen benign. Oral\n mucosa with dried blood, pt states all teeth are her original, they do\n not appear lose. Hematoma present on posterior occiput, skin intact.\n Right lower arm severely eccymotic. Alert and oriented to self and\n date, though she was in Rehab. Pt with hx of left sided\n weakness but limited assessment in bed normal. Repeat labs on admission\n with INR 2.7 and a 4 point Hct drop.\n Action:\n EKG done showing Afib with frequent PVC, right bundle branch block, ST\n changes. Enzymes flat in ED. Placed on 3 L NC\nfoley placed after\n incontinent episode x2. CBC with coags drawn with morning labs. NS\n running @ 75 cc/hr\n Response:\n Pt now alert and oriented to person, place, and time. No active s/s\n bleeding\nIV site still oozing blood since admission. Hct stable at 33.\n INR now 2.4 without intervention since MICU admission. Sp02 96% on 3 L\n NC. SBP 120\ns, Afib in the 50-70\ns with some pauses. UO adequate.\n Plan:\n Hct q4h. Watch for s/s of bleeding. Blood products as needed.\n Pt\ns vagina with questionable folds and what appears to be wart like\n tissue. MD made aware\nordered RPR (STS) with social work consult.\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 628787, "text": "Chief Complaint: Supratherapeutic INR s/p fall\n 24 Hour Events:\n -10 mg Vitamin K and 2 units FFP received in ED, INR trended down from\n 20.2 to 2.7 to 2.4\n -Hct stable at 33.3, no transfusions required\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 59 (52 - 96) bpm\n BP: 147/48(71) {117/40(61) - 147/61(81)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 572 mL\n PO:\n TF:\n IVF:\n 572 mL\n Blood products:\n Total out:\n 0 mL\n 260 mL\n Urine:\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 312 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 5/5\n throughout, sensation grossly intact throughout, DTRs 2+ and symmetric,\n cerebellar exam intact, steady gait\n Labs / Radiology\n 270 K/uL\n 11.1 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:07 AM\n 03:41 AM\n WBC\n 9.7\n 8.5\n Hct\n 34.7\n 33.3\n Plt\n 280\n 270\n Cr\n 1.0\n 0.9\n Glucose\n 128\n 102\n Other labs: PT / PTT / INR:25.1/33.7/2.4, ALT / AST:14/22,\n Fibrinogen:438 mg/dL, Albumin:3.7 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20 and gross blood in\n rectal vault.\n .\n #. Elevated INR - Pt denies any change to her coumadin dosage, new\n medications, change in diet or supplements, so cause of her increased\n INR is unclear. Pt received 10 mg Vitamin K and 2 units of FFP, with\n repeat INR now 2.4 down from 20.2.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs, most recent Hct stable at 33.3\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine, most recent Cr 0.9\n .\n #. Chronic Atrial Fibrillation - Pt with CHADS2 score of 4, therefore\n is very high risk for stroke and MUST be anticogulated. The timing will\n be for the PCP to decide. She is currently rate-controlled with\n metoprolol.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Swith from simvastatin to atorvastatin according to SPARCL (NEJM )\n ..\n #. Contact - (daughter) \n ICU Care\n Nutrition: Regular cardiac healthy diet. NPO until Hct stable\n Glycemic Control:\n Lines:\n PIV 18 Gauge and 20 gauge\n Prophylaxis:\n DVT: Boots, supratherapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Floor pending stable HCT, trending down INR, hemodynamic\n stability\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 628788, "text": "Chief Complaint: Supratherapeutic INR s/p fall\n 24 Hour Events:\n -10 mg Vitamin K and 2 units FFP received in ED, INR trended down from\n 20.2 to 2.7 to 2.4\n -Hct stable at 33.3, no transfusions required\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 59 (52 - 96) bpm\n BP: 147/48(71) {117/40(61) - 147/61(81)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 572 mL\n PO:\n TF:\n IVF:\n 572 mL\n Blood products:\n Total out:\n 0 mL\n 260 mL\n Urine:\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 312 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength 5/5\n throughout, sensation grossly intact throughout, DTRs 2+ and symmetric,\n cerebellar exam intact, steady gait\n Labs / Radiology\n 270 K/uL\n 11.1 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:07 AM\n 03:41 AM\n WBC\n 9.7\n 8.5\n Hct\n 34.7\n 33.3\n Plt\n 280\n 270\n Cr\n 1.0\n 0.9\n Glucose\n 128\n 102\n Other labs: PT / PTT / INR:25.1/33.7/2.4, ALT / AST:14/22,\n Fibrinogen:438 mg/dL, Albumin:3.7 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20 and gross blood in\n rectal vault.\n .\n #. Elevated INR - Pt denies any change to her coumadin dosage, new\n medications, change in diet or supplements, so cause of her increased\n INR is unclear. Pt received 10 mg Vitamin K and 2 units of FFP, with\n repeat INR now 2.4 down from 20.2.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs, most recent Hct stable at 33.3\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine, most recent Cr 0.9\n .\n #. Chronic Atrial Fibrillation - Pt with CHADS2 score of 4, therefore\n is very high risk for stroke and MUST be anticogulated. The timing will\n be for the PCP to decide. She is currently rate-controlled with\n metoprolol.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Swith from simvastatin to atorvastatin according to SPARCL (NEJM )\n ..\n #. Contact - (daughter) \n ICU Care\n Nutrition: Regular cardiac healthy diet. NPO until Hct stable\n Glycemic Control:\n Lines:\n PIV 18 Gauge and 20 gauge\n Prophylaxis:\n DVT: Boots, supratherapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Floor pending stable HCT, trending down INR, hemodynamic\n stability\n" }, { "category": "Physician ", "chartdate": "2121-05-08 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 628796, "text": "Chief Complaint: Supratherapeutic INR s/p fall\n 24 Hour Events:\n -10 mg Vitamin K and 2 units FFP received in ED, INR trended down from\n 20.2 to 2.7 to 2.4\n -Hct stable at 33.3, no transfusions required\n Allergies:\n Ace Inhibitors\n Angioedema;\n Sulfa (Sulfonamide Antibiotics)\n swollen eyes an\n Fish Product Derivatives\n puffy eyes and\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 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.6\nC (99.6\n Tcurrent: 37.6\nC (99.6\n HR: 59 (52 - 96) bpm\n BP: 147/48(71) {117/40(61) - 147/61(81)} mmHg\n RR: 15 (13 - 24) insp/min\n SpO2: 99%\n Heart rhythm: AF (Atrial Fibrillation)\n Total In:\n 572 mL\n PO:\n TF:\n IVF:\n 572 mL\n Blood products:\n Total out:\n 0 mL\n 260 mL\n Urine:\n 260 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 312 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///24/\n Physical Examination\n GENERAL - elderly-appearing woman in NAD, comfortable, appropriate\n HEENT - Hematoma over R occiput (8 cm aprox in diameter), PERRLA, EOMI,\n sclerae anicteric, MMM, Dry blood over lower lip, good range of motion\n of both eyes\n NECK - supple, no thyromegaly, no JVD, no carotid bruits\n LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no\n accessory muscle use\n HEART - PMI non-displaced, irregular rate, no MRG, nl S1-S2\n ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding.\n EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)\n SKIN - Ecchymosis extending from L forearm to L hand, nontender\n LYMPH - no cervical, axillary, or inguinal LAD\n NEURO - awake, A&Ox2 ( Hospital, does not know year or month), CNs\n II-XII grossly intact, muscle strength 5/5 throughout, sensation\n grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam\n intact, steady gait\n Labs / Radiology\n 270 K/uL\n 11.1 g/dL\n 102 mg/dL\n 0.9 mg/dL\n 24 mEq/L\n 3.6 mEq/L\n 20 mg/dL\n 106 mEq/L\n 143 mEq/L\n 33.3 %\n 8.5 K/uL\n [image002.jpg]\n 12:07 AM\n 03:41 AM\n WBC\n 9.7\n 8.5\n Hct\n 34.7\n 33.3\n Plt\n 280\n 270\n Cr\n 1.0\n 0.9\n Glucose\n 128\n 102\n Other labs: PT / PTT / INR:25.1/33.7/2.4, ALT / AST:14/22,\n Fibrinogen:438 mg/dL, Albumin:3.7 g/dL, Ca++:8.5 mg/dL, Mg++:1.6 mg/dL,\n PO4:2.8 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN:\n Mrs. is an 87 yo F with chronic atrial fibrillation on coumadin,\n hypertension, hyperlipidemia, and recent left caudate lobe infarct who\n presents after unwitnessed fall and an INR of 20 and gross blood in\n rectal vault.\n .\n #. Elevated INR - Pt denies any change to her coumadin dosage, new\n medications, change in diet or supplements, so cause of her increased\n INR is unclear. Pt received 10 mg Vitamin K and 2 units of FFP, with\n repeat INR now 2.4 down from 20.2.\n - continue to hold coumadin\n - Follow up HCT\n - Serial neurologic exams\n - FFP as needed\n - Pt already received 10 mg of Vitamin K\n .\n #. Lower GI Bleed - Pt noted to have gross blood in rectum in ED. No\n signs of active bleeding currently. Stable hemodynamics. Source most\n likely either diverticulosis or hemorrhoids bleeding in the setting of\n high INR.\n - Trend Hct q6 hrs, most recent Hct stable at 33.3\n - Guaiac all stools\n - Transfuse for HCT >30 given concern for bleeding\n - Transfuse FFP as needed if active bleeding\n - Will obtain PCP records to see last colonoscopy (though age does not\n recommend regular screening)\n .\n #. Acute Kidney Injury - Patient initially arrived with creatinine of\n 1.4 from baseline of ~0.9 She received IVF (500cc NS) in the ER and\n repeat measurement was 1 suggesting pre-renal etiology now resolved.\n - Trend creatinine, most recent Cr 0.9\n .\n #. Chronic Atrial Fibrillation - Pt with CHADS2 score of 4, therefore\n is very high risk for stroke and MUST be anticogulated. The timing will\n be for the PCP to decide. She is currently rate-controlled with\n metoprolol.\n - Hold coumadin in the setting of INR Of 20\n - Rate control with metoprolol (short acting for now)\n .\n #. Hypertension - Pt is currently hemodynamically stable, but will hold\n amlodipine until we see trend of BP.\n -Continue home dose metoprolol, but on short acting for now\n -Hold amlodipine for now\n .\n #. Hyperlipidemia - Last LDL 89, HDL 62, Chol 168 and TG 83 in \n ALMOST on target. However, given the recent TIA she should be on\n high-dose atorvastatin according to recommendations in the SPARCL trial\n (NEJM )\n -Swith from simvastatin to atorvastatin according to SPARCL (NEJM )\n ..\n #. Contact - (daughter) \n ICU Care\n Nutrition: Regular cardiac healthy diet. NPO until Hct stable\n Glycemic Control:\n Lines:\n PIV 18 Gauge and 20 gauge\n Prophylaxis:\n DVT: Boots, supratherapeutic INR\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: Floor pending stable HCT, trending down INR, hemodynamic\n stability\n" } ]

[ { "category": "Radiology", "chartdate": "2200-07-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1249370, "text": " 10:27 PM\n CHEST (PA & LAT) Clip # \n Reason: please evaluate for acute processs\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 42 year old man with thrombocytopenia\n REASON FOR THIS EXAMINATION:\n please evaluate for acute processs\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 43-year-old man with thrombocytopenia. Please evaluate for acute\n process.\n\n COMPARISON: No relevant comparisons available.\n\n TWO VIEWS OF THE CHEST:\n\n The lungs are well expanded and clear. The cardiomediastinal silhouette,\n hilar contours and pleural surfaces are normal. No pleural effusion or\n pneumothorax is present.\n\n IMPRESSION:\n\n No acute intrathoracic process.\n\n\n" }, { "category": "ECG", "chartdate": "2200-07-10 00:00:00.000", "description": "Report", "row_id": 306930, "text": "Sinus rhythm. Q-T interval prolongation. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515390, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and off sedation. Pt awake and\n alert following commands and making his needs met with alphabet board\n and gestures. Vent setting at beginning of shift at 40%/. LS CTA.\n Pt present with a strong prod cough with sml amountsof thick white\n secretions.\n Action:\n VAP protocol followed and freq oral care done due to copious amounts of\n clear oral secretions.\n Response:\n O2sat 93-95%. ABG as noted this am, and weaning peep down to 8 was\n aborted.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515391, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and off sedation. Pt awake and\n alert following commands and making his needs met with alphabet board\n and gestures. Vent setting at beginning of shift at 40%/. LS CTA.\n Pt present with a strong prod cough with sml amountsof thick white\n secretions.\n Action:\n VAP protocol followed and freq oral care done due to copious amounts of\n clear oral secretions.\n Response:\n O2sat 93-95%. ABG as noted this am, and weaning peep down to 8 was\n aborted along with SBT.\n Plan:\n Continue to wean vent settings as pt tolerates.\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515795, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 117/57(78) {97/55(73) - 138/81(102)} mmHg\n RR: 15 (14 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 173 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 173 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -707 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. Continues to improve. CT with worsening\n multifocal pneumonia from . PEEP down to 10 overnight. Fi02 to 40%.\n Overall improving. Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Extubate\n - Ipratropium nebs q6h, Albuterol nebs q2h\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515806, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n - Extubated in early a.m. - did very well\n - Talking, eating.\n - Fluid balance net negative: - 1.5 L at midnight without diuresis.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 113/58(78) {97/55(73) - 138/81(102)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 180 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 180 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 90%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 515809, "text": "Chief Complaint: Respiratory failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n feeling better\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n History obtained from Medical records\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision, No(t) Conjunctival edema\n Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis, No(t) OG / NG tube\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Tachycardia, No(t) Orthopnea\n Nutritional Support: No(t) NPO, No(t) Tube feeds, No(t) Parenteral\n nutrition\n Respiratory: Cough, Dyspnea, No(t) Tachypnea, Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: Immunocompromised, No(t) Influenza vaccine, HIV\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 113/58(78) {97/55(73) - 138/81(102)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 195 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 195 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -685 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 90%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n General Appearance: Well nourished, No acute distress, Overweight /\n Obese, No(t) Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic), 2/6 sem\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: No(t) Clear : , No(t) Crackles : , No(t) Bronchial: ,\n Wheezes : diffuse exp, No(t) Diminished: , No(t) Absent : , No(t)\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, Unable to stand, prior CVA\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, No(t) Oriented (to): , Movement: Purposeful, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 12.3 g/dL\n 277 K/uL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n Improving resp failure. We do not have a good explanation for his acute\n episode. One possibility is aspiration. We will nevertheless complete\n 14d course of abx for severe CAP. Unclear what his underlying lung dis\n is - diffuse wheezing on exam now. He also has CT and echo c/w pulm\n HTN - possibly HIV related but need to understand the nature of his\n pulm dis to determine if pulm HTN is secondary to lung dis. Needs PFTs\n and full pulm eval this adm.\n ICU Care\n Nutrition:\n Comments: Full\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition :Transfer to floor\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 515488, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 8mm\n :\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: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Nursing", "chartdate": "2196-01-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 515910, "text": "TITLE: 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia. Pt required intubation for hypoxic respiratory\n failure. Subsequently extubated successfully and weaned to 4L via NC.\n Events: Pt developed hives on RUE and RLE this am while receiving\n vancomycin; however, pt has been receiving vancomycin w/o previous s/s\n reaction. No rash to chest back or Left extremities. Hives resolved w/\n benadryl 25mg PO X 1. Monitor for s/s allergic reaction w/ further\n dosing of vancomycin or other meds.\n Dyspnea (Shortness of breath)\n Assessment:\n Respiratory status has been stable w/ supplemental O2 4L via NC.\n Episode desating to 80\ns overnoc in the setting of mouth breathing\n while sleeping. SpO2 up to 90\ns on 40% venit mask which was again\n changed to 4L NC this am w/ pt awake. Pt has had weak cough. Remains\n afebrile. Hemodynamically stable.\n Action:\n Monitoring respiratory assessment closely. Encouraging IS and C+DB\n exercises Q1hr WA. Pt continues on vancomycin, cefepime and flagyl as\n ordered.\n Response:\n SpO2 has remained >93% on supplemental O2 4L via NC. Self-motivated w/\n IS use and C+DB exercises and achieiving increasing TV now to 1800ml on\n IS. Cough much stronger, non-congested, non-productive. BBS CTA to\n slightly diminished at bilateral bases. Pt tolerating cardiac diet\n well.\n Plan:\n Continue to monitor respiratory assessment. Continue abx as ordered.\n Encourage IS use and C+DB exercises Q1hr WA. Increase activity as\n tolerated.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n 60 Inch\n Admission weight:\n 112 kg\n Daily weight:\n 115 kg\n Allergies/Reactions:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Precautions: No Additional Precautions\n PMH:\n CV-PMH: CAD, Hypertension, PVD\n Additional history: cva3/99, cabg , dyslipidemia, HIV cd4 cnt\n stable at 500, HCV, dermatitis\n Surgery / Procedure and date: cabg , chronic diastolic failure ef\n 40%\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:82\n D:55\n Temperature:\n 97.1\n Arterial BP:\n S:128\n D:72\n Respiratory rate:\n 12 insp/min\n Heart Rate:\n 68 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 4 L/min\n FiO2 set:\n 40% %\n 24h total in:\n 2,198 mL\n 24h total out:\n 3,295 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:38 AM\n Potassium:\n 4.2 mEq/L\n 02:38 AM\n Chloride:\n 97 mEq/L\n 02:38 AM\n CO2:\n 32 mEq/L\n 02:38 AM\n BUN:\n 15 mg/dL\n 02:38 AM\n Creatinine:\n 0.9 mg/dL\n 02:38 AM\n Glucose:\n 94 mg/dL\n 02:38 AM\n Hematocrit:\n 36.4 %\n 02:38 AM\n Finger Stick Glucose:\n 111\n 04:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 681\n Transferred to: 709\n Date & time of Transfer: \n" }, { "category": "Nutrition", "chartdate": "2196-01-25 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 515837, "text": "Objective\n Pertinent medications: Bowel meds, heparin, protonix, abx, HIV meds,\n RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 94 mg/dL\n 02:38 AM\n Glucose Finger Stick\n 151\n 10:00 AM\n BUN\n 15 mg/dL\n 02:38 AM\n Creatinine\n 0.9 mg/dL\n 02:38 AM\n Sodium\n 135 mEq/L\n 02:38 AM\n Potassium\n 4.2 mEq/L\n 02:38 AM\n Chloride\n 97 mEq/L\n 02:38 AM\n TCO2\n 32 mEq/L\n 02:38 AM\n PO2 (arterial)\n 73. mm Hg\n 02:41 AM\n PCO2 (arterial)\n 61 mm Hg\n 02:41 AM\n pH (arterial)\n 7.35 units\n 02:41 AM\n CO2 (Calc) arterial\n 35 mEq/L\n 02:41 AM\n Albumin\n 3.1 g/dL\n 04:00 AM\n Calcium non-ionized\n 8.6 mg/dL\n 02:38 AM\n Phosphorus\n 3.7 mg/dL\n 02:38 AM\n Ionized Calcium\n 1.22 mmol/L\n 02:41 AM\n Magnesium\n 2.2 mg/dL\n 02:38 AM\n WBC\n 8.2 K/uL\n 02:38 AM\n Hgb\n 12.3 g/dL\n 02:38 AM\n Hematocrit\n 36.4 %\n 02:38 AM\n Current diet order / nutrition support: Cardiac/Heart Healthy\n GI: Abd: soft/nbs\n Assessment of Nutritional Status\n Specifics:\n 52 year old male w/ HIV , on HAART, presented w/ LLL PNA. Patient was\n receiving tube feeds while intubated, now extubated and diet advanced.\n Per discussion w/ RN, patient tolerating po\ns s/ issue. Plan for\n transfer to floor.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin daily\n Will continue to monitor po intake and make additional\n recommendations as need\n" }, { "category": "Nursing", "chartdate": "2196-01-25 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 515841, "text": "TITLE: 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia. Pt required intubation for hypoxic respiratory\n failure. Subsequently extubated successfully and weaned to 4L via NC.\n Events: Pt developed hives on RUE and RLE this am while receiving\n vancomycin; however, pt has been receiving vancomycin w/o previous s/s\n reaction. No rash to chest back or Left extremities. Hives resolved w/\n benadryl 25mg PO X 1. Monitor for s/s allergic reaction w/ further\n dosing of vancomycin or other meds.\n Dyspnea (Shortness of breath)\n Assessment:\n Respiratory status has been stable w/ supplemental O2 4L via NC.\n Episode desating to 80\ns overnoc in the setting of mouth breathing\n while sleeping. SpO2 up to 90\ns on 40% venit mask which was again\n changed to 4L NC this am w/ pt awake. Pt has had weak cough. Remains\n afebrile. Hemodynamically stable.\n Action:\n Monitoring respiratory assessment closely. Encouraging IS and C+DB\n exercises Q1hr WA. Pt continues on vancomycin, cefepime and flagyl as\n ordered.\n Response:\n SpO2 has remained >93% on supplemental O2 4L via NC. Self-motivated w/\n IS use and C+DB exercises and achieiving increasing TV now to 1800ml on\n IS. Cough much stronger, non-congested, non-productive. BBS CTA to\n slightly diminished at bilateral bases. Pt tolerating cardiac diet\n well.\n Plan:\n Continue to monitor respiratory assessment. Continue abx as ordered.\n Encourage IS use and C+DB exercises Q1hr WA. Increase activity as\n tolerated.\n" }, { "category": "Nursing", "chartdate": "2196-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515765, "text": "TITLE: 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n EVENTS: Pt noted to desat on 4LNCO2 while asleep to mid 80\ns, remedied\n with 40% Venti-mask. Resp exam noted for decreased lung sounds in all\n fields and poor cough reflex, Incentive spirometer provided with\n instruction/encouragement with fair return demonstration. Pt reports\n broken sleep pattern overnight. The pt remains a Full Code. The pt is\n expected to be called out to the floor today.\n Dyspnea (Shortness of breath)\n Assessment:\n Pt received on 4LNCO2 with nl sats/RR while awake. Decreased air\n movement in all lung fields noted that were basically clear with no\n acute wheezing/rhonchi. Very poor cough reflex noted. Pt noted to\n have sustained desat to mid 80\ns while asleep on 4LNCO2.\n Action:\n Pt provided with incentive spirometer with instruction/encouragement\n and fair return demonstration. Pt encouraged to CDB. Pt sat upright\n 30-45 degrees to facilitate gas exchange. IV antibx admin as timed\n around the clock. Pt encouraged to get OOB to chair this AM to\n facilitate optimal resp fxn.\n Response:\n Pt required 40% Venti mask @ night to achieve sats in mid 90\ns. AM ABG\n on 40% Venti mask: 7.35-61-73. Team notified of ABG values/need to\n provide 40% Venti-mask O2 support.\n Plan:\n Cont to encourage pt to utilize Incentive spirometer Q1 hr, CDB and\n move pt OOB to sit upright in chair.\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515883, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n - Extubated in early a.m. - did very well\n - Talking, eating.\n - Fluid balance net negative: - 1.5 L at midnight without diuresis.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 113/58(78) {97/55(73) - 138/81(102)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 180 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 180 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 90%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Mild bibasilar crackles.\n Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia. Was extubated yesterday without issues with plan to\n transfer to floor today.\n # Hypoxia/Respiratory Failure. Continues to improve and patient\n extubated without issues yesterday. CT with worsening multifocal\n pneumonia from . Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ) for 14 day course. No need to expand\n Pseudomonal coverage at present.\n - Patient should get PFTs done as outpatient for ?underlying COPD (Most\n recent ABG with CO2 61)\n - Ipratropium nebs q6h, Albuterol nebs q2h\n patient will benefit from\n continuing these or MDI versions as outpatient for ?underlying COPD\n # Seizure d/o s/p CVA. Patient had 10 second episode yesterday morning\n of what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n better in last 12 hours\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Continue ACE inhibitor and beta-blocker (re-started yesterday)\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Regular\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514480, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Oliguria/Anuria\n Assessment:\n Action:\n Response:\n Plan:\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514633, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum.\n Action:\n Response:\n Plan:\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514689, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum. Initial vent\n settings AC 550-60%-14 with Peep=12 with good Sats and ABG, FI02\n decreased to 50 % with no change in Sats or ABG, continues on antibx,\n lactate=1.1, Tmax= 99.1. ABG on 50 %= 7.34-54-104.. Sedated on IV\n Propofol at 50 mcgs/kg/min, pt able to follow simple commands but falls\n right back to sleep\n Action:\n Aggressive pulmonary toileting, inhalers as ordered, ABG\ns monitored,\n FI02 reduced to 50 %, vanco level sent and 17.9, received\n vanco/cefepime/flagyl, IV Propofol weaned to 40 mcgs/kg/min\n Response:\n Tolerating slow wean of FI02. Stable on current vent settings\n Plan:\n F/U BAL results, F/U chest CT results, continue aggressive pulmonary\n toileting, wean vent as tolerated\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Afebrile, WBC= 5.9 with lactate= 1.1, continues on antivirals as\n ordered\n Action:\n Cultures and WBC monitored, antivirals as ordered\n Response:\n Stable cell counts\n Plan:\n Obtain ID consult for pna, continue saquinivir and ritonovir and use\n gloves and mask to prepare and administer\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n HR= 80\ns SR, no ectopy noted,BP via right radial aline with good\n waveform and correlation to NBP, BP= 110-120\ns/70\ns, urine output\n 30-100ml/hr, BUN= 19 and creatinine= 1.0, Hct stable at 36.6, suctioned\n for thick whitish tan and not frothy, bilat LE edema +\n Action:\n Echo completed yesterday, no diuretics overnight, pt kept even, strict\n I+O\n Response:\n Stable cardiac function at present time, no evidence of CHF\n Plan:\n Continue to monitor heart and lungs closely, keep pt even, F/U results\n of echo, continue ASA and statin\n Addendum: FI02 weaned to 40 % with Sats down to 90% and\n ABG=7.38-51-77. Peep increased to 15 and new ABG to be sent in 1 hour\n" }, { "category": "Respiratory ", "chartdate": "2196-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 514814, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 3\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 25 cmH2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt received on AC as noted with no vent changes at this time.\n Assessment of breathing comfort: No claim of dyspnea\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\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515062, "text": "52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n Patient has a history of seizure since his CVA. Today he had a seizure\n which lasted for one minute(whole body was convulsive) . Right after\n the seizure he was able to communicate with staff. I have also noted\n jaw twitching and nystagmus. The right eye drifts to the upper right up\n wards.\n Code Status: full code.\n" }, { "category": "Physician ", "chartdate": "2196-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515202, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - AC 550 x 14, 12 PEEP - brief desat then spontaneously rose, so\n decided to wait for a while. ABG 7.4 51 72.\n - Simple partial motor siezure unilateral on left noted at 7 a.m. then\n bilateral later with reduced mental status. Neurology \n recommended dilantin 250 mg, but not taken and patient comfortable\n without at present. Suffered for about 10 years s/p stroke. Was given 1\n mg Ativan after bilateral seizure.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:59 PM\n Vancomycin - 08:57 PM\n Metronidazole - 12:02 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 09:00 AM\n Midazolam (Versed) - 01:25 PM\n Fentanyl - 04:39 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.6\nC (97.9\n HR: 73 (72 - 86) bpm\n BP: 131/75(93) {93/56(72) - 132/83(98)} mmHg\n RR: 14 (14 - 17) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,570 mL\n 557 mL\n PO:\n TF:\n 1,200 mL\n 356 mL\n IVF:\n 840 mL\n 171 mL\n Blood products:\n Total out:\n 1,680 mL\n 740 mL\n Urine:\n 1,680 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 890 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 21 cmH2O\n SpO2: 92%\n ABG: 7.40/48/77/31/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 223 K/uL\n 11.8 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 99 mEq/L\n 135 mEq/L\n 35.5 %\n 8.7 K/uL\n [image002.jpg]\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n WBC\n 5.9\n 8.0\n 8.7\n Hct\n 36.6\n 37.0\n 35.5\n Plt\n 222\n 264\n 223\n Cr\n 1.0\n 1.0\n 0.8\n TCO2\n 34\n 31\n 32\n 31\n 34\n 33\n 31\n Glucose\n 106\n 122\n 115\n Other labs: PT / PTT / INR:13.6/39.9/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n CXR\n Pending\n NO NEW CULTURE DATA.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood cultures for tomorrow AM\n - Consider ID (BAL has come back negative)\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Hold ACEI and beta-blocker given hypotensive episodes\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:32 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515396, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and off sedation. Pt awake and\n alert following commands and making his needs met with alphabet board\n and gestures. Vent setting at beginning of shift at 40%/. LS CTA.\n Pt present with a strong prod cough with sml amountsof thick white\n secretions.\n Action:\n VAP protocol followed and freq oral care done due to copious amounts of\n clear oral secretions.\n Response:\n O2sat 93-95%. ABG as noted this am, and weaning peep down to 8 was\n aborted along with SBT.\n Plan:\n Continue to wean vent settings as pt tolerates.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515311, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 130s-160s/60s-70s, HR 70s, SR. K+3.7.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab. Given triple antibiotics. Given 20meQ oral\n KCL. Restarted on home regimen of antihypertensives\nlisinopril &\n metoprolol.\n Response:\n ABG 7.38/50/82/33 ( 7.40/48/77/31). ABP 100s to 120s systolic, HR in\n the 70s. No ectopy. Cultures negative to date.\n Plan:\n Cont to wean vent as able, follow ABGs, monitor temp, f/u on cultures,\n monitor labs and replete lytes as needed.\n Seizure, without status epilepticus\n Assessment:\n Occasional facial twitching\n.pt himself is unaware of this happening.\n Team aware. Occasional twitching of LLE when coughing or turning.\n Action:\n Monitoring for seizure activity. No ativan required.\n Response:\n No seizure activity.\n Plan:\n PRN ativan, f/u w/ neuro as outpt.\n" }, { "category": "Respiratory ", "chartdate": "2196-01-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 515564, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 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 /\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 / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont intub with OETT and on mech vent as per Metavision.\n Lung sounds coarse suct mod th yellow sput. MDI given as per order. Pt\n switched to A/C from PSV due to increased need for sedation; returned\n to PSV will obt ABG and monitor closely. Cont PSV.\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515869, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n - Extubated in early morning yesterday\n did very well\n - Talking, eating\n - Fluid balance net negative: -1.5 L at midnight without diuresis\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 117/57(78) {97/55(73) - 138/81(102)} mmHg\n RR: 15 (14 - 21) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 173 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 173 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -707 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 93%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n General: Alert, oriented, no acute distress, extubated and comfortable\n on nasal cannula\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs. PMI located in\n 5^th intercosal space\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. Continues to improve. CT with worsening\n multifocal pneumonia from . PEEP down to 10 overnight. Fi02 to 40%.\n Overall improving. Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Extubate\n - Ipratropium nebs q6h, Albuterol nebs q2h\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515871, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n - Extubated in early a.m. - did very well\n - Talking, eating.\n - Fluid balance net negative: - 1.5 L at midnight without diuresis.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 113/58(78) {97/55(73) - 138/81(102)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 180 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 180 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 90%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Mild bibasilar crackles.\n Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. Continues to improve. CT with worsening\n multifocal pneumonia from . PEEP down to 10 overnight. Fi02 to 40%.\n Overall improving. Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Extubate\n - Ipratropium nebs q6h, Albuterol nebs q2h\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-25 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515872, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 08:59 AM\n - Extubated in early a.m. - did very well\n - Talking, eating.\n - Fluid balance net negative: - 1.5 L at midnight without diuresis.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:47 PM\n Vancomycin - 08:15 PM\n Metronidazole - 03:11 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 35.4\nC (95.7\n HR: 68 (62 - 74) bpm\n BP: 113/58(78) {97/55(73) - 138/81(102)} mmHg\n RR: 14 (14 - 21) insp/min\n SpO2: 90%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,220 mL\n 180 mL\n PO:\n 620 mL\n TF:\n 200 mL\n IVF:\n 1,040 mL\n 180 mL\n Blood products:\n Total out:\n 3,715 mL\n 880 mL\n Urine:\n 3,715 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,495 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Spontaneous): 51 (51 - 51) mL\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 0 cmH2O\n SpO2: 90%\n ABG: 7.35/61/73./32/5\n PaO2 / FiO2: 183\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Mild bibasilar crackles.\n Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 277 K/uL\n 12.3 g/dL\n 94 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.2 mEq/L\n 15 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.4 %\n 8.2 K/uL\n [image002.jpg]\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n 02:38 AM\n 02:41 AM\n WBC\n 9.3\n 8.3\n 8.2\n Hct\n 35.3\n 36.3\n 36.4\n Plt\n \n Cr\n 0.8\n 0.8\n 0.9\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n 35\n Glucose\n 102\n 98\n 110\n 94\n Other labs: PT / PTT / INR:14.2/58.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:0.9 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.6 mg/dL,\n Mg++:2.2 mg/dL, PO4:3.7 mg/dL\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia. Was extubated yesterday without issues with plan to\n transfer to floor today.\n # Hypoxia/Respiratory Failure. Continues to improve and patient\n extubated without issues yesterday. CT with worsening multifocal\n pneumonia from . Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ) for 14 day course. No need to expand\n Pseudomonal coverage at present.\n - Patient should get PFTs done as outpatient for ?underlying COPD (Most\n recent ABG with CO2 61)\n - Ipratropium nebs q6h, Albuterol nebs q2h\n patient will benefit from\n continuing these or MDI versions as outpatient for ?underlying COPD\n # Seizure d/o s/p CVA. Patient had 10 second episode yesterday morning\n of what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n better in last 12 hours\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Continue ACE inhibitor and beta-blocker (re-started yesterday)\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-21 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 515018, "text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Did not tolerate attempt to wean PEEP overnight --> dropped O2 sats\n 24 Hour Events:\n Sz-like activity this AM --> pt was able to epress to the team that he\n has had these in the past since his stroke\n History obtained from Medical records, icu team\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:24 PM\n Cefipime - 08:00 AM\n Metronidazole - 09:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:27 PM\n Furosemide (Lasix) - 08:34 PM\n Heparin Sodium (Prophylaxis) - 10:34 PM\n Fentanyl - 08:40 AM\n Midazolam (Versed) - 08:45 AM\n Lorazepam (Ativan) - 09:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Cardiovascular: Tachycardia\n Respiratory: mechanical ventilation\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:22 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.9\nC (100.3\n Tcurrent: 37.6\nC (99.7\n HR: 80 (74 - 94) bpm\n BP: 119/65(84) {95/56(78) - 145/90(103)} mmHg\n RR: 14 (14 - 19) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,644 mL\n 1,090 mL\n PO:\n TF:\n 587 mL\n 508 mL\n IVF:\n 1,617 mL\n 351 mL\n Blood products:\n Total out:\n 2,535 mL\n 750 mL\n Urine:\n 2,535 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n 340 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 21 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 93%\n ABG: 7.38/51/77/33/3\n Ve: 9 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General Appearance: No acute distress, intubated\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 Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.6 g/dL\n 264 K/uL\n 122 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.0 %\n 8.0 K/uL\n [image002.jpg]\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n WBC\n 5.9\n 8.0\n Hct\n 36.6\n 37.0\n Plt\n 222\n 264\n Cr\n 1.1\n 1.0\n 1.0\n TCO2\n 34\n 33\n 33\n 34\n 31\n 32\n 31\n Glucose\n 109\n 106\n 122\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n 1. Respiratory Failure: bilateral infiltrates plus mild-mod pulm HTN\n --Cont vanc/cefepime/flagyl\n --Remains dependent on 15 of PEEP to maintain oxygenation\n --Recheck peripheral eosinophila\n 2. HIV\n --HAART --> boosted single drug regimen\n 3. Seizure:\n --Appears to be chronic issue for which he was only being monitored.\n Will contact his neurologist.\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:34 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515019, "text": "TITLE:\n Chief Complaint: Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID Recs: Did not come by.\n - I/O: Positive at , 20mg IV Lasix given\n - Updated Family.\n - Tried to decrease PEEP without success\n - Changed sedation to bolus.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:24 PM\n Cefipime - 08:24 PM\n Metronidazole - 12:39 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:27 PM\n Furosemide (Lasix) - 08:34 PM\n Heparin Sodium (Prophylaxis) - 10:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 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: 37.9\nC (100.3\n HR: 81 (78 - 94) bpm\n BP: 122/60(80) {94/60(79) - 145/90(103)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,644 mL\n 726 mL\n PO:\n TF:\n 587 mL\n 330 mL\n IVF:\n 1,617 mL\n 166 mL\n Blood products:\n Total out:\n 2,535 mL\n 510 mL\n Urine:\n 2,535 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n 216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/33/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 264 K/uL\n 12.6 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.0 %\n 8.0 K/uL\n [image002.jpg]\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n WBC\n 5.9\n 8.0\n Hct\n 36.6\n 37.0\n Plt\n 222\n 264\n Cr\n 1.1\n 1.0\n 1.0\n TCO2\n 34\n 33\n 33\n 34\n 31\n 32\n 31\n Glucose\n 109\n 106\n 122\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.9 mg/dL\n Imaging: CT Chest: 1. Interval progression of multifocal pneumonia with\n more confluent opacities\n within the lingula, left lower lobe, and right lower lobe. No residual\n pleural effusions. Slight progression in adenopathy is also likely\n reactive,\n but can be re-assessed on follow up exams once infection resolves.\n 2. Dilated pulmonary artery consistent with known severe pulmonary\n hypertension (also noted on recent echo) which may HIV induced.\n Unchanged\n cholelithiasis without any secondary signs of acute cholecystitis.\n CXR: Pending\n Microbiology: 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n KOH TEST REQUESTED BY DR .\n NO FUNGAL ELEMENTS SEEN.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n No Virus isolated so far.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Defer on Bronch today.\n - Follow ID recommendations (they will see if BAL comes back positive)\n .\n # Seizure/ s/p CVA. Patient had 10 second episode this morning of what\n appeared to be partial seizure, self-resolved, no post-ictal signs.\n Patient notes that he has had these episodes s/p CVA.\n - Obtain neurology records\n - Continue Ativan prn\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:34 PM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending clinical improvement\n" }, { "category": "Physician ", "chartdate": "2196-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515020, "text": "TITLE:\n Chief Complaint: Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID Recs: Did not come by.\n - I/O: Positive at , 20mg IV Lasix given\n - Updated Family.\n - Tried to decrease PEEP without success\n - Changed sedation to bolus.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:24 PM\n Cefipime - 08:24 PM\n Metronidazole - 12:39 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:27 PM\n Furosemide (Lasix) - 08:34 PM\n Heparin Sodium (Prophylaxis) - 10:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 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: 37.9\nC (100.3\n HR: 81 (78 - 94) bpm\n BP: 122/60(80) {94/60(79) - 145/90(103)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,644 mL\n 726 mL\n PO:\n TF:\n 587 mL\n 330 mL\n IVF:\n 1,617 mL\n 166 mL\n Blood products:\n Total out:\n 2,535 mL\n 510 mL\n Urine:\n 2,535 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n 216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/33/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress, Sedated, Intubated,\n Twitching of facial muscles.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 264 K/uL\n 12.6 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.0 %\n 8.0 K/uL\n [image002.jpg]\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n WBC\n 5.9\n 8.0\n Hct\n 36.6\n 37.0\n Plt\n 222\n 264\n Cr\n 1.1\n 1.0\n 1.0\n TCO2\n 34\n 33\n 33\n 34\n 31\n 32\n 31\n Glucose\n 109\n 106\n 122\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.9 mg/dL\n Imaging: CT Chest: 1. Interval progression of multifocal pneumonia with\n more confluent opacities\n within the lingula, left lower lobe, and right lower lobe. No residual\n pleural effusions. Slight progression in adenopathy is also likely\n reactive,\n but can be re-assessed on follow up exams once infection resolves.\n 2. Dilated pulmonary artery consistent with known severe pulmonary\n hypertension (also noted on recent echo) which may HIV induced.\n Unchanged\n cholelithiasis without any secondary signs of acute cholecystitis.\n CXR: Pending\n Microbiology: 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n KOH TEST REQUESTED BY DR .\n NO FUNGAL ELEMENTS SEEN.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n No Virus isolated so far.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Follow ID recommendations (they will see if BAL comes back positive)\n .\n # Seizure/ s/p CVA. Patient had 10 second episode this morning of what\n appeared to be partial seizure, self-resolved, no post-ictal signs.\n Patient notes that he has had these episodes s/p CVA.\n - Obtain neurology records\n - Continue Ativan prn\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:34 PM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514844, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/14/15.BLSLungs clear to diminish at the\n bases, Sats via pulse oximetry = 91-94% and a little higher by ABG=\n 94-96%.. Pt follow commands able to communicarte his needs,on 40 mics\n propofol.\n Action:\n Suctioned for thick white secretions from ETT as well as lots of oral\n secretions . Cont neb treatment as well as Abx for PNA. UOP fine wants\n to keep him even. TF increased upto 40 from 20cc/hr\n Response:\n ABG this afternoon7.36/54/112,sats stable denies any pain or SOB.\n Weaned PEEP from 13 from 15\n Plan:\n Cont Pulm toileting, wean vent as tolerated. Cont Abx. Follow ABG\n after 1 hr around .\n" }, { "category": "Respiratory ", "chartdate": "2196-01-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 515108, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 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: /\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:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nutrition", "chartdate": "2196-01-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 514517, "text": "Subjective\n Patient intubated/sedated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 177.8 cm\n 112 kg\n 112.5 kg ( 08:00 AM)\n 35.44\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 75.45 Kg\n 148%\n unknown\n Diagnosis: PNA\n PMHx:\n Coronary artery disease, status post CABG with LIMA to the LAD in\n .\n Residual chronic systolic heart failure, with EF of 40%.\n Hypertension.\n Dyslipidemia.\n CVA believed to be hypertensive/hemorrhagic in with residual\n left-sided weakness.\n HIV. viral load was less than 48 copies. His CD4 count is 442 and has\n been stable around 500\n HCV genotype 1B; thought to be poor candidate for treatment given CVD\n and HIV. Liver biopsies, one in and one in with the later\n showing grade 1 inflammation with stage I-II fibrosis. Liver USG \n normal. Alpha fetoprotein was 3.9 back in . Normal EGD in\n .\n Stasis dermatitis\n Grade II hemorrhoids\n Right small hydrocele\n Food allergies and intolerances: NKFA\n Pertinent medications: propofol drip, bowel meds, protonix, heaprin,\n antiretrovirals, others noted\n Labs:\n Value\n Date\n Glucose\n 139 mg/dL\n 12:50 AM\n BUN\n 21 mg/dL\n 12:50 AM\n Creatinine\n 1.3 mg/dL\n 12:50 AM\n Sodium\n 134 mEq/L\n 12:50 AM\n Potassium\n 4.2 mEq/L\n 12:50 AM\n Chloride\n 96 mEq/L\n 12:50 AM\n TCO2\n 31 mEq/L\n 12:50 AM\n PO2 (arterial)\n 126 mm Hg\n 12:20 PM\n PCO2 (arterial)\n 53 mm Hg\n 12:20 PM\n pH (arterial)\n 7.38 units\n 12:20 PM\n CO2 (Calc) arterial\n 33 mEq/L\n 12:20 PM\n Albumin\n 3.1 g/dL\n 04:00 AM\n Calcium non-ionized\n 8.4 mg/dL\n 12:50 AM\n Phosphorus\n 2.8 mg/dL\n 12:50 AM\n Ionized Calcium\n 1.17 mmol/L\n 12:59 AM\n Magnesium\n 2.2 mg/dL\n 12:50 AM\n WBC\n 6.7 K/uL\n 12:50 AM\n Hgb\n 12.9 g/dL\n 12:50 AM\n Hematocrit\n 38.9 %\n 12:50 AM\n Current diet order / nutrition support: NPO\n GI: Abd: form/distended/+bowel sounds\n Assessment of Nutritional Status\n Obese, At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet, HIV\n Estimated Nutritional Needs\n Calories: 1690-2113 (20-25 cal/kg)\n Protein: 85-118 (1-1.4 g/kg)\n Fluid: per team\n Calculations based on: Adjusted weight\n Estimation of current intake: Inadequate given NPO status\n Specifics:\n 52 year old male w/ HIV presented c/ cough and fever, found to have LLL\n PNA. Patient transferred to MICU and subsequently intubated for\n hypoxia. Nutrition consult for tube feeds received. Will use high\n protein formula to come as close as possible to estimated protein needs\n at this time as propofol currently providing ~600 kcals/day.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feeds\n While patient continues on propofol, start Replete c/ Fiber\n @ 10mL/hr to increase 10mL/ q4 hr to goal 50mL/hr (1200 kcals/75 gr\n protein)\n Will need to change tube feeds once propofol off- Would\n recommend Isosource 1.5 @55mL/hr ( kcals/90 gr protein)\n Residual checks q4 hr, hold if >200mL\n If blood sugars > 150mg/dL, start RISS\n Lyte management as you are\n Following #\n" }, { "category": "Physician ", "chartdate": "2196-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514764, "text": "TITLE:\n Chief Complaint: Pneumonia, Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID consulted and noted that they will see tomorrow after we have\n further culture data from BAL.\n - Repeat chest CT ordered during early afternoon given patient's lack\n of clinical improvement\n - Based on these findings, we will likely consider bronch on .\n Throughout the evening, tried to wean down FiO2 (even while increasing\n PEEP)\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Vancomycin - 09:00 PM\n Metronidazole - 12:23 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 11:22 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.2\nC (99\n HR: 77 (77 - 89) bpm\n BP: 123/66(86) {92/60(73) - 130/79(98)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,174 mL\n 762 mL\n PO:\n TF:\n 29 mL\n 139 mL\n IVF:\n 2,085 mL\n 393 mL\n Blood products:\n Total out:\n 960 mL\n 545 mL\n Urine:\n 960 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,214 mL\n 217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/31/3\n Ve: 7.9 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 222 K/uL\n 12.3 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 36.6 %\n 5.9 K/uL\n [image002.jpg]\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n WBC\n 6.7\n 5.9\n Hct\n 38.9\n 36.6\n Plt\n 212\n 222\n Cr\n 1.3\n 1.1\n 1.0\n TropT\n 0.02\n TCO2\n 35\n 34\n 34\n 33\n 33\n 34\n 31\n Glucose\n 139\n 109\n 106\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Vanc Trough: 17.9\n Imaging:\n CT Chest: Worsening opacities consistent with multifocal pneumonia.\n Echo: EF 40-45%, LV focal distal septal/apical hypokinesis is suggested\n though poor image quality. Severe pulmonary artery systolic\n hypertension.\n : 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n TEST CANCELLED, PATIENT CREDITED.\n This is a low yield procedure based on our in-house studies if\n pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, contact the\n Laboratory (7-2306).\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia.\n Urine legionella negative, PCP (last CD4 count 442), Flu\n negative. BNP 34, less likely CHF although with bilateral pleural\n effusion. Troponin negative x 2 set, unlikely MI. PE very low\n likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ).\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Bronch today recheck cell count, keep in mind may need to broaden\n coverage empirically if no significant improvement\n - Appreciate ID Recommendations\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:05 PM 20 mL/hour\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Bed to 30 Degrees, Mouth Care\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-21 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514967, "text": "TITLE:\n Chief Complaint: Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID Recs: Did not come by.\n - I/O: Positive at , 20mg IV Lasix given\n - Updated Family.\n - Tried to decrease PEEP without success\n - Changed sedation to bolus.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 08:24 PM\n Cefipime - 08:24 PM\n Metronidazole - 12:39 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:27 PM\n Furosemide (Lasix) - 08:34 PM\n Heparin Sodium (Prophylaxis) - 10:34 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:42 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: 37.9\nC (100.3\n HR: 81 (78 - 94) bpm\n BP: 122/60(80) {94/60(79) - 145/90(103)} mmHg\n RR: 15 (14 - 19) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,644 mL\n 726 mL\n PO:\n TF:\n 587 mL\n 330 mL\n IVF:\n 1,617 mL\n 166 mL\n Blood products:\n Total out:\n 2,535 mL\n 510 mL\n Urine:\n 2,535 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 109 mL\n 216 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 2\n PEEP: 14 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 28 cmH2O\n Plateau: 21 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/33/3\n Ve: 7.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 264 K/uL\n 12.6 g/dL\n 122 mg/dL\n 1.0 mg/dL\n 33 mEq/L\n 4.1 mEq/L\n 20 mg/dL\n 99 mEq/L\n 135 mEq/L\n 37.0 %\n 8.0 K/uL\n [image002.jpg]\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n WBC\n 5.9\n 8.0\n Hct\n 36.6\n 37.0\n Plt\n 222\n 264\n Cr\n 1.1\n 1.0\n 1.0\n TCO2\n 34\n 33\n 33\n 34\n 31\n 32\n 31\n Glucose\n 109\n 106\n 122\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.3 mg/dL,\n Mg++:2.5 mg/dL, PO4:2.9 mg/dL\n Imaging: CT Chest: 1. Interval progression of multifocal pneumonia with\n more confluent opacities\n within the lingula, left lower lobe, and right lower lobe. No residual\n pleural effusions. Slight progression in adenopathy is also likely\n reactive,\n but can be re-assessed on follow up exams once infection resolves.\n 2. Dilated pulmonary artery consistent with known severe pulmonary\n hypertension (also noted on recent echo) which may HIV induced.\n Unchanged\n cholelithiasis without any secondary signs of acute cholecystitis.\n CXR: Pending\n Microbiology: 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Final ): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n KOH TEST REQUESTED BY DR .\n NO FUNGAL ELEMENTS SEEN.\n Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final\n ): NEGATIVE for Pneumocystis jirovecii (carinii)..\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n No Virus isolated so far.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Defer on Bronch today.\n - Appreciate ID Recommendations\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:34 PM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Communication: Comments:\n Code status: Full code\n Disposition: ICU pending clinical improvement\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514968, "text": "Team Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia.\n However, FiO2 requirement lower today. Clinically improved. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n NPN 01:30-07:00\n Respiratory failure, acute (not ARDS/)\n Assessment:\n s/p needing to go back on peep yest aft/eve to 14, d/t pO2 outside of\n goal\n Action:\n No further wean attempted this noc\n Continued to be orally suctioned q1 hr, and ETT suction approx q 2-3\n hrs\n Response:\n O2 sats remained w/in goal range\n Plan:\n Cont abx\n pO2 has found to be 4 pts higher than O2 sat, likely because of PVD\n highly doubt plan for extubation today\n Oliguria/Anuria\n Assessment:\n s/p IV lasix approx 20:30, with fairly good result of diuresis\n Action:\n Hrly urine output continued to be monitored\n Response:\n Urine output continued to be good this noc, tapering off toward the end\n of the shift\n Plan:\n Diuresis plan per team rounds\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Pt w/ known and documented HIV\n Action:\n Cont to receive HIV meds\n Response:\n ----\n Plan:\n Cont per HIV plan of care\n" }, { "category": "Nursing", "chartdate": "2196-01-24 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 515660, "text": "53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514602, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514839, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/14/15.BLSLungs clear to diminish at the\n bases, Sats via pulse oximetry = 91-94% and a little higher by ABG=\n 94-96%.. Pt follow commands able to communicarte his needs,on 40 mics\n propofol.\n Action:\n Suctioned for thick white secretions from ETT as well as lots of oral\n secretions . Cont neb treatment as well as Abx for PNA. UOP fine wants\n to keep him even. TF increased upto 40 from 20cc/hr\n Response:\n ABG this afternoon7.36/54/112,sats stable denies any pain or SOB.\n Plan:\n Cont Pulm toileting, wean vent as tolerated. Cont Abx.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515165, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 550 x 14, +12, 40%. Breath sounds clear. RR 14-16, Sats\n 91-97%. Sx several times for small amt thick white secretions. Copious\n clear oral secretions.\n Action:\n No vent changes made. ABG 7.40/48/77/31. Antibx for HAP, asp PNA.\n Response:\n Tolerating lower peep overnight.\n Plan:\n Wean from vent as tolerated. Antibx. MDIs, pulmonary hygiene.\n Seizure, without status epilepticus\n Assessment:\n Calm, awake at times or easily arouseable when sleeping. Nodding yes/no\n to questions, denies pain. Facial twitching noted at times, left leg\n twitching x 1 after turning. No seizure activity noted.\n Action:\n No ativan required overnight.\n Response:\n No seizures. Pt is comfortable off of sedation.\n Plan:\n Monitor for any seizure activity. Ativan prn. Fent/versed prn boluses.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515167, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 550 x 14, +12, 40%. Breath sounds clear. RR 14-16, Sats\n 91-97%. Sx several times for small amt thick white secretions. Copious\n clear oral secretions.\n Action:\n No vent changes made. ABG 7.40/48/77/31. Antibx for HAP, asp PNA.\n Response:\n Tolerating lower peep overnight.\n Plan:\n Wean from vent as tolerated. Antibx. MDIs, pulmonary hygiene.\n Seizure, without status epilepticus\n Assessment:\n Calm, awake at times or easily arouseable when sleeping. Nodding yes/no\n to questions, denies pain. Facial twitching noted at times, left leg\n twitching x 1 after turning. No seizure activity noted.\n Action:\n No ativan required overnight.\n Response:\n No seizures. Pt is comfortable off of sedation.\n Plan:\n Monitor for any seizure activity. Ativan prn. Fent/versed prn boluses.\n" }, { "category": "Physician ", "chartdate": "2196-01-22 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515279, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n - AC 550 x 14, 12 PEEP - brief desat then spontaneously rose, so\n decided to wait for a while. ABG 7.4 51 72.\n - Simple partial motor siezure unilateral on left noted at 7 a.m. then\n bilateral later with reduced mental status. Neurology \n recommended dilantin 250 mg, but not taken and patient comfortable\n without at present. Suffered for about 10 years s/p stroke. Was given 1\n mg Ativan after bilateral seizure.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 07:59 PM\n Vancomycin - 08:57 PM\n Metronidazole - 12:02 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 09:00 AM\n Midazolam (Versed) - 01:25 PM\n Fentanyl - 04:39 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:07 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.6\nC (97.9\n HR: 73 (72 - 86) bpm\n BP: 131/75(93) {93/56(72) - 132/83(98)} mmHg\n RR: 14 (14 - 17) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,570 mL\n 557 mL\n PO:\n TF:\n 1,200 mL\n 356 mL\n IVF:\n 840 mL\n 171 mL\n Blood products:\n Total out:\n 1,680 mL\n 740 mL\n Urine:\n 1,680 mL\n 740 mL\n NG:\n Stool:\n Drains:\n Balance:\n 890 mL\n -183 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 21 cmH2O\n SpO2: 92%\n ABG: 7.40/48/77/31/3\n Ve: 7.8 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 223 K/uL\n 11.8 g/dL\n 115 mg/dL\n 0.8 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 99 mEq/L\n 135 mEq/L\n 35.5 %\n 8.7 K/uL\n [image002.jpg]\n 02:57 AM\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n WBC\n 5.9\n 8.0\n 8.7\n Hct\n 36.6\n 37.0\n 35.5\n Plt\n 222\n 264\n 223\n Cr\n 1.0\n 1.0\n 0.8\n TCO2\n 34\n 31\n 32\n 31\n 34\n 33\n 31\n Glucose\n 106\n 122\n 115\n Other labs: PT / PTT / INR:13.6/39.9/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n CXR\n Pending\n NO NEW CULTURE DATA.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood cultures for tomorrow AM\n - Consider ID (BAL has come back negative)\n - Obtain sputum culture\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Restart ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:32 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 515168, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 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 /\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 / 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: t cont intub with OETT and on mech vent as per Metavision.\n Lung sounds coarse suct mod th yellow sput. MDI given as per order.\n ABGs compensated resp acidosis with marginal oxygenation. Cont mech\n vent support.\n" }, { "category": "Physician ", "chartdate": "2196-01-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515640, "text": "TITLE:\n Chief Complaint: HIV, Hypoxic Respiratory Failure\n 24 Hour Events:\n - Wean to PEEP of 5 - ABG: 7.41/50/65 -> PEEP to 8.\n - I/O: -1L at , no lasix given.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:45 PM\n Vancomycin - 09:15 PM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:55 PM\n Fentanyl - 09:00 PM\n Heparin Sodium (Prophylaxis) - 10:25 PM\n Midazolam (Versed) - 10:25 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 65 (60 - 76) bpm\n BP: 119/58(79) {96/47(65) - 163/145(283)} mmHg\n RR: 11 (9 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,892 mL\n 639 mL\n PO:\n TF:\n 1,202 mL\n 200 mL\n IVF:\n 1,000 mL\n 179 mL\n Blood products:\n Total out:\n 3,540 mL\n 750 mL\n Urine:\n 3,540 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n -648 mL\n -111 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 444 (444 - 740) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.40/51/68/33/4\n Ve: 6.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 258 K/uL\n 12.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.3 %\n 8.3 K/uL\n [image002.jpg]\n 12:51 AM\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n WBC\n 8.7\n 9.3\n 8.3\n Hct\n 35.5\n 35.3\n 36.3\n Plt\n 223\n 236\n 258\n Cr\n 0.8\n 0.8\n 0.8\n TCO2\n 31\n 31\n 29\n 34\n 33\n 33\n Glucose\n 115\n 113\n 102\n 98\n 110\n Other labs: PT / PTT / INR:13.7/41.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Pending\n Microbiology: Nothing New.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. Continues to improve. CT with worsening\n multifocal pneumonia from . PEEP down to 10 overnight. Fi02 to 40%.\n Overall improving. Urine legionella negative, PCP (last CD4\n count 442), Flu negative. BNP 34, less likely CHF although with\n bilateral pleural effusion. Troponin negative x 2 set, unlikely MI. PE\n very low likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Extubate\n - Ipratropium nebs q6h, Albuterol nebs q2h\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514503, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Patient BUN up the 21 today from 13, and now CR 1.3 which is up from\n 1.1. UOP 50ml hour of clear yellow urine.\n Action:\n Response:\n Plan:\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 514588, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 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: 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: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\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:\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": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514590, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Patient BUN up the 21 today from 13, and now CR 1.3 which is up from\n 1.1. UOP 50ml hour of clear yellow urine.\n Action:\n Monitor hourly out put.\n No lasix today.\n Response:\n Plan:\n Goal is to keep even today.\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Get ID consult pneumonia.\n Action:\n Re-start his medications.\n Response:\n Plan:\n Continue with the saquinavir and the ritonavire. Where gloves\n and a mask to crush meds and administer.\n CT chest done. New TF orders In the :14\n" }, { "category": "Physician ", "chartdate": "2196-01-20 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 514747, "text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n FIO2 able to weaned to 40% with increase of PEEP\n 24 Hour Events:\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Vancomycin - 09:00 PM\n Metronidazole - 12:23 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 11:22 PM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:57 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 36.3\nC (97.4\n HR: 78 (77 - 89) bpm\n BP: 115/73(89) {92/60(77) - 130/79(98)} mmHg\n RR: 16 (14 - 16) insp/min\n SpO2: 92%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,174 mL\n 873 mL\n PO:\n TF:\n 29 mL\n 202 mL\n IVF:\n 2,085 mL\n 441 mL\n Blood products:\n Total out:\n 960 mL\n 755 mL\n Urine:\n 960 mL\n 755 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,214 mL\n 118 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 3\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 31 cmH2O\n Plateau: 26 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 92%\n ABG: 7.38/51/77/31/3\n Ve: 8.9 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General Appearance: No acute distress, intubated\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:\n Rhonchorous: scattered b/l)\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: No(t) Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.3 g/dL\n 222 K/uL\n 106 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 36.6 %\n 5.9 K/uL\n [image002.jpg]\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n WBC\n 6.7\n 5.9\n Hct\n 38.9\n 36.6\n Plt\n 212\n 222\n Cr\n 1.3\n 1.1\n 1.0\n TropT\n 0.02\n TCO2\n 35\n 34\n 34\n 33\n 33\n 34\n 31\n Glucose\n 139\n 109\n 106\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure of\n unclear etiology, L>R infiltrates on CT.\n 1. Respiratory Failure\n --BAL unrevealing to this point\n --Cont vanc/cefepime/flagyl\n --Less hypoxemic with PEEP of 15\n --Hold on rebronch for now\n --Evidence of pulm HTN on TTE --> could be HIV\n 2. HIV\n --Restart HAART now that he has NG tube access\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:05 PM 20 mL/hour\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515275, "text": "53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 130s-160s/60s-70s, HR 70s, SR. K+3.7.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab.Given 20meQ oral KCL. Restarted on home regimen\n of antihypertensives\nlisinopril & metoprolol.\n Response:\n ABG 7.38/50/82/33 ( 7.40/48/77/31). ABP 100s to 120s systolic, HR in\n the 70s. No ectopy.\n Plan:\n Cont to wean vent as able, follow ABGs, monitor temp, f/u on cultures,\n monitor labs and replete lytes as needed.\n Seizure, without status epilepticus\n Assessment:\n Pt w/ twitching of his face. Team aware. Occasional twitching of LLE\n when coughing.\n Action:\n No action taken. Monitoring for seizure activity.\n Response:\n Plan:\n PRN ativan, f/u w/ neuro as outpt.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515286, "text": "53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology. CT scan from __ showing worsening\n multifocal PNA\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 130s-160s/60s-70s, HR 70s, SR. K+3.7.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab. Given 20meQ oral KCL. Restarted on home\n regimen of antihypertensives\nlisinopril & metoprolol.\n Response:\n ABG 7.38/50/82/33 ( 7.40/48/77/31). ABP 100s to 120s systolic, HR in\n the 70s. No ectopy. Cultures negative to date.\n Plan:\n Cont to wean vent as able, follow ABGs, monitor temp, f/u on cultures,\n monitor labs and replete lytes as needed.\n Seizure, without status epilepticus\n Assessment:\n Occasional facial twitching\n.pt himself is unaware of this happening.\n Team aware. Occasional twitching of LLE when coughing or turning.\n Action:\n No ativan required\nMonitoring for seizure activity.\n Response:\n No seizure activity.\n Plan:\n PRN ativan, f/u w/ neuro as outpt.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515287, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 130s-160s/60s-70s, HR 70s, SR. K+3.7.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab. Given 20meQ oral KCL. Restarted on home\n regimen of antihypertensives\nlisinopril & metoprolol.\n Response:\n ABG 7.38/50/82/33 ( 7.40/48/77/31). ABP 100s to 120s systolic, HR in\n the 70s. No ectopy. Cultures negative to date.\n Plan:\n Cont to wean vent as able, follow ABGs, monitor temp, f/u on cultures,\n monitor labs and replete lytes as needed.\n Seizure, without status epilepticus\n Assessment:\n Occasional facial twitching\n.pt himself is unaware of this happening.\n Team aware. Occasional twitching of LLE when coughing or turning.\n Action:\n No ativan required\nMonitoring for seizure activity.\n Response:\n No seizure activity.\n Plan:\n PRN ativan, f/u w/ neuro as outpt.\n" }, { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515367, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and off sedation. Pt awake and\n alert following commands and making his needs met with alphabet board\n and gestures. Vent setting at beginning of shift at 40%/. LS CTA.\n Pt present with a strong prod cough with sml amountsof thick white\n secretions.\n Action:\n VAP protocol followed and freq oral care done due to copious amounts of\n clear oral secretions.\n Response:\n O2sat 93-95%.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514259, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated\n Action:\n Pt having episodes of desatting down to 88%, improved with coughing and\n deep breathing, but then sats decreased again\n CPT and nebs given with transient effect\n Pt placed on NRB with improvement of sats to 93-94%\n Lasix 20mg IV given also with slow improvement, pt still desatts with\n talking or activity\n ~1340 pt intub with #8 ETT\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2196-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 514387, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 24 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: 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: Maintain PEEP at current level and reduce FiO2 as\n tolerated, Reduce PEEP as tolerated; Comments: Pt needing recruitment\n breaths for low sats and Pa02. Peep neede to be increased. Pt remains\n on 80%.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: MDI\nS given for diminished BS and wheezes.\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514505, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Patient BUN up the 21 today from 13, and now CR 1.3 which is up from\n 1.1. UOP 50ml hour of clear yellow urine.\n Action:\n Monitor hourly out put.\n No lasix today.\n Response:\n Plan:\n Goal is to keep even today.\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Get ID consult pneumonia.\n Action:\n Re-start his medications.\n Response:\n Plan:\n Continue with the saquinavir and the ritonavire. Where gloves\n and a mask to crush meds and administer.\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514834, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/14/15.BLSLungs clear to diminish at the\n bases, Sats via pulse oximetry = 91-94% and a little higher by ABG=\n 94-96%. Pt has lots of oral secretions. Pt follow commands able to\n communicarte his needs,on 40 mics propofol.\n Action:\n Suctioned for thick white secretions from ETT . Cont neb treatment as\n wellas Abx for PNA.\n Response:\n ABG this afternoon7.36/54/112,sats stable denies any pain or SOB.\n Plan:\n Cont Pulm toileting, wean vent as tolerated. Cont Abx.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n HR= 80\ns SR, no ectopy noted,BP via right radial aline with good\n waveform and correlation to NBP, BP= 110-120\ns/70\ns, urine output\n 30-100ml/hr, BUN= 19 and creatinine= 1.0, Hct stable at 36.6, suctioned\n for thick whitish tan and not frothy, bilat LE edema +\n Action:\n Echo completed yesterday, no diuretics overnight, pt kept even, strict\n I+O\n Response:\n Stable cardiac function at present time, no evidence of CHF\n Plan:\n Continue to monitor heart and lungs closely, keep pt even, F/U results\n of echo, continue ASA and statin\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515276, "text": "53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 130s-160s/60s-70s, HR 70s, SR. K+3.7.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab.Given 20meQ oral KCL. Restarted on home regimen\n of antihypertensives\nlisinopril & metoprolol.\n Response:\n ABG 7.38/50/82/33 ( 7.40/48/77/31). ABP 100s to 120s systolic, HR in\n the 70s. No ectopy.\n Plan:\n Cont to wean vent as able, follow ABGs, monitor temp, f/u on cultures,\n monitor labs and replete lytes as needed.\n Seizure, without status epilepticus\n Assessment:\n Pt w occasional facial twitching\n.pt himself is unaware of this\n happening. Team aware. Occasional twitching of LLE when coughing or\n turning.\n Action:\n No ativan required\nMonitoring for seizure activity.\n Response:\n Plan:\n PRN ativan, f/u w/ neuro as outpt.\n" }, { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515366, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515473, "text": "TITLE:\n Chief Complaint: HIV, Hypoxic Respiratory Failure\n 24 Hour Events:\n - Restarted patient's Lisinopril and Metoprolol.\n - Patient with abundant sputum production from ETT in morning. Sent for\n culture and preliminarily negative.\n - Weaned to PSV 10/10 FiO2 40% during late evening.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 03:37 PM\n Cefipime - 07:58 PM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:35 AM\n Heparin Sodium (Prophylaxis) - 09:32 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 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.2\nC (97.1\n HR: 63 (63 - 81) bpm\n BP: 122/59(81) {108/53(77) - 143/78(215)} mmHg\n RR: 12 (10 - 15) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 3,170 mL\n 697 mL\n PO:\n TF:\n 1,200 mL\n 364 mL\n IVF:\n 1,050 mL\n 73 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,390 mL\n Urine:\n 2,240 mL\n 1,390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 930 mL\n -693 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 617 (545 - 688) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 21 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 95%\n ABG: 7.40/53/75/29/5\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 236 K/uL\n 11.7 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 35.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n WBC\n 8.0\n 8.7\n 9.3\n Hct\n 37.0\n 35.5\n 35.3\n Plt\n \n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 34\n 33\n 31\n 31\n 29\n 34\n Glucose\n 122\n 115\n 113\n 102\n Other labs: PT / PTT / INR:13.5/39.0/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: Pending\n Microbiology: 11:02 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . PEEP down to 10 overnight. Fi02 to 40%. Overall improving.\n Urine legionella negative, PCP (last CD4 count 442), Flu\n negative. BNP 34, less likely CHF although with bilateral pleural\n effusion. Troponin negative x 2 set, unlikely MI. PE very low\n likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Trend CXR\n While Intubated.\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood cultures for tomorrow AM\n - Consider ID (BAL has come back negative)\n - Obtain sputum culture\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515553, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "General", "chartdate": "2196-01-18 00:00:00.000", "description": "Generic Note", "row_id": 514158, "text": "Chief Complaint: Cough\n Reason for MICU transfer: hypoxia\n HPI:\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n .\n In the ER he developed low SpO2 (not recorded) and was placed on NRB.\n His breathing improved without any specific therapy and they were able\n to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n .\n During his hospital stay he was initially treated with Levofloxacin\n (d1= ) for CAP. Given failure to improve, patient was broadened to\n Vanc, Cefepime, Flagyl (d1=) but continued to require 5L nc and was\n generally satting in the mid-90s.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring.\n .\n On MICU evaluation, patient denies pain or discomfort. He denies\n shortness of breath, and says he does not feel more short of breath\n than earlier today. No CP.\n .\n .\n" }, { "category": "General", "chartdate": "2196-01-18 00:00:00.000", "description": "Generic Note", "row_id": 514161, "text": "Chief Complaint: Cough\n Reason for MICU transfer: hypoxia\n HPI:\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n .\n In the ER he developed low SpO2 (not recorded) and was placed on NRB.\n His breathing improved without any specific therapy and they were able\n to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n .\n During his hospital stay he was initially treated with Levofloxacin\n (d1= ) for CAP. Given failure to improve, patient was broadened to\n Vanc, Cefepime, Flagyl (d1=) but continued to require 5L nc and was\n generally satting in the mid-90s.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring.\n .\n On MICU evaluation, patient denies pain or discomfort. He denies\n shortness of breath, and says he does not feel more short of breath\n than earlier today. No CP.\n .\n .\n Dyspnea (Shortness of breath)\n Assessment:\n Pt arrive to icu, garbled speech due to cva in history, talking without\n dyspnea, hi flow mask on, no distress\n Action:\n High flow mask, droplet precautions, supportive care\n Response:\n Stable vs\n Plan:\n observe\n" }, { "category": "Physician ", "chartdate": "2196-01-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514490, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:30 PM\n PICC LINE - START 02:30 PM\n MIDLINE - START 02:30 PM\n BRONCHOSCOPY - At 03:20 PM\n PICC LINE - STOP 04:30 PM\n ARTERIAL LINE - START 01:09 AM\n - Intubated\n - I/O sp (Lasix 20mg IV)-> 1.6 liters negative at 1700\n - Bronch: BAL from Lingula, LLL. Scant frothy secretions throughout.\n Airways otherwise nl.\n - Influenza negative\n - ICU Consent Signed\n - PICC line went up into neck, pulled back to midline, will advance in\n AM.\n - Aline placed.\n - Overnight Pulse of at 90 while pa02 at 118. Unclear why the\n disconnect.\n - Urine output dropped off. MAPs stable in the 70s. Initially bolused\n 250cc x two. Creatinine bumped to 1.3. Thought patient most likely dry\n secondary to Lasix -> 500cc NS.\n - Family updated.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 11:18 PM\n Metronidazole - 12:00 AM\n Cefipime - 01:07 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 09:28 AM\n Propofol - 04:06 AM\n Fentanyl - 04:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 83 (71 - 92) bpm\n BP: 101/59(74) {88/48(3) - 103/61(76)} mmHg\n RR: 14 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 1,462 mL\n 849 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,302 mL\n 849 mL\n Blood products:\n Total out:\n 2,635 mL\n 125 mL\n Urine:\n 2,635 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,173 mL\n 724 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n Compliance: 45.8 cmH2O/mL\n SpO2: 93%\n ABG: 7.38/56/92 /31/5\n Ve: 7.9 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 212 K/uL\n 12.9 g/dL\n 139 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 96 mEq/L\n 134 mEq/L\n 38.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 04:00 AM\n 04:34 PM\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n WBC\n 7.6\n 6.7\n Hct\n 40.4\n 38.9\n Plt\n 196\n 212\n Cr\n 1.1\n 1.2\n 1.3\n TropT\n <0.01\n TCO2\n 34\n 35\n 34\n 34\n Glucose\n 116\n 102\n 139\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:134/2/<0.01, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.8 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.8 mg/dL\n CXR: Final read pending;\n CXR: Final read pending; Unchanged bibasilar opacification,\n bilateral pleural effusions and interstitial prominence.\n 3:42 pm Rapid Respiratory Viral Screen & Culture\n BRONCHIAL LAVAGE FLUID.\n Respiratory Viral Culture (Preliminary):\n Respiratory Viral Antigen Screen (Final ):\n Respiratory viral antigen test is uninterpretable due to the lack of\n cells.\n Refer to respiratory viral culture for further information.\n 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. Stable and not clearly improving.\n Unclear etiology. Perhaps related with LLL pneumonia which was seen on\n CT but has not been clearly demonstrated on repeat CXR. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = )\n - Vancomycin trough this PM\n - Follow BAL cultures\n - Obtain echo\n - Trend CXR\n - Trend cardiac enzymes\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Consider re-bronch in PM to recheck cell count, keep in mind may need\n to broaden coverage empirically if no significant improvement\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Consult ID formally regarding HIV and also lack of clear improvement\n during this time\n .\n # Chronic Diastolic Heart Failure with EF 40%. Patient looks euvolemic.\n Question acute exacerbation in the setting of infection. Will closely\n monitor fluid status and BP.\n - Obtain echo\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to -500cc\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514501, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Action:\n Response:\n Plan:\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514502, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Patient\n Action:\n Response:\n Plan:\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514901, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and on propofol gtt for\n sedation. Pt found to be alert, awake and following commands. LS CTA\n with diminished bases.\n Action:\n VAP protocol followed with freq oral care due to copious amounts of\n clear oral secretions. Pt has been deep sx\nd for mod amounts of thick\n white secretions. HOB > 30\n. Propofol gtt stopped at mn and will be\n getting sedation prn. ABG done at 19:30 and results as noted. Peep\n increased back up to 14.\n Response:\n No change to LS. O2sat 91-94% and PO2 has been 4 point higher than\n O2sat.\n Plan:\n Wean vent settings as tolerated by pt. Follow up with ABG this am.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515273, "text": "53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt orally intubated on AC 40%/550x14/12+. LS CTA throughout.\n Copious clear oral secretions and copious clear/thick secretions deep\n sxn\n.strong productive cough. Temp max 99.4 orally. Pt alert,\n following commands, denies c/o pain, MAEs. Pt using communication board\n and making needs known. ABP 140s-160s/____, HR 70s-80s, SR. K+____.\n Action:\n Switched to 10 of PS this morning and remains on 12 peep. Sputum\n sample sent to the lab.Given 20meQ oral KCL. Restarted on home regimen\n of antihypertensives\nlisinopril & metoprolol.\n Response:\n ABG 7.38/50/82/33. ABP 1-teens to 120s systolic, HR in the 70s. No\n ectopy.\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-23 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 515458, "text": "TITLE:\n Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n Sig sputum sent for cx\n History obtained from Medical records\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 03:37 PM\n Cefipime - 07:58 PM\n Vancomycin - 09:02 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:35 AM\n Heparin Sodium (Prophylaxis) - 09:03 AM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.6\nC (97.8\n HR: 60 (60 - 81) bpm\n BP: 131/74(95) {112/53(77) - 139/77(215)} mmHg\n RR: 11 (10 - 16) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 3,170 mL\n 1,301 mL\n PO:\n TF:\n 1,200 mL\n 576 mL\n IVF:\n 1,050 mL\n 365 mL\n Blood products:\n Total out:\n 2,240 mL\n 2,050 mL\n Urine:\n 2,240 mL\n 2,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 930 mL\n -749 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 740 (545 - 740) mL\n PS : 10 cmH2O\n RR (Spontaneous): 14\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SpO2: 94%\n ABG: 7.40/53/75/29/5\n Ve: 5.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: 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:\n Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 11.7 g/dL\n 236 K/uL\n 102 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 35.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n WBC\n 8.0\n 8.7\n 9.3\n Hct\n 37.0\n 35.5\n 35.3\n Plt\n \n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 34\n 33\n 31\n 31\n 29\n 34\n Glucose\n 122\n 115\n 113\n 102\n Other labs: PT / PTT / INR:13.5/39.0/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory Failure:\n -b/l infiltrates improving\n -pHTN\n --Cont vanc/cefepime/flagyl empirically\n -Cx data remains unrevealing\n -weaning PEEP as tolerated\n HIV\n --HAART --> boosted single drug regimen\n -cont current regimen\naccess mid, aline\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n OLIGURIA/ANURIA\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-01-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 514163, "text": "Chief Complaint: Chief Complaint: Cough\n Reason for MICU transfer: hypoxia\n HPI:\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n .\n In the ER he developed low SpO2 (not recorded) and was placed on NRB.\n His breathing improved without any specific therapy and they were able\n to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n .\n During his hospital stay he was initially treated with Levofloxacin\n (d1= ) for CAP. Given failure to improve, patient was broadened to\n Vanc, Cefepime, Flagyl (d1=) but continued to require 5L nc and was\n generally satting in the mid-90s.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring.\n .\n On MICU evaluation, patient denies pain or discomfort. He denies\n shortness of breath, and says he does not feel more short of breath\n than earlier today. No CP.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Ritonavir 400 mg \n Saquinavir 200 mg PO BID\n Pravastatin 20 mg PO QHS\n Aspirin 81 mg PO Daily\n Lisinopril 5 mg PO Daily\n Toprol XL 12.5 mg PO Daily\n Triamcinolone acetonide 0.1% ointment 2 weeks on/2 weeks off Daily use\n Mupirocin 2% ointment \n Urea 20% topical cream Daily\n Colace 50 mg TID\n .\n Medications on transfer:\n Vancomycin 1250 mg IV Q 12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n CefePIME 2 g IV Q12H\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H\n traZODONE 25 mg PO/NG HS:PRN insomnia\n Polyethylene Glycol 17 g PO/NG DAILY\n Senna 1 TAB PO/NG Constipation\n Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY\n Heparin 5000 UNIT SC TID\n Docusate Sodium 100 mg PO BID\n Metoprolol Succinate XL 12.5 mg PO DAILY\n Lisinopril 5 mg PO/NG DAILY\n Aspirin 81 mg PO/NG DAILY\n Pravastatin 20 mg PO DAILY\n Saquinavir (Invirase) Cap 400 mg PO BID\n RiTONAvir 400 mg PO BID\n Past medical history:\n Family history:\n Social History:\n #. Coronary artery disease, status post CABG with LIMA to the\n LAD in .\n #. Residual chronic systolic heart failure, with EF of 40%.\n #. Hypertension.\n #. Dyslipidemia.\n #. CVA believed to be hypertensive/hemorrhagic in with residual\n left-sided weakness.\n #. HIV. viral load was less than 48\n copies. His CD4 count is 442 and has been stable around 500\n #. HCV genotype 1B; thought to be poor candidate for treatment given\n CVD and HIV. Liver biopsies, one in and one in with the later\n showing grade 1 inflammation with stage I-II fibrosis. Liver USG \n normal. Alpha fetoprotein was 3.9 back in . Normal EGD in\n .\n #. Stasis dermatitis\n #. Grade II hemorrhoids\n #. Right small hydrocele\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Social History:\n No current or past tobacco use. No history of drug or alcohol abuse.\n The patient is single. He lives alone with the help of PCAs and goes to\n daycare programs during the day. He ambulates with a scooter.\n Review of systems:\n Flowsheet Data as of 03:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (83 - 85) bpm\n BP: 133/79(93) {133/79(93) - 133/79(93)} mmHg\n RR: 19 (17 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n Physical Examination\n Vitals: T:98.6 BP: 133/79 P: 83 R: 18 O2: 93% on High flow FiO2 40%\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: ABG: 7.32/67/58 while on NRB\n Imaging: CT Chest (wet read)\n 1. Multiple opacities at the left lung base, concerning for pneumonia.\n There is a small left pleural effusion.\n 2. No obstructing mass is present in the airways, although left lower\n lobe\n bronchi are obscured by motion artifact.\n 3. Enlarged subcarinal lymph node, likely reactive.\n 4. Stones within a nondistended gallbladder.\n Microbiology: Blood cultures x2\n Blood cultures x2\n Legionella negative\n HIV VL 158\n ECG: EKG: NSR @ 79bpm. Nl axis. J point elevation in anterior leads. No\n ST segment changes.\n Assessment and Plan\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented with LLL\n pna, transferred to MICU for hypoxia.\n .\n 1. Hypoxia: Most likely secondary to LLL pneumonia, clearly seen on\n Chest CT. Patient has large amount of purulent sputum. Urine legionella\n negative. Minimal pleural effusion. Given CD4 count of 442, this is\n less likely PCP, . Chest CT does not appear typical for viral\n pneumonia, however this may be viral with overlying bacterial\n infection. Differential always includes MI, PE, CHF. Chest CT does not\n show large effusion or fluid overload, and in the past 24 hours he is\n net negative 1L.\n -continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = )\n -obtain sputum cultures\n -rule out influenza\n -consider bronch in AM.\n -obtain repeat ABG: if persistently hypercarbic may benefit from\n noninvasive ventilation\n -ipratropium nebs q6h, albuterol nebs q2h\n -trend CEs\n -obtain EKG\n .\n #. HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable. Continue home-regimen of Ritonavir, Saquinavir.\n .\n .\n #. Chronic Diastolic Heart Failure with EF 40% - Pt looks euvolemic. No\n signs of acute exacerbation even in the setting of infection. Will\n closely monitor fluid status and BP.\n - Continue ACEI and beta-\n - I/O goal even to -500cc\n - No IVF\n .\n #. Coronary artery Disease - Pt s/p CABG. Chest pain free.\n - Continue beta-, , statin and ACEI\n .\n #. Hypertension - Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. need to be uptitrated\n as outpatient.\n - continue outpatient Lisinopril 5mg po daily, Metoprolol 12.5mg po bid\n .\n .\n #. HCV - Pt not candidate for therapy and has had negative malignancy\n work up with USGs and AFP.\n .\n .\n # FEN: No IVF now, replete electrolytes, heart healthy diet\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n # Access: peripheral x1. Consider PICC line in AM.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514256, "text": "Dyspnea (Shortness of breath)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514640, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum. Initial vent\n settings AC 550-60%-14 with Peep=12 with good Sats and ABG, FI02\n decreased to 50 % with no change in Sats or ABG, continues on antibx,\n lactate=1.1, Tmax= 99.1. ABG on 50 %= 7.34-54-104.. Sedated on IV\n Propofol at 50 mcgs/kg/min, pt able to follow simple commands but falls\n right back to sleep\n Action:\n Aggressive pulmonary toileting, inhalers as ordered, ABG\ns monitored,\n FI02 reduced to 50 %, vanco level sent and 17.9, received\n vanco/cefepime/flagyl, IV Propofol weaned to 40 mcgs/kg/min\n Response:\n Tolerating slow wean of FI02. Stable on current vent settings\n Plan:\n F/U BAL results, F/U chest CT results, continue aggressive pulmonary\n toileting, wean vent as tolerated\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Afebrile, WBC= 5.9 with lactate= 1.1, continues on antivirals as\n ordered\n Action:\n Cultures and WBC monitored, antivirals as ordered\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514641, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum. Initial vent\n settings AC 550-60%-14 with Peep=12 with good Sats and ABG, FI02\n decreased to 50 % with no change in Sats or ABG, continues on antibx,\n lactate=1.1, Tmax= 99.1. ABG on 50 %= 7.34-54-104.. Sedated on IV\n Propofol at 50 mcgs/kg/min, pt able to follow simple commands but falls\n right back to sleep\n Action:\n Aggressive pulmonary toileting, inhalers as ordered, ABG\ns monitored,\n FI02 reduced to 50 %, vanco level sent and 17.9, received\n vanco/cefepime/flagyl, IV Propofol weaned to 40 mcgs/kg/min\n Response:\n Tolerating slow wean of FI02. Stable on current vent settings\n Plan:\n F/U BAL results, F/U chest CT results, continue aggressive pulmonary\n toileting, wean vent as tolerated\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Afebrile, WBC= 5.9 with lactate= 1.1, continues on antivirals as\n ordered\n Action:\n Cultures and WBC monitored, antivirals as ordered\n Response:\n Stable cell counts\n Plan:\n Obtain ID consult for pna, continue saquinivir and ritonovir and use\n gloves and mask to prepare and administer\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n HR= 80\ns SR, no ectopy noted,BP via right radial aline with good\n waveform and correlation to NBP, BP= 110-120\ns/70\ns, urine output\n 30-100ml/hr, BUN= 19 and creatinine= 1.0, Hct stable at 36.6, suctioned\n for thick whitish tan and not frothy, bilat LE edema +\n Action:\n Echo completed yesterday, no diuretics overnight, pt kept even, strict\n I+O\n Response:\n Stable cardiac function at present time, no evidence of CHF\n Plan:\n Continue to monitor heart and lungs closely, keep pt even, F/U results\n of echo, continue ASA and statin\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514642, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum. Initial vent\n settings AC 550-60%-14 with Peep=12 with good Sats and ABG, FI02\n decreased to 50 % with no change in Sats or ABG, continues on antibx,\n lactate=1.1, Tmax= 99.1. ABG on 50 %= 7.34-54-104.. Sedated on IV\n Propofol at 50 mcgs/kg/min, pt able to follow simple commands but falls\n right back to sleep\n Action:\n Aggressive pulmonary toileting, inhalers as ordered, ABG\ns monitored,\n FI02 reduced to 50 %, vanco level sent and 17.9, received\n vanco/cefepime/flagyl, IV Propofol weaned to 40 mcgs/kg/min\n Response:\n Tolerating slow wean of FI02. Stable on current vent settings\n Plan:\n F/U BAL results, F/U chest CT results, continue aggressive pulmonary\n toileting, wean vent as tolerated\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Afebrile, WBC= 5.9 with lactate= 1.1, continues on antivirals as\n ordered\n Action:\n Cultures and WBC monitored, antivirals as ordered\n Response:\n Stable cell counts\n Plan:\n Obtain ID consult for pna, continue saquinivir and ritonovir and use\n gloves and mask to prepare and administer\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n HR= 80\ns SR, no ectopy noted,BP via right radial aline with good\n waveform and correlation to NBP, BP= 110-120\ns/70\ns, urine output\n 30-100ml/hr, BUN= 19 and creatinine= 1.0, Hct stable at 36.6, suctioned\n for thick whitish tan and not frothy, bilat LE edema +\n Action:\n Echo completed yesterday, no diuretics overnight, pt kept even, strict\n I+O\n Response:\n Stable cardiac function at present time, no evidence of CHF\n Plan:\n Continue to monitor heart and lungs closely, keep pt even, F/U results\n of echo, continue ASA and statin\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514372, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum..\n . In the ER he developed low SpO2 (not recorded) and was placed on\n NRB. His breathing improved without any specific therapy and they were\n able to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring. Acute desat lead to intubation on ICU day 2.\n Shift Events:\n Art line placed\n Increase peep to 12\n Bolus total 750 cc ns for low to no urine output\n Added fentanyl bolus for pain management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Rec\nd 80% fio2, tv 550,rr 14, ,p10, secretions tenacious, require\n instill, one episode desat to 87% required recruitment efforts,\n decrease breath sounds upper right lobe transiently, advanced ETT after\n futher eval CXR with recheck, now lung fields clear diminished left\n base, oral secretions large, sedation/analgesia with bolus only\n fentanly suffient at this time,\n Action:\n Fentanyl bolus for pain, art line placed, sedation increased to\n maintain rr 14, peep 12\n Response:\n Slight improvement sats, remains on 80% peep now 12\n Plan:\n Titrate fio2 below 80% asap as tol. , serial abgs, nebs,\n Oliguria/Anuria\n Assessment:\n Maps 60/s, ceased to produce urine output,earlier today lasix, rise in\n bun cr\n Action:\n Bolus total 750 cc ns, urine sample to lytes\n Response:\n Maps now 72, bun cr cont to trend up, urine 10-20 cc hr\n Plan:\n Monitor closely, may cont. to bolus as needed to maintain urine output\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514898, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt found at 8 pm to be orally intubated and on propofol gtt for\n sedation. Pt found to be alert, awake and following commands.\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-23 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515424, "text": "TITLE:\n Chief Complaint: HIV, Hypoxic Respiratory Failure\n 24 Hour Events:\n - Restarted patient's Lisinopril and Metoprolol.\n - Patient with abundant sputum production from ETT in morning. Sent for\n culture and preliminarily negative.\n - Weaned to PSV 10/10 FiO2 40% during late evening.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Metronidazole - 03:37 PM\n Cefipime - 07:58 PM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 11:35 AM\n Heparin Sodium (Prophylaxis) - 09:32 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 07:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.4\nC (99.4\n Tcurrent: 36.2\nC (97.1\n HR: 63 (63 - 81) bpm\n BP: 122/59(81) {108/53(77) - 143/78(215)} mmHg\n RR: 12 (10 - 15) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 3,170 mL\n 697 mL\n PO:\n TF:\n 1,200 mL\n 364 mL\n IVF:\n 1,050 mL\n 73 mL\n Blood products:\n Total out:\n 2,240 mL\n 1,390 mL\n Urine:\n 2,240 mL\n 1,390 mL\n NG:\n Stool:\n Drains:\n Balance:\n 930 mL\n -693 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 617 (545 - 688) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 13\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n Plateau: 21 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 95%\n ABG: 7.40/53/75/29/5\n Ve: 8.6 L/min\n PaO2 / FiO2: 188\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 236 K/uL\n 11.7 g/dL\n 102 mg/dL\n 0.8 mg/dL\n 29 mEq/L\n 3.9 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 35.3 %\n 9.3 K/uL\n [image002.jpg]\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n WBC\n 8.0\n 8.7\n 9.3\n Hct\n 37.0\n 35.5\n 35.3\n Plt\n \n Cr\n 1.0\n 0.8\n 0.8\n TCO2\n 34\n 33\n 31\n 31\n 29\n 34\n Glucose\n 122\n 115\n 113\n 102\n Other labs: PT / PTT / INR:13.5/39.0/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.9 mg/dL\n Imaging: CXR: Pending\n Microbiology: 11:02 am SPUTUM Source: Endotracheal.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . Difficulty reducing PEEP overnight. Fi02 stable. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Trend CXR\n While Intubated.\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood cultures for tomorrow AM\n - Consider ID (BAL has come back negative)\n - Obtain sputum culture\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-24 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 515610, "text": "TITLE:\n Chief Complaint: HIV, Hypoxic Respiratory Failure\n 24 Hour Events:\n - Wean to PEEP of 5 - ABG: 7.41/50/65 -> PEEP to 8.\n - I/O: -1L at , no lasix given.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:45 PM\n Vancomycin - 09:15 PM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:55 PM\n Fentanyl - 09:00 PM\n Heparin Sodium (Prophylaxis) - 10:25 PM\n Midazolam (Versed) - 10:25 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 08:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 65 (60 - 76) bpm\n BP: 119/58(79) {96/47(65) - 163/145(283)} mmHg\n RR: 11 (9 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,892 mL\n 639 mL\n PO:\n TF:\n 1,202 mL\n 200 mL\n IVF:\n 1,000 mL\n 179 mL\n Blood products:\n Total out:\n 3,540 mL\n 750 mL\n Urine:\n 3,540 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n -648 mL\n -111 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 444 (444 - 740) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.40/51/68/33/4\n Ve: 6.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General: Alert, oriented, no acute distress, Intubated.\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 258 K/uL\n 12.2 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.3 %\n 8.3 K/uL\n [image002.jpg]\n 12:51 AM\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n WBC\n 8.7\n 9.3\n 8.3\n Hct\n 35.5\n 35.3\n 36.3\n Plt\n 223\n 236\n 258\n Cr\n 0.8\n 0.8\n 0.8\n TCO2\n 31\n 31\n 29\n 34\n 33\n 33\n Glucose\n 115\n 113\n 102\n 98\n 110\n Other labs: PT / PTT / INR:13.7/41.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Imaging: CXR: Pending\n Microbiology: Nothing New.\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia\n from . PEEP down to 10 overnight. Fi02 to 40%. Overall improving.\n Urine legionella negative, PCP (last CD4 count 442), Flu\n negative. BNP 34, less likely CHF although with bilateral pleural\n effusion. Troponin negative x 2 set, unlikely MI. PE very low\n likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor. BAL negative\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Trend CXR\n While Intubated.\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood cultures for tomorrow AM\n - Consider ID (BAL has come back negative)\n - Obtain sputum culture\n # Seizure d/o s/p CVA. Patient had 10 second episode this morning of\n what appeared to be partial seizure, self-resolved, no post-ictal\n signs. Appears to be simple partial. Patient notes that he has had\n these episodes s/p CVA. Patient last saw neurology for these episodes\n in . He has not had treatment for it since that time (although they\n had recommended Dilantin), and does not express desire to obtain\n treatment for it.\n - Continue Ativan prn\n # HIV. Pt has been well controlled with CD4 count most recently 442 and\n VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Continue ACE inhibitor and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to even\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Restart ACE inhibitor and beta-blocker\n - Continue statin\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Restart ACE inhibitor and beta-blocker\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n # FEN: IVF bolus prn, replete electrolytes, tube feeds;\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, midline\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition: Tube Feeds\n Replete with Fiber (Full) - 03:58 AM 50 mL/hour\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Per Protocol\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2196-01-24 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 515616, "text": "TITLE:\n Chief Complaint: resp failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n -PEEP weaned\n -SBT this morning - RSBI 65\n -mod secretions\n History obtained from Medical records\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:45 PM\n Vancomycin - 09:15 PM\n Metronidazole - 04:16 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:55 PM\n Fentanyl - 09:00 PM\n Heparin Sodium (Prophylaxis) - 10:25 PM\n Midazolam (Versed) - 10:25 PM\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.1\nC (98.7\n Tcurrent: 36.8\nC (98.2\n HR: 65 (60 - 76) bpm\n BP: 119/58(79) {96/47(65) - 163/145(283)} mmHg\n RR: 11 (9 - 18) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,892 mL\n 646 mL\n PO:\n TF:\n 1,202 mL\n 200 mL\n IVF:\n 1,000 mL\n 186 mL\n Blood products:\n Total out:\n 3,540 mL\n 750 mL\n Urine:\n 3,540 mL\n 750 mL\n NG:\n Stool:\n Drains:\n Balance:\n -648 mL\n -104 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: PSV/SBT\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 444 (444 - 696) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 14\n PEEP: 0 cmH2O\n FiO2: 40%\n PIP: 10 cmH2O\n Plateau: 17 cmH2O\n SpO2: 95%\n ABG: 7.39/44/68/33/0\n Ve: 6.3 L/min\n PaO2 / FiO2: 170\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : anteriorly)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.2 g/dL\n 258 K/uL\n 110 mg/dL\n 0.8 mg/dL\n 33 mEq/L\n 3.6 mEq/L\n 17 mg/dL\n 97 mEq/L\n 135 mEq/L\n 36.3 %\n 8.3 K/uL\n [image002.jpg]\n 02:47 AM\n 10:00 AM\n 11:36 AM\n 05:45 PM\n 04:01 AM\n 04:08 AM\n 05:35 PM\n 03:39 AM\n 05:58 AM\n 08:20 AM\n WBC\n 8.7\n 9.3\n 8.3\n Hct\n 35.5\n 35.3\n 36.3\n Plt\n 223\n 236\n 258\n Cr\n 0.8\n 0.8\n 0.8\n TCO2\n 31\n 29\n 34\n 33\n 33\n 28\n Glucose\n 115\n 113\n 102\n 98\n 110\n Other labs: PT / PTT / INR:13.7/41.3/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n Respiratory Failure:\n -b/l infiltrates cont improving\n -pHTN\n --Cont vanc/cefepime/flagyl empirically\n -Cx data remains unrevealing\n -looks like ready for extubation this morning\n\n HIV\n --HAART --> boosted single drug regimen\n -cont current regimen\naccess mid, aline\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n -no seizure activity\n OLIGURIA/ANURIA\n -resolved\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\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: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2196-01-19 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 514456, "text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Bronch yesterday --> cxs pending\n Remains on FIO2 0.8, PEEP of 12\n 1.1L negative yesterday\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:30 PM\n PICC LINE - START 02:30 PM\n MIDLINE - START 02:30 PM\n BRONCHOSCOPY - At 03:20 PM\n PICC LINE - STOP 04:30 PM\n ARTERIAL LINE - START 01:09 AM\n History obtained from Medical records, icu team\n Patient unable to provide history: Sedated\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 11:18 PM\n Metronidazole - 08:00 AM\n Cefipime - 08:33 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Propofol - 04:06 AM\n Fentanyl - 04:07 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: mechanical ventilation\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 10:15 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 82 (71 - 92) bpm\n BP: 109/60(78) {88/48(3) - 109/64(81)} mmHg\n RR: 14 (13 - 22) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 1,462 mL\n 1,082 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,302 mL\n 1,082 mL\n Blood products:\n Total out:\n 2,635 mL\n 275 mL\n Urine:\n 2,635 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,173 mL\n 807 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 23 cmH2O\n Compliance: 50 cmH2O/mL\n SpO2: 94%\n ABG: 7.38/56/91./31/5\n Ve: 7.9 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 12.9 g/dL\n 212 K/uL\n 139 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 96 mEq/L\n 134 mEq/L\n 38.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 04:00 AM\n 04:34 PM\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n WBC\n 7.6\n 6.7\n Hct\n 40.4\n 38.9\n Plt\n 196\n 212\n Cr\n 1.1\n 1.2\n 1.3\n TropT\n <0.01\n 0.02\n TCO2\n 34\n 35\n 34\n 34\n Glucose\n 116\n 102\n 139\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.8 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.8 mg/dL\n Fluid analysis / Other labs: BAL cell count: 74P, 15L, 3E\n Assessment and Plan\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure of\n unclear etiology, L>R infiltrates on CT.\n 1. Respiratory Failure\n --Continues to require high FIO2\n --Awaiting BAL cx results\n --Cell count on BAL with 3% eos, 7% eos peripherally\n --Cont vanc/cefepime/flagyl\n --TTE\n --ARDSnet ventilation\n --goal neg 500cc\n 2. HIV\n --Restart HAART now that he has NG tube access\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: will start\n VAP: HOB elevation, Mouth care, Daily wake up\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": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514559, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated and sedated. Vent settings\n CMV80X500X14X12Peep. O2sat 93-95%. Lung sounds are diminished through.\n Suctioned for pink secretions in a moderate amount. Oral secretions\n thin and clear in a copious amount.\n Action:\n Vanoc/Flagy/Cefepime given for coverage of HAP, or aspiration\n pneumonia.\n f/u BAL\n Nebs Q6H\n CT of chest.\n Response:\n Patient continues with mild temp 99.0 oral.\n Lung sounds remain diminished boat.\n Plan:\n Wean vent as tolerated.\n Obtain vanco level at 1900. The vanco is do at \n f/u results of the CT chest.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Patient has EF of 40%. Lung sounds are diminished bilateral. Suctioned\n for thin pink secretions.\n Action:\n ECHO done today.\n D/C beta blocker and AVEI\n Response:\n Blood pressure remain in the one teens to the 90\n Plan:\n f/u ECHO results.\n Continue with the ASA and statin\n Keep patient fluid status even.\n Oliguria/Anuria\n Assessment:\n Patient BUN up the 21 today from 13, and now CR 1.3 which is up from\n 1.1. UOP 50ml hour of clear yellow urine.\n Action:\n Monitor hourly out put.\n No lasix today.\n Response:\n Plan:\n Goal is to keep even today.\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Get ID consult pneumonia.\n Action:\n Re-start his medications.\n Response:\n Plan:\n Continue with the saquinavir and the ritonavire. Where gloves\n and a mask to crush meds and administer.\n CT chest done. New TF orders In the .\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514478, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n Oliguria/Anuria\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514714, "text": "TITLE:\n Chief Complaint: Pneumonia, Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID consulted and noted that they will see tomorrow after we have\n further culture data from BAL.\n - Repeat chest CT ordered during early afternoon given patient's lack\n of clinical improvement\n - Based on these findings, we will likely consider bronch on .\n Throughout the evening, tried to wean down FiO2 (even while increasing\n PEEP)\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Vancomycin - 09:00 PM\n Metronidazole - 12:23 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 11:22 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.2\nC (99\n HR: 77 (77 - 89) bpm\n BP: 123/66(86) {92/60(73) - 130/79(98)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,174 mL\n 762 mL\n PO:\n TF:\n 29 mL\n 139 mL\n IVF:\n 2,085 mL\n 393 mL\n Blood products:\n Total out:\n 960 mL\n 545 mL\n Urine:\n 960 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,214 mL\n 217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/31/3\n Ve: 7.9 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 222 K/uL\n 12.3 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 36.6 %\n 5.9 K/uL\n [image002.jpg]\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n WBC\n 6.7\n 5.9\n Hct\n 38.9\n 36.6\n Plt\n 212\n 222\n Cr\n 1.3\n 1.1\n 1.0\n TropT\n 0.02\n TCO2\n 35\n 34\n 34\n 33\n 33\n 34\n 31\n Glucose\n 139\n 109\n 106\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Vanc Trough: 17.9\n Imaging:\n CT Chest: Worsening opacities consistent with multifocal pneumonia.\n Echo: EF 40-45%, LV focal distal septal/apical hypokinesis is suggested\n though poor image quality. Severe pulmonary artery systolic\n hypertension.\n : 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n TEST CANCELLED, PATIENT CREDITED.\n This is a low yield procedure based on our in-house studies if\n pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, contact the\n Laboratory (7-2306).\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia.\n Urine legionella negative, PCP (last CD4 count 442), Flu\n negative. BNP 34, less likely CHF although with bilateral pleural\n effusion. Troponin negative x 2 set, unlikely MI. PE very low\n likelihood given other findings as per above. Severe pulmonary\n hypertension most likely an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ).\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Bronch today recheck cell count, keep in mind may need to broaden\n coverage empirically if no significant improvement\n - Appreciate ID Recommendations\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:05 PM 20 mL/hour\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Bed to 30 Degrees, Mouth Care\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2196-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515594, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on CPAP 40%, LS rhonchorous bilaterally and pt with\n large amounts of oral secretions. Alert, follows commands, afebrile. Pt\n able to use call bell when suction needed and make all other needs\n known.\n Action:\n Pt transitioned to CMV/550x14/40%/+8 to rest overnight given sats\n 91-90% when on CPAP regardless of increase in PEEP. Suctioned for\n large amounts of thin clear secretions. Given bolus sedation x2 for\n sleep. In early AM pt placed back on CPAP 40%.\n Response:\n Pt rested well on CMV with sats 94-95%. On AM CPAP settings RR teens\n and sats 95%, ABG 7.40/51/68.\n Plan:\n Continue to wean vent as pt tolerates, SBT, suction PRN, meds per\n order.\n" }, { "category": "Physician ", "chartdate": "2196-01-19 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514423, "text": "TITLE:\n Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - START 01:30 PM\n PICC LINE - START 02:30 PM\n MIDLINE - START 02:30 PM\n BRONCHOSCOPY - At 03:20 PM\n PICC LINE - STOP 04:30 PM\n ARTERIAL LINE - START 01:09 AM\n - Intubated\n - I/O sp (Lasix 20mg IV)-> 1.6 liters negative at 1700\n - Bronch: BAL from Lingula, LLL. Scant frothy secretions throughout.\n Airways otherwise nl.\n - Influenza negative\n - ICU Consent Signed\n - PICC line went up into neck, pulled back to midline, will advance in\n AM.\n - Aline placed.\n - Overnight Pulse of at 90 while pa02 at 118. Unclear why the\n disconnect.\n - Urine output dropped off. MAPs stable in the 70s. Initially bolused\n 250cc x two. Creatinine bumped to 1.3. Thought patient most likely dry\n secondary to Lasix -> 500cc NS.\n - Family updated.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Vancomycin - 11:18 PM\n Metronidazole - 12:00 AM\n Cefipime - 01:07 AM\n Infusions:\n Propofol - 35 mcg/Kg/min\n Other ICU medications:\n Furosemide (Lasix) - 09:28 AM\n Propofol - 04:06 AM\n Fentanyl - 04:07 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100\n Tcurrent: 37.6\nC (99.6\n HR: 83 (71 - 92) bpm\n BP: 101/59(74) {88/48(3) - 103/61(76)} mmHg\n RR: 14 (13 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 1,462 mL\n 849 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,302 mL\n 849 mL\n Blood products:\n Total out:\n 2,635 mL\n 125 mL\n Urine:\n 2,635 mL\n 125 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,173 mL\n 724 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 80%\n RSBI Deferred: PEEP > 10\n PIP: 26 cmH2O\n Plateau: 24 cmH2O\n Compliance: 45.8 cmH2O/mL\n SpO2: 93%\n ABG: 7.38/56/92 /31/5\n Ve: 7.9 L/min\n PaO2 / FiO2: 115\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 212 K/uL\n 12.9 g/dL\n 139 mg/dL\n 1.3 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 96 mEq/L\n 134 mEq/L\n 38.9 %\n 6.7 K/uL\n [image002.jpg]\n 03:35 AM\n 04:00 AM\n 04:34 PM\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n WBC\n 7.6\n 6.7\n Hct\n 40.4\n 38.9\n Plt\n 196\n 212\n Cr\n 1.1\n 1.2\n 1.3\n TropT\n <0.01\n TCO2\n 34\n 35\n 34\n 34\n Glucose\n 116\n 102\n 139\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:134/2/<0.01, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.8 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.4 mg/dL,\n Mg++:2.2 mg/dL, PO4:2.8 mg/dL\n CXR: Final read pending;\n CXR: Final read pending; Unchanged bibasilar opacification,\n bilateral pleural effusions and interstitial prominence.\n 3:42 pm Rapid Respiratory Viral Screen & Culture\n BRONCHIAL LAVAGE FLUID.\n Respiratory Viral Culture (Preliminary):\n Respiratory Viral Antigen Screen (Final ):\n Respiratory viral antigen test is uninterpretable due to the lack of\n cells.\n Refer to respiratory viral culture for further information.\n 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary):\n POTASSIUM HYDROXIDE PREPARATION (Preliminary):\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Preliminary):\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. Etiology likely secondary to LLL\n pneumonia which was clearly seen on CT. Patient with large amount of\n purulent sputum. Less likely viral pneumonia per imaging, but possible\n superimposed on bacterial process. Urine legionella negative, PCP\n (last CD4 count 442), Flu negative. BNP 34, less likely CHF\n although with bilateral pleural effusion. Troponin negative x 1 set,\n unlikely MI. PE very low likelihood given other findings as per above.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = )\n - Follow BAL\n - Consider echo\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerated\n - Obtain blood culture\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir\n .\n # Chronic Diastolic Heart Failure with EF 40%. Patient looks euvolemic.\n Question acute exacerbation in the setting of infection. Will closely\n monitor fluid status and BP.\n - Consider echo\n - Continue ACEI and beta-blocker\n - Gentle IVF prn low UOP\n - I/O goal to -500cc\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Continue ACEI and beta-blocker\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514632, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, ETtube\n suctioned for mod amts thick whitish tan sputum, oral suctioned for mod\n amts thick whitish/clear sputum, Sedated on IV Propofol at\n 50mcgs/kg/min, able to open eyes to voice and follow simple commands\n but then goes back to sleep, Not overbreathing vent, RR= 14, Sats=\n 92-94% via pulse oximetry and a little bit higher by ABG= 94-96%,\n Action\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515076, "text": "52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n Patient has a history of seizure since his CVA. Today he had a seizure\n which lasted for one minute(whole body was convulsive) . Right after\n the seizure he was able to communicate with staff. I have also noted\n jaw twitching and nystagmus. The right eye drifts to the upper right up\n wards.\n Code Status: full code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated without sedation. Vent settings\n 40%X550X14X14. o2 sat 94%. Lung sounds are clear bilateral. Copious\n amounts of oral secretion noted. Last CT of chest showed worse\n multi-focal pneumonia. Temperature ma 99.7 oral.\n Action:\n Peep wean to 13.\n Suction every 2-3 hours.\n Oral suction every 2 hours.\n Response:\n ABG obtained. 7.39/54/89/5/34/96 this was on the 13 of PEEP.\n Plan:\n Serial CXR\n Nebs\n with IV ABX\n Blood cultures is temp increased up to 101.0\n During vent rounds this ICU team will discuss weaning regime\n for tonight.\n Seizure, without status epilepticus\n Assessment:\n This morning seizure activity noted as above. During the day I noted\n jaw twitching. But the patient was able to respond to verbal commands.\n Move all extremities.\n Action:\n Ativan 1MG given.\n Response:\n Jaw twitching noted. But remains responsive.\n Plan:\n Ativan 1mg PRN for seizure activity.\n The ICU team stated to just ask him if he feel that he needs\n ativan.\n ICU team will talk to his primary Neuro MD.\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Yesterday he received lasix. Today his UOP 50ml/hr.\n Action:\n Monitor UOP.\n Response:\n Plan:\n Goal is to keep him even.\n" }, { "category": "Nursing", "chartdate": "2196-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515148, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Seizure, without status epilepticus\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515074, "text": "52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n Patient has a history of seizure since his CVA. Today he had a seizure\n which lasted for one minute(whole body was convulsive) . Right after\n the seizure he was able to communicate with staff. I have also noted\n jaw twitching and nystagmus. The right eye drifts to the upper right up\n wards.\n Code Status: full code.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n I received the patient intubated without sedation. Vent settings\n 40%X550X14X14. o2 sat 94%. Lung sounds are clear bilateral. Copious\n amounts of oral secretion noted. Last CT of chest showed worse\n multi-focal pneumonia. Temperature ma 99.7 oral.\n Action:\n Peep wean to 13.\n Suction every 2-3 hours.\n Oral suction every 2 hours.\n Response:\n ABG obtained. 7.39/54/89/5/34/96 this was on the 13 of PEEP.\n Plan:\n Serial CXR\n Nebs\n with IV ABX\n Blood cultures is temp increased up to 101.0\n During vent rounds this ICU team will discuss weaning regime\n for tonight.\n Seizure, without status epilepticus\n Assessment:\n This morning seizure activity noted as above. During the day I noted\n jaw twitching. But the patient was able to respond to verbal commands.\n Action:\n Response:\n Plan:\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 515522, "text": "52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt received on PS 10/10/40%. RR low teens TV 450-500. Lungs\n rhonchorous at bases. Suctioned for large amounts of clear\n secretions. Sats 94-96%. Pt currently on bolus sedation only.\n Received versed x 2 and fentanyl x 1 prior to advancement of ET tube.\n Afebrile.\n Action:\n PEEP weaned to 5, ET tube advanced, ANBX given as ordered.\n Response:\n Repeat ABP 7.41/50/65. Sats 91-92. Pt denies any change in Work of\n Breathing, PEEP increased to 8. PM CXR completed\n Plan:\n RSBI in AM, Lasix PRN to maintain uvolemia, pulmonary toilet. VAP\n care.\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514790, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: Remains intubated and sedated, FI02 weaned overnight and\n tolerated with good Sats and good ABG, started on tube feedings\n overnight\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs clear bilat upper lobes and diminished at bilat bases, RR= 14,\n not overbreathing vent, Sats via pulse oximetry = 92-94% and a little\n higher by ABG= 94-96%, ETtube suctioned for mod amts thick whitish/tan\n sputum and oral suction for mod. Amts thick white sputum. Initial vent\n settings AC 550-60%-14 with Peep=12 with good Sats and ABG, FI02\n decreased to 50 % with no change in Sats or ABG, continues on antibx,\n lactate=1.1, Tmax= 99.1. ABG on 50 %= 7.34-54-104.. Sedated on IV\n Propofol at 50 mcgs/kg/min, pt able to follow simple commands but falls\n right back to sleep\n Action:\n Aggressive pulmonary toileting, inhalers as ordered, ABG\ns monitored,\n FI02 reduced to 50 %, vanco level sent and 17.9, received\n vanco/cefepime/flagyl, IV Propofol weaned to 40 mcgs/kg/min\n Response:\n Tolerating slow wean of FI02. Stable on current vent settings\n Plan:\n F/U BAL results, F/U chest CT results, continue aggressive pulmonary\n toileting, wean vent as tolerated\n HIV (human immunodeficiency virus, acquired immunodeficiency syndrome,\n AIDS)\n Assessment:\n Afebrile, WBC= 5.9 with lactate= 1.1, continues on antivirals as\n ordered\n Action:\n Cultures and WBC monitored, antivirals as ordered\n Response:\n Stable cell counts\n Plan:\n Obtain ID consult for pna, continue saquinivir and ritonovir and use\n gloves and mask to prepare and administer\n Heart failure (CHF), Diastolic, Chronic\n Assessment:\n HR= 80\ns SR, no ectopy noted,BP via right radial aline with good\n waveform and correlation to NBP, BP= 110-120\ns/70\ns, urine output\n 30-100ml/hr, BUN= 19 and creatinine= 1.0, Hct stable at 36.6, suctioned\n for thick whitish tan and not frothy, bilat LE edema +\n Action:\n Echo completed yesterday, no diuretics overnight, pt kept even, strict\n I+O\n Response:\n Stable cardiac function at present time, no evidence of CHF\n Plan:\n Continue to monitor heart and lungs closely, keep pt even, F/U results\n of echo, continue ASA and statin\n" }, { "category": "Physician ", "chartdate": "2196-01-22 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 515245, "text": "Chief Complaint: Respiratory Failure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Increased secretions this AM\n 24 Hour Events:\n History obtained from Medical records, icu team\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:05 AM\n Metronidazole - 08:20 AM\n Vancomycin - 09:41 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 01:25 PM\n Fentanyl - 04:39 PM\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Other medications:\n per ICU resident note\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fever\n Ear, Nose, Throat: OG / NG tube\n Respiratory: No(t) Dyspnea, mechanical ventilation\n Genitourinary: Foley\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.1\nC (98.8\n HR: 73 (70 - 86) bpm\n BP: 135/70(92) {93/56(72) - 143/83(103)} mmHg\n RR: 15 (14 - 17) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 115 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,570 mL\n 1,478 mL\n PO:\n TF:\n 1,200 mL\n 548 mL\n IVF:\n 840 mL\n 560 mL\n Blood products:\n Total out:\n 1,680 mL\n 1,050 mL\n Urine:\n 1,680 mL\n 1,050 mL\n NG:\n Stool:\n Drains:\n Balance:\n 890 mL\n 428 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 12 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 27 cmH2O\n Plateau: 21 cmH2O\n Compliance: 61.1 cmH2O/mL\n SpO2: 93%\n ABG: 7.40/48/77/31/3\n Ve: 9.1 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right lower extremity edema: Absent, Left lower extremity\n edema: Absent\n Skin: Warm\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Movement: Not assessed, Tone: Not assessed, alert - able to\n communicate with letter board\n / Radiology\n 11.8 g/dL\n 223 K/uL\n 113\n 0.8 mg/dL\n 31 mEq/L\n 3.7 mEq/L\n 19 mg/dL\n 99 mEq/L\n 135 mEq/L\n 35.5 %\n 8.7 K/uL\n [image002.jpg]\n 03:16 AM\n 05:54 AM\n 04:30 PM\n 07:41 PM\n 02:07 AM\n 02:33 PM\n 04:39 PM\n 12:51 AM\n 02:47 AM\n 10:00 AM\n WBC\n 8.0\n 8.7\n Hct\n 37.0\n 35.5\n Plt\n 264\n 223\n Cr\n 1.0\n 0.8\n TCO2\n 34\n 31\n 32\n 31\n 34\n 33\n 31\n Glucose\n 122\n 115\n 113\n Other : PT / PTT / INR:13.6/39.9/1.2, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:74.0 %, Lymph:13.3 %, Mono:6.9 %, Eos:5.5 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.1 mg/dL,\n Mg++:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n SEIZURE, WITHOUT STATUS EPILEPTICUS\n HIV (HUMAN IMMUNODEFICIENCY VIRUS, ACQUIRED IMMUNODEFICIENCY\n SYNDROME, AIDS)\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n DYSPNEA (SHORTNESS OF BREATH)\n OLIGURIA/ANURIA\n 53 yo man with HIV (CD4 of 500) with hypoxemic respiratory failure and\n b/l infiltrates of unclear etiology.\n 1. Respiratory Failure: bilateral infiltrates plus mild-mod pulm HTN\n --Cont vanc/cefepime/flagyl\n --PEEP down to 12 --> change to PSV\n --Increased secretions --> send culture\n 2. HIV\n --HAART --> boosted single drug regimen\n Remainder of issues per ICU team\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:32 PM 50 mL/hour\n Glycemic Control:\n Lines:\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2196-01-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 515331, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 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 / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated, Pt tolerated change to PSV\n today and peep weaned to 10. Plan to wean peep as tolerated for\n possible RSBI and SBT tomorrow. Sxn freq. today for thin clear\n white\n secretions. Combivent MDI as ordered\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514863, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: PEEP Decreased from 15 to 13.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/14/15.BLSLungs clear to diminish at the\n bases, Sats via pulse oximetry = 91-94% and a little higher by ABG=\n 94-96%.. Pt follow commands able to communicarte his needs,on 40 mics\n propofol.\n Action:\n Suctioned for thick white secretions from ETT as well as lots of oral\n secretions . Cont neb treatment as well as Abx for PNA. UOP fine wants\n to keep him even. TF increased upto 40 from 20cc/hr (Goal 50cc/hr).\n Response:\n ABG this afternoon7.36/54/112,sats stable denies any pain or SOB.\n Weaned PEEP from 13 from 15\n Plan:\n Cont Pulm toileting, wean vent as tolerated. Cont Abx. Follow ABG after\n 1 hr around . If pt get worse paln to rebronch tomorrow\n" }, { "category": "Nursing", "chartdate": "2196-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514849, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events: PEEP Decreased from 15 to 13.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC 40%/550/14/15.BLSLungs clear to diminish at the\n bases, Sats via pulse oximetry = 91-94% and a little higher by ABG=\n 94-96%.. Pt follow commands able to communicarte his needs,on 40 mics\n propofol.\n Action:\n Suctioned for thick white secretions from ETT as well as lots of oral\n secretions . Cont neb treatment as well as Abx for PNA. UOP fine wants\n to keep him even. TF increased upto 40 from 20cc/hr (Goal 50cc/hr).\n Response:\n ABG this afternoon7.36/54/112,sats stable denies any pain or SOB.\n Weaned PEEP from 13 from 15\n Plan:\n Cont Pulm toileting, wean vent as tolerated. Cont Abx. Follow ABG\n after 1 hr around .\n" }, { "category": "Respiratory ", "chartdate": "2196-01-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 514916, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 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: 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: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No 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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts; Comments: Pt decompensates 02 when weanin peep.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt awake and alert. MDI\nS given. Needing to increase peep\n for drop in Pa02.\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514603, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n He was transferred to MICU 6 and intubated hypoxia respiratory\n failure on . He was bronched, hand a A line placed and a picc line\n placed. The picc line was in the SVC on CXR. So it was pulled back to a\n midline.\n Code Status: Full Code\n Events:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-20 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 514770, "text": "TITLE:\n Chief Complaint: Pneumonia, Hypoxic Respiratory Failure\n 24 Hour Events:\n - ID consulted and noted that they will see tomorrow after we have\n further culture data from BAL.\n - Repeat chest CT ordered during early afternoon given patient's lack\n of clinical improvement\n - Based on these findings, we will likely consider bronch on .\n Throughout the evening, tried to wean down FiO2 (even while increasing\n PEEP)\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Cefipime - 08:00 PM\n Vancomycin - 09:00 PM\n Metronidazole - 12:23 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 03:00 PM\n Heparin Sodium (Prophylaxis) - 11:22 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.7\nC (99.9\n Tcurrent: 37.2\nC (99\n HR: 77 (77 - 89) bpm\n BP: 123/66(86) {92/60(73) - 130/79(98)} mmHg\n RR: 14 (14 - 16) insp/min\n SpO2: 91%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 112.5 kg (admission): 112 kg\n Height: 60 Inch\n Total In:\n 2,174 mL\n 762 mL\n PO:\n TF:\n 29 mL\n 139 mL\n IVF:\n 2,085 mL\n 393 mL\n Blood products:\n Total out:\n 960 mL\n 545 mL\n Urine:\n 960 mL\n 545 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,214 mL\n 217 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 14\n PEEP: 15 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 25 cmH2O\n Plateau: 22 cmH2O\n Compliance: 78.6 cmH2O/mL\n SpO2: 91%\n ABG: 7.38/51/77/31/3\n Ve: 7.9 L/min\n PaO2 / FiO2: 193\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: Supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: Soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: No foley\n Ext: Warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n 222 K/uL\n 12.3 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 19 mg/dL\n 98 mEq/L\n 133 mEq/L\n 36.6 %\n 5.9 K/uL\n [image002.jpg]\n 05:39 PM\n 09:24 PM\n 12:50 AM\n 12:59 AM\n 12:20 PM\n 06:51 PM\n 08:03 PM\n 02:57 AM\n 03:16 AM\n 05:54 AM\n WBC\n 6.7\n 5.9\n Hct\n 38.9\n 36.6\n Plt\n 212\n 222\n Cr\n 1.3\n 1.1\n 1.0\n TropT\n 0.02\n TCO2\n 35\n 34\n 34\n 33\n 33\n 34\n 31\n Glucose\n 139\n 109\n 106\n Other labs: PT / PTT / INR:13.4/31.2/1.1, CK / CKMB /\n Troponin-T:266/3/0.02, ALT / AST:23/32, Alk Phos / T Bili:52/0.5,\n Differential-Neuts:73.7 %, Lymph:14.2 %, Mono:4.4 %, Eos:7.0 %, Lactic\n Acid:1.1 mmol/L, Albumin:3.1 g/dL, LDH:215 IU/L, Ca++:8.2 mg/dL,\n Mg++:2.4 mg/dL, PO4:3.1 mg/dL\n Vanc Trough: 17.9\n Imaging:\n CT Chest: Worsening opacities consistent with multifocal pneumonia.\n Echo: EF 40-45%, LV focal distal septal/apical hypokinesis is suggested\n though poor image quality. Severe pulmonary artery systolic\n hypertension.\n : 3:42 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL\n LAVAGE FLUID.\n GRAM STAIN (Final ):\n 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.\n NO MICROORGANISMS SEEN.\n RESPIRATORY CULTURE (Preliminary): NO GROWTH, <1000 CFU/ml.\n POTASSIUM HYDROXIDE PREPARATION (Final ):\n TEST CANCELLED, PATIENT CREDITED.\n This is a low yield procedure based on our in-house studies if\n pulmonary Histoplasmosis, Coccidioidomycosis, Blastomycosis,\n Aspergillosis or Mucormycosis is strongly suspected, contact the\n Laboratory (7-2306).\n Immunoflourescent test for Pneumocystis jirovecii (carinii)\n (Preliminary):\n FUNGAL CULTURE (Preliminary):\n ACID FAST SMEAR (Final ):\n NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.\n ACID FAST CULTURE (Preliminary):\n VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):\n Assessment and Plan\n 52 year-old gentleman with history of HTN, HL, CVA in with\n residual L-side weakness, HIV on HAART with most recent CD4 of 442 and\n undetectable VL on who presented with LLL transferred to\n MICU for hypoxia.\n .\n # Hypoxia/Respiratory Failure. CT with worsening multifocal pneumonia.\n However, FiO2 requirement lower today. Clinically improved. Urine\n legionella negative, PCP (last CD4 count 442), Flu negative.\n BNP 34, less likely CHF although with bilateral pleural effusion.\n Troponin negative x 2 set, unlikely MI. PE very low likelihood given\n other findings as per above. Severe pulmonary hypertension most likely\n an underlying contributor.\n - Continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = ). No need to expand Pseudomonal coverage at\n present.\n - Follow BAL cultures\n - Trend CXR\n - Ipratropium nebs q6h, Albuterol nebs q2h\n - Wean vent as tolerate; continue ARDSnet protocol\n - Obtain blood culture\n - Defer on Bronch today.\n - Appreciate ID Recommendations\n .\n # HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable.\n - Continue home-regimen of Ritonavir, Saquinavir; will give liquid\n Ritonavir and break up Saquinavir capsule and give through OG. Will\n monitor given concern for Ritonavir in reducing Fentanyl clearance.\n - Appreciate ID Recommendations\n .\n # Chronic Diastolic Heart Failure with EF 40%. ECHO without definite\n change since . Question acute exacerbation in the setting of\n infection. Will closely monitor fluid status and BP.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Gentle IVF prn low UOP\n - I/O goal to Even\n .\n # Coronary Artery Disease. Patient s/p CABG. Chest pain free.\n - Hold ACEI and beta-blocker given hypotensive episodes\n - Continue statin\n .\n # Hypertension. Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. Continue home regimen.\n - Continue ACEI and beta-blocker\n .\n # HCV. Patient not candidate for therapy and has had negative\n malignancy work up with USGs and AFP.\n .\n # FEN: IVF bolus prn, replete electrolytes, NPO currently and consider\n OG tube for tube feeds\n # Prophylaxis: Subcutaneous heparin, bowel regimen; famotidine\n # Access: Peripherals, arterial line, PICC line advancement in AM\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:05 PM 20 mL/hour\n Lines:\n 20 Gauge - 03:09 AM\n Midline - 02:30 PM\n Arterial Line - 01:09 AM\n Prophylaxis:\n DVT: Subcutaneous Heparin\n Stress ulcer: Famotidine\n VAP: Bed to 30 Degrees, Mouth Care\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Rehab Services", "chartdate": "2196-01-18 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 514210, "text": "Subjective:\n \"I want breakfast\"\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for other:\n Updated medical status: transferred to ICU\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n T\n\n\n Supine/\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n NT\n\n\n\n\n\n\n Ambulation:\n n/a\n\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 74\n 136/66\n 18\n 96 on 80%FM\n Activity\n Supine\n 80\n /\n 18\n 88-92\n Recovery\n Supine\n 74\n /\n 18\n 94 on 80% FM\n Total distance walked:\n Minutes:\n Gait: NT\n Balance: NT\n Education / Communication: Pt. edu re: Role of PT, , benefits of\n CPT, RN comm re: pt. status\n Other: BS: Rhoncherous throughout lung fields\n Percussion and vibration performed to bilat. lower and middle lobes.\n Pt. able to clear whitish, yellow secretion afterwards.\n Assessment: Pt. is 52 y.o. male with h/o CVA, admitted with cough and\n fever likely secondary to PNA, that tolerated CPT well today, and was\n able to clear secretions afterwards. Continue to anticipate d/c home\n once medically ready as pt. reports at his functional baseline.\n Anticipated Discharge: Home without PT\n : percussion and vibration, transfers\n Nsg recs: CPT as tolerated, stand-pivot bed to chair to R.\n Face time: 8:40-8:54\n" }, { "category": "Physician ", "chartdate": "2196-01-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 514212, "text": "Chief Complaint: Chief Complaint: Cough\n Reason for MICU transfer: hypoxia\n HPI:\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n .\n In the ER he developed low SpO2 (not recorded) and was placed on NRB.\n His breathing improved without any specific therapy and they were able\n to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n .\n During his hospital stay he was initially treated with Levofloxacin\n (d1= ) for CAP. Given failure to improve, patient was broadened to\n Vanc, Cefepime, Flagyl (d1=) but continued to require 5L nc and was\n generally satting in the mid-90s.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring.\n .\n On MICU evaluation, patient denies pain or discomfort. He denies\n shortness of breath, and says he does not feel more short of breath\n than earlier today. No CP.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Ritonavir 400 mg \n Saquinavir 200 mg PO BID\n Pravastatin 20 mg PO QHS\n Aspirin 81 mg PO Daily\n Lisinopril 5 mg PO Daily\n Toprol XL 12.5 mg PO Daily\n Triamcinolone acetonide 0.1% ointment 2 weeks on/2 weeks off Daily use\n Mupirocin 2% ointment \n Urea 20% topical cream Daily\n Colace 50 mg TID\n .\n Medications on transfer:\n Vancomycin 1250 mg IV Q 12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n CefePIME 2 g IV Q12H\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H\n traZODONE 25 mg PO/NG HS:PRN insomnia\n Polyethylene Glycol 17 g PO/NG DAILY\n Senna 1 TAB PO/NG Constipation\n Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY\n Heparin 5000 UNIT SC TID\n Docusate Sodium 100 mg PO BID\n Metoprolol Succinate XL 12.5 mg PO DAILY\n Lisinopril 5 mg PO/NG DAILY\n Aspirin 81 mg PO/NG DAILY\n Pravastatin 20 mg PO DAILY\n Saquinavir (Invirase) Cap 400 mg PO BID\n RiTONAvir 400 mg PO BID\n Past medical history:\n Family history:\n Social History:\n #. Coronary artery disease, status post CABG with LIMA to the\n LAD in .\n #. Residual chronic systolic heart failure, with EF of 40%.\n #. Hypertension.\n #. Dyslipidemia.\n #. CVA believed to be hypertensive/hemorrhagic in with residual\n left-sided weakness.\n #. HIV. viral load was less than 48\n copies. His CD4 count is 442 and has been stable around 500\n #. HCV genotype 1B; thought to be poor candidate for treatment given\n CVD and HIV. Liver biopsies, one in and one in with the later\n showing grade 1 inflammation with stage I-II fibrosis. Liver USG \n normal. Alpha fetoprotein was 3.9 back in . Normal EGD in\n .\n #. Stasis dermatitis\n #. Grade II hemorrhoids\n #. Right small hydrocele\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Social History:\n No current or past tobacco use. No history of drug or alcohol abuse.\n The patient is single. He lives alone with the help of PCAs and goes to\n daycare programs during the day. He ambulates with a scooter.\n Review of systems:\n Flowsheet Data as of 03:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (83 - 85) bpm\n BP: 133/79(93) {133/79(93) - 133/79(93)} mmHg\n RR: 19 (17 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n Physical Examination\n Vitals: T:98.6 BP: 133/79 P: 83 R: 18 O2: 93% on High flow FiO2 40%\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: ABG: 7.32/67/58 while on NRB\n Imaging: CT Chest (wet read)\n 1. Multiple opacities at the left lung base, concerning for pneumonia.\n There is a small left pleural effusion.\n 2. No obstructing mass is present in the airways, although left lower\n lobe\n bronchi are obscured by motion artifact.\n 3. Enlarged subcarinal lymph node, likely reactive.\n 4. Stones within a nondistended gallbladder.\n Microbiology: Blood cultures x2\n Blood cultures x2\n Legionella negative\n HIV VL 158\n ECG: EKG: NSR @ 79bpm. Nl axis. J point elevation in anterior leads. No\n ST segment changes.\n Assessment and Plan\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented with LLL\n pna, transferred to MICU for hypoxia.\n .\n 1. Hypoxia: Most likely secondary to LLL pneumonia, clearly seen on\n Chest CT. Patient has large amount of purulent sputum. Urine legionella\n negative. Minimal pleural effusion. Given CD4 count of 442, this is\n less likely PCP, . Chest CT does not appear typical for viral\n pneumonia, however this may be viral with overlying bacterial\n infection. Differential always includes MI, PE, CHF. Chest CT does not\n show large effusion or fluid overload, and in the past 24 hours he is\n net negative 1L.\n -continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = )\n -obtain sputum cultures\n -rule out influenza\n -consider bronch in AM.\n -obtain repeat ABG: if persistently hypercarbic may benefit from\n noninvasive ventilation\n -ipratropium nebs q6h, albuterol nebs q2h\n -trend CEs\n -obtain EKG\n .\n #. HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable. Continue home-regimen of Ritonavir, Saquinavir.\n .\n .\n #. Chronic Diastolic Heart Failure with EF 40% - Pt looks euvolemic. No\n signs of acute exacerbation even in the setting of infection. Will\n closely monitor fluid status and BP.\n - Continue ACEI and beta-\n - I/O goal even to -500cc\n - No IVF\n .\n #. Coronary artery Disease - Pt s/p CABG. Chest pain free.\n - Continue beta-, , statin and ACEI\n .\n #. Hypertension - Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. need to be uptitrated\n as outpatient.\n - continue outpatient Lisinopril 5mg po daily, Metoprolol 12.5mg po bid\n .\n .\n #. HCV - Pt not candidate for therapy and has had negative malignancy\n work up with USGs and AFP.\n .\n .\n # FEN: No IVF now, replete electrolytes, heart healthy diet\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n # Access: peripheral x1. Consider PICC line in AM.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n I saw and examined the patient, and was physically present with the ICU\n resident for the key portions of the services provided. I agree with\n the note above, including the assessment and plan. To that I would add\n the following:\n 52 yo man with HIV (CD4 in 400s) admitted to MICU overnight with\n ongoing hypoxemia requiring high flow O2. He currently has borderline\n O2 sats in the high 80s\n low 90s despite high flow mask at 80%. We\n have discussed with him and proceed with intubation and bronchoscopy.\n Also possible that he is in some CHF\n will check BNP and empirically\n diurese. Interestingly, he has a 7% eosinophilia with his profound\n hypoxemia\n will check BAL for cell count for eosinophils as well.\n Cont empiric abx.\n Pt is critically ill. Time spent 40 minutes.\n ------ Protected Section Addendum Entered By: , MD\n on: 09:23 ------\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514348, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum..\n . In the ER he developed low SpO2 (not recorded) and was placed on\n NRB. His breathing improved without any specific therapy and they were\n able to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring. Acute desat lead to intubation on ICU day 2.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514349, "text": "Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum..\n . In the ER he developed low SpO2 (not recorded) and was placed on\n NRB. His breathing improved without any specific therapy and they were\n able to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring. Acute desat lead to intubation on ICU day 2.\n Shift Events:\n Art line placed\n Increase peep to 12\n Bolus total 750 cc ns for low to no urine output\n Added fentanyl bolus for pain management\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Oliguria/Anuria\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-01-18 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 514148, "text": "Chief Complaint: Chief Complaint: Cough\n Reason for MICU transfer: hypoxia\n HPI:\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented on \n with productive cough and fever.\n He was in his prior state of health until 2 days prior to admission\n when he started noticing productive cough with occasional bright red\n blood in his sputum. He also had been having chills, rigors, but had\n not taken his temperature at home. He had not noted any changes in the\n amount of activity he can do. No history of travel or sick contacts, no\n pets at home and has been taking his medications as prescribed,\n including his HIV regimen. His productive cough is now with dark-red\n sputum.\n .\n In the ER he developed low SpO2 (not recorded) and was placed on NRB.\n His breathing improved without any specific therapy and they were able\n to wean him down to 4L NC, where he is %. He had consolidation\n syndrome in the LLL.\n .\n .\n During his hospital stay he was initially treated with Levofloxacin\n (d1= ) for CAP. Given failure to improve, patient was broadened to\n Vanc, Cefepime, Flagyl (d1=) but continued to require 5L nc and was\n generally satting in the mid-90s.\n .\n On the night of transfer, on routine vitals patient was found to be\n hypoxic to high 80s while sleeping. Despite NRB, oxygen saturation did\n not improve. ABG was done which was 7.32/67/58. Oxygen saturation\n gradually came up to 100% on NRB. He was able to be weaned to 5L with\n O2 sat of 95%. However given nursing concern, poor access (PIV x1 was\n placed), and hypercarbia, patient was transferred to the MICU for\n closer monitoring.\n .\n On MICU evaluation, patient denies pain or discomfort. He denies\n shortness of breath, and says he does not feel more short of breath\n than earlier today. No CP.\n .\n .\n Review of systems:\n (+) Per HPI\n (-) Denies fever, chills, night sweats, recent weight loss or gain.\n Denies headache, sinus tenderness, rhinorrhea or congestion. Denies\n chest pain, chest pressure, palpitations, or weakness. Denies nausea,\n vomiting, diarrhea, constipation, abdominal pain, or changes in bowel\n habits. Denies dysuria, frequency, or urgency. Denies arthralgias or\n myalgias. Denies rashes or skin changes.\n Allergies:\n Ilosone (Oral) (Erythromycin Estolate)\n \"RENAL PROBLEMS\n Dicloxacillin\n Nausea/Vomiting\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home Medications:\n Ritonavir 400 mg \n Saquinavir 200 mg PO BID\n Pravastatin 20 mg PO QHS\n Aspirin 81 mg PO Daily\n Lisinopril 5 mg PO Daily\n Toprol XL 12.5 mg PO Daily\n Triamcinolone acetonide 0.1% ointment 2 weeks on/2 weeks off Daily use\n Mupirocin 2% ointment \n Urea 20% topical cream Daily\n Colace 50 mg TID\n .\n Medications on transfer:\n Vancomycin 1250 mg IV Q 12H\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n CefePIME 2 g IV Q12H\n Bisacodyl 10 mg PO DAILY:PRN constipation\n Ipratropium Bromide Neb 1 NEB IH Q6H\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H\n traZODONE 25 mg PO/NG HS:PRN insomnia\n Polyethylene Glycol 17 g PO/NG DAILY\n Senna 1 TAB PO/NG Constipation\n Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY\n Heparin 5000 UNIT SC TID\n Docusate Sodium 100 mg PO BID\n Metoprolol Succinate XL 12.5 mg PO DAILY\n Lisinopril 5 mg PO/NG DAILY\n Aspirin 81 mg PO/NG DAILY\n Pravastatin 20 mg PO DAILY\n Saquinavir (Invirase) Cap 400 mg PO BID\n RiTONAvir 400 mg PO BID\n Past medical history:\n Family history:\n Social History:\n #. Coronary artery disease, status post CABG with LIMA to the\n LAD in .\n #. Residual chronic systolic heart failure, with EF of 40%.\n #. Hypertension.\n #. Dyslipidemia.\n #. CVA believed to be hypertensive/hemorrhagic in with residual\n left-sided weakness.\n #. HIV. viral load was less than 48\n copies. His CD4 count is 442 and has been stable around 500\n #. HCV genotype 1B; thought to be poor candidate for treatment given\n CVD and HIV. Liver biopsies, one in and one in with the later\n showing grade 1 inflammation with stage I-II fibrosis. Liver USG \n normal. Alpha fetoprotein was 3.9 back in . Normal EGD in\n .\n #. Stasis dermatitis\n #. Grade II hemorrhoids\n #. Right small hydrocele\n NC\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Social History:\n No current or past tobacco use. No history of drug or alcohol abuse.\n The patient is single. He lives alone with the help of PCAs and goes to\n daycare programs during the day. He ambulates with a scooter.\n Review of systems:\n Flowsheet Data as of 03:13 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37\nC (98.6\n Tcurrent: 37\nC (98.6\n HR: 85 (83 - 85) bpm\n BP: 133/79(93) {133/79(93) - 133/79(93)} mmHg\n RR: 19 (17 - 19) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 60 Inch\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 200 mL\n Urine:\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -200 mL\n Respiratory\n O2 Delivery Device: High flow neb\n SpO2: 94%\n Physical Examination\n Vitals: T:98.6 BP: 133/79 P: 83 R: 18 O2: 93% on High flow FiO2 40%\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Bronchial breath sounds over L base. Otherwise clear.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 1+ pulses, no edema\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: ABG: 7.32/67/58 while on NRB\n Imaging: CT Chest (wet read)\n 1. Multiple opacities at the left lung base, concerning for pneumonia.\n There is a small left pleural effusion.\n 2. No obstructing mass is present in the airways, although left lower\n lobe\n bronchi are obscured by motion artifact.\n 3. Enlarged subcarinal lymph node, likely reactive.\n 4. Stones within a nondistended gallbladder.\n Microbiology: Blood cultures x2\n Blood cultures x2\n Legionella negative\n HIV VL 158\n ECG: EKG: NSR @ 79bpm. Nl axis. J point elevation in anterior leads. No\n ST segment changes.\n Assessment and Plan\n Mr. is a 52 year-old gentleman with history of HTN, HL,\n CVA in with residual L-side weakness, HIV on HAART with most\n recent CD4 of 442 and undetectable VL on who presented with LLL\n pna, transferred to MICU for hypoxia.\n .\n 1. Hypoxia: Most likely secondary to LLL pneumonia, clearly seen on\n Chest CT. Patient has large amount of purulent sputum. Urine legionella\n negative. Minimal pleural effusion. Given CD4 count of 442, this is\n less likely PCP, . Chest CT does not appear typical for viral\n pneumonia, however this may be viral with overlying bacterial\n infection. Differential always includes MI, PE, CHF. Chest CT does not\n show large effusion or fluid overload, and in the past 24 hours he is\n net negative 1L.\n -continue Vanc, Cefepime, Flagyl to cover for HAP and aspiration\n pneumonia (day 1 = )\n -obtain sputum cultures\n -rule out influenza\n -consider bronch in AM.\n -obtain repeat ABG: if persistently hypercarbic may benefit from\n noninvasive ventilation\n -ipratropium nebs q6h, albuterol nebs q2h\n -trend CEs\n -obtain EKG\n .\n #. HIV - Pt has been well controlled with CD4 count most recently 442\n and VL undetectable. Continue home-regimen of Ritonavir, Saquinavir.\n .\n .\n #. Chronic Diastolic Heart Failure with EF 40% - Pt looks euvolemic. No\n signs of acute exacerbation even in the setting of infection. Will\n closely monitor fluid status and BP.\n - Continue ACEI and beta-\n - I/O goal even to -500cc\n - No IVF\n .\n #. Coronary artery Disease - Pt s/p CABG. Chest pain free.\n - Continue beta-, , statin and ACEI\n .\n #. Hypertension - Will let be slightly hypertensive for now given\n infection and wanting to avoid hypotension. need to be uptitrated\n as outpatient.\n - continue outpatient Lisinopril 5mg po daily, Metoprolol 12.5mg po bid\n .\n .\n #. HCV - Pt not candidate for therapy and has had negative malignancy\n work up with USGs and AFP.\n .\n .\n # FEN: No IVF now, replete electrolytes, heart healthy diet\n # Prophylaxis: Subcutaneous heparin, bowel regimen\n # Access: peripheral x1. Consider PICC line in AM.\n # Communication: Patient\n # Code: Full (discussed with patient)\n # Disposition: ICU pending clinical improvement\n .\n .\n \n \n PGY-2\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:09 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514292, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated\n Action:\n Pt having episodes of desatting down to 88%, improved with coughing and\n deep breathing, but then sats decreased again\n CPT and nebs given with transient effect\n Pt placed on NRB with improvement of sats to 93-94%\n Lasix 20mg IV given also with slow improvement, pt still desatts with\n talking or activity\n ~1340 pt intub with #8 ETT\n Bronch done and BAL sent\n Desatting after bronch and peep increased to 8\n PICC line placed, and tip noted to be in IJ on CXR, line pulled back to\n midline\n OGT placed after intub and placement confirmed with CXR\n Response:\n Hypoxic and intub\n Plan:\n f/u cx\n pulmonary toilet\n ? to go to IR for change of midline to pICC line\n" }, { "category": "Nursing", "chartdate": "2196-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 514288, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt intubated\n Action:\n Pt having episodes of desatting down to 88%, improved with coughing and\n deep breathing, but then sats decreased again\n CPT and nebs given with transient effect\n Pt placed on NRB with improvement of sats to 93-94%\n Lasix 20mg IV given also with slow improvement, pt still desatts with\n talking or activity\n ~1340 pt intub with #8 ETT\n Bronch done and BAL sent\n Desatting after bronch and peep increased to 8\n PICC line placed, and tip noted to be in IJ on CXR, line pulled back to\n midline\n OGT placed after intub and placement confirmed with CXR\n Response:\n Hypoxic and intub\n Plan:\n f/u cx\n" }, { "category": "Respiratory ", "chartdate": "2196-01-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 514300, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 1\n Ideal body weight: 48.1 None\n Ideal tidal volume: 192.4 / 288.6 / 384.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 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: 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: Normal quiet breathing;\n Comments: Pt intubated secondary to hypoxia. Pt intubated with a #8.0.\n ETCO2 had a positive color change. BS equal. PEEP increased from 5cm to\n 8cm after Bronch secondary to desatting.\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: Maintain PEEP at current level and reduce FiO2 as\n tolerated; Comments: Plan to continue on current settings at this time.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (15:30)\n Comments: BAL of LLL and L lingular obtained and sent to lab.\n" }, { "category": "Echo", "chartdate": "2196-01-19 00:00:00.000", "description": "Report", "row_id": 101502, "text": "PATIENT/TEST INFORMATION:\nIndication: Congestive heart failure. Left ventricular function. Shortness of breath.\nHeight: (in) 68\nWeight (lb): 224\nBSA (m2): 2.15 m2\nBP (mm Hg): 106/65\nHR (bpm): 77\nStatus: Inpatient\nDate/Time: at 11:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Depressed LVEF. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Aortic valve not well seen. No AS. No AR.\n\nMITRAL VALVE: Mitral valve leaflets not well seen. No MS. MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Severe PA systolic\nhypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nPoor image quality. The left atrium is normal in size. Left ventricular wall\nthicknesses are normal. The left ventricular cavity size is normal. Due to\nsuboptimal technical quality, a focal wall motion abnormality cannot be fully\nexcluded. LV systolic function appears depressed (focal distal septal/apical\nhypokinesis is suggested). There is no ventricular septal defect. with normal\nfree wall contractility. The aortic valve is not well seen. There is no aortic\nvalve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are\nnot well seen. No mitral regurgitation is seen. There is severe pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the prior study (images reviewed) of , no definite\nchange.\n\n\n" }, { "category": "ECG", "chartdate": "2196-01-18 00:00:00.000", "description": "Report", "row_id": 303866, "text": "Sinus rhythm. The previously-mentioned findings recorded on persist\nwithout diagnostic interim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-01-12 00:00:00.000", "description": "Report", "row_id": 304096, "text": "Sinus rhythm. Left atrial abnormality. Question Q waves in leads V1-V2 which\nare difficult to interpret with the baseline artifact, but they are suggestive\nof an old anteroseptal myocardial infarction. T wave inversions in leads V4-V6\nsuggestive of anterolateral myocardial ischemia. Compared to the previous\ntracing of the ST segment and T wave abnormalities are new. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2196-01-18 00:00:00.000", "description": "Report", "row_id": 303867, "text": "Sinus rhythm. Left atrial abnormality. QS deflections in leads V1-V3 are\nconsistent with prior anteroseptal myocardial infarction. Compared to the\nprevious tracing of there is variation in precordial lead placement.\nThe ischemic-appearing lateral ST-T wave changes have improved. Otherwise,\nthere is no diagnostic interim change.\nTRACING #1\n\n" } ]

[ { "category": "ECG", "chartdate": "2160-10-22 00:00:00.000", "description": "Report", "row_id": 207050, "text": "Normal sinus rhythm. Non-specific ST-T wave abnormalities. No change from\ntracing #1.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2160-10-22 00:00:00.000", "description": "Report", "row_id": 207051, "text": "Normal sinus rhythm. Frequent premature ventricular contractions. Non-specific\nST-T wave abnormalities. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2160-10-22 00:00:00.000", "description": "Report", "row_id": 1412205, "text": "Nursing Note:\n\nNeuro: pt awake, alert, dozing occasionally, disoriented to place and time, follows commands, moves extremities well, denies pain.\n\nResp: lungs diminished bilaterally, sats 90-96 on 2 L NC, ABG's done, RR 20-30's, denies SOB.\n\nCV: HR 70-95 SR no ectopy, BP 120-140/60-80, pos distal pulses, no edema.\n\nGU: pt voiding via bedpan 450cc out total at present.\n\nGI: pos bowel sounds, regular diet, ate large portion breakfast, small amt of lunch. no BM.\n\nIV: one PIV R arm, flushes well.\n\nSkin: no skin breakdown noted, brusing noted on left arm, pt unsure of cause.\n\nSocial: pts son at bedside since last night, social worker in to see pt and son.\n\nPlan: pt may be C/O tommorow, cont to monitor resp status, vitals, mental status. Update family as needed, plan for pt post discharge, assessment ongoing.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-10-23 00:00:00.000", "description": "Report", "row_id": 1412206, "text": "NPN 7P-7A;\n\nNEURO: PT IS A/OX2. SHE IS COOP W/ CARE. OOB TO COMMIDE WITH ONE ASSINT.\n\nRESP: LS DIMINSHED BILAT. ON 2L NC SAT ARE 94-99%. WHILE SLEEPING HER O2 SAT DROP TO 88%. FACE MASK WS PLACED AT 40%. NOW HER O2 SAT ARE 92-97%. SHE HAS A NONPRODUCTIVE COUGH.\n\nCV: NSR HR 85-90 NO ECTOPY NOTED.\n\nGI/GU: HOUSE DIET. DRINKING FLUIDS. + BS SMALL BM. VOIDING ON COMMODE.\n\nENDO: FS Q6 HOURS.\n\nSKIN: INTACT.\n\nPOC: O2 SUPPORT. CALL OUT.\n" }, { "category": "Nursing/other", "chartdate": "2160-10-22 00:00:00.000", "description": "Report", "row_id": 1412203, "text": "MICU NPN ADMIT NOTE\n68 Y/O FEMALE ADMITTED TO MICU FROM / HOSPITAL DUE TO NO ICU BEDS AT THAT FACILITY. SHE WAS BROUGHT HERE TO GO ON BIPAP. SHE LIVES IN AND IS HERE VISITING HERE SON, OVER THE PAST COUPLE OF DAYS PT. HAS BEEN MORE AND PT'S SON NOTICED THAT 14 OF HER ATIVAN PILLS WERE MISSING. ABG ON ARRIVAL TO WAS 7.25/96/130. THEY PLACED HER BIPAP AND ABG'S CORRECTED. HER SON IS HER HEALTH CARE PROXY AND HAS MADE HIS MOTHERS NEEDS AND WANTS VERY CLEAR, SHE DOES NOT WANT TO BE INTUBATED SHE IS A DNR/DNI, WANTS MINIMAL CARE, REFUSES A FOLEY, WILL TRY BIPAP, DOES NOT WANT ANY CENTRAL LINES.\nPLAN: RECHECK ABG'S, BIPAP AS NEEDED. BE CALLED OUT TO FLOOR IN AM. NEEDS SOCIAL WORK CONSULT.\n" }, { "category": "Nursing/other", "chartdate": "2160-10-22 00:00:00.000", "description": "Report", "row_id": 1412204, "text": "Respiratory Care\nPt. with severe COPD admitted to unit for close monitoring and possible need for NIV. ABGs improved (partially compensated respiratory acidosis with marginal oxygenation) negating need for NIV but pt respiratory status tenuous. BS markedly decreased, very tight wheezy cough. VC at maximum 500cc, unable to muster any measurable Peak Flow. Alb/Atr neb administered, VC increased to 800cc. Pt. C/R yellow plug, sent for culture. Respiratory CAre will continue to monitor and treat aggressively with nebulized bronchodilators. Plan is to manage current COPD exacerbation non invasively as per pt. wishes.\n" }, { "category": "Radiology", "chartdate": "2160-10-24 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 937376, "text": " 6:38 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: r/o CVA\n Admitting Diagnosis: COPD FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with COPD p/w new word finding difficulty.\n REASON FOR THIS EXAMINATION:\n r/o CVA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with COPD with new word finding difficulty.\n\n TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion axial images\n of the brain were obtained. 3D time-of-flight MRA of the circle of \n acquired.\n\n FINDINGS:\n\n BRAIN MRI:\n\n The ventricles and extraaxial spaces are normal in size. There is no evidence\n of midline shift, mass effect, or hydrocephalus seen. There is no evidence of\n significant subcortical white matter ischemic disease or evidence of acute\n infarct seen on diffusion images. A linear flow void is incidentally noted in\n the right corona radiata extending to the margin of the right lateral\n ventricle indicative of a developmental venous normally.\n\n There are no chronic microhemorrhages visualized on susceptibility images.\n\n Small retention cysts are visualized in both maxillary sinuses.\n\n IMPRESSION: No evidence of acute infarct.\n\n MRA OF THE HEAD:\n\n Head MRA demonstrates normal flow signal within the arteries of anterior and\n posterior circulation.\n\n IMPRESSION: Normal MRA of the head.\n\n\n" }, { "category": "Radiology", "chartdate": "2160-10-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 937004, "text": " 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? acute cardiopulmonary process\n Admitting Diagnosis: COPD FLARE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 68 year old woman with hx COPD, presents with SOB, hypercarbia\n REASON FOR THIS EXAMINATION:\n ? acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath and hypercarbia.\n\n Portable AP chest radiograph was reviewed with no previous films available for\n comparison.\n\n The heart size is normal. There is no evidence of mediastinal widening. The\n bilateral hilar enlargement is most likely related to enlarged pulmonary\n arteries. There is paucity of the vasculature in lower lung with upper zone\n redistribution, which is most likely related to the underlying chronic lung\n disease. The relatively large lung volumes and architectural distortion of\n the lungs suggest COPD or emphysema. There is no pleural effusion or focal\n consolidation.\n\n IMPRESSION:\n 1. Findings suggesting COPD.\n 2. Suspected pulmonary hypertension.\n 3. No evidence of focal consolidation or congestive heart failure.\n\n" } ]

[ { "category": "ECG", "chartdate": "2133-11-16 00:00:00.000", "description": "Report", "row_id": 154868, "text": "Sinus tachycardia. Compared to the previous tracing sinus tachycardia is\nslightly slower.\n\n" }, { "category": "ECG", "chartdate": "2133-11-16 00:00:00.000", "description": "Report", "row_id": 154869, "text": "Sinus tachycardia, rate 131. Indeterminate frontal plane axis. Delayed\nprecordial R wave progression, probably a normal variant. Probable left atrial\nabnormality and right atrial abnormality - cannot exclude right ventricular\nhypertrophy. No previous tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-17 00:00:00.000", "description": "Report", "row_id": 1391368, "text": " 4 ICU nursing progress note:\n AODM: Remains on insulin gtt at 7.5u/hr..despite humalog and glargine insuline doses. Pt eating well..following diet. IVF dc'd. BS up to 461 by 1500..HO aware and continued insulin gtt. Given dinner dose of ss humalog..will hopefully dc insuling gtt at 1900. MD in to see pt this am..to follow pt.\n Cardiac: BP 120-140/78-104. HR 80-90sr..Has not required antihypertensives..continueing to evaluate.\n Social: Parents not living together..both in to see pt. Updated on condition.\n Dispo: Will be called out to floor once bs stable off insulin.\n\n" }, { "category": "Nursing/other", "chartdate": "2133-11-18 00:00:00.000", "description": "Report", "row_id": 1391369, "text": "Patient's insulin drip restarted at 0300 patient's FS > 200; glargine 20 units given at 2100. denies dizziness, no nausea and vomiting. Hypertensive episodes 150's; NSR without ectopy; sligth edema of lower extremeties; no polydipsia noted, urine output adequate. Able to sleep after bath @ 0100, denies any pain. brother in and stayed at bedside. Please refer to careview for details.\n\nplan:\n\ntransfer to floor once normalize; possible start on low dose anti-hypertensive meds; reinforce health teaching on risk for pregnancy with hypertension and diabetes.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-18 00:00:00.000", "description": "Report", "row_id": 1391370, "text": "NPN\n\nNeuro: Pt is alert and oriented, OOB to commode and walking around the unit. She is interested in her disease process and is asking apropriate questions.\n\nCV: Her BP cont to be elevated so she was started on labetolol and her BP has been 115/70, HR 70s.\n\nGI: Good appitite, no stool.\n\nGU: OOB to the commode, good u/o ~ 600cc neg for today.\n\nEndo: She conts to have elevated blood sugars 197 this evening with a high of 248 this afternoon. She was given 10 units of NPH this morning to try and cover her constant elevated BS. Her humalog dosing was increased to a more aggresive dose and she will receive 60 of glargine this tonight. I talked with her about her diet, the different carbohydrates - simple vs complex, her need to lose weight. She is interested and engaged, knows that she needs to keep her BS under good control and this will take a good deal of effort on her part.\n" }, { "category": "Nursing/other", "chartdate": "2133-11-17 00:00:00.000", "description": "Report", "row_id": 1391367, "text": "Patient is 24 year old without medical history of DM came to her PCP's office with critical glucose level. The past 2 weeks patient has been having abdominal bloating, nause and vomiting, general malaise, easy fatigability, increased thrist and frequency urinating. denies any sinus infection, dental work or sore/ wounds that may cause elevated blood sugar. In the EW patient was hypotensive, ABG revealed acidosis with pH 7.38 gap 26; she was started on Insulin drip at EW and was given 2L of NS.\n\nNeuro: alert and oriented, very pleasant, conversant. denies any pain, ambulates to commode, gait steady. Had difficulty falling asleep, patient eventually fell asleep at around 0330.\n\nCV: SBP high 130-140's with history of hypertension but was not given any hypertensive meds by PCP instead was advised to loose weight. Plan is to start patient with low dose of anti-hypertensive meds when DKA has resolved. ST 110-120's when she first came to the unit, NSR without ectopy thereafter. pedal pulses palpable. edema noted.\n\nRespi: ling sounds clear, no respiratory distress. Sats> 95% at room air. denies shortness of breath. ABG done results within normal limits.\n\nGI/GU: lips very dry, patient request for fluids often. on NPO except meds but may take clear liquids / ice chips. denies nause, no vomiting noted. voiding to adequate amount of yellow cloudy urine.\n\nF/E: receiving 1/2NS with 20 KCl @ 500cc/hr; received Phosphorous repletion. patient on Chem 10 monitoring eveyr 2 hrs since -0200\n\nEndo: on insulin drip, please see careview for details.\n\nSocial: patient's brothers in for visit, stayed at bedside. mother updated of patient's status.\n\nplan:\n\nmonitor blood glucose level and continue insulin drip as needed, start patient on low dose of anti-hypertensive medications, possible trabsfer to floor once DKA has resolved, consult in AM\n\nplan:\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2133-11-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 931795, "text": " 4:41 PM\n CHEST (PA & LAT) Clip # \n Reason: eval pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 24 year old woman with DKA\n REASON FOR THIS EXAMINATION:\n eval pna\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST\n\n INDICATION: Diabetic ketoacidosis.\n\n PA and lateral views of the chest are obtained . No prior films are\n available for comparison. The cardiomediastinal silhouette is unremarkable.\n The lung fields appear clear with no evidence of acute infiltrate, pleural\n effusion or pneumothorax.\n\n IMPRESSION:\n\n No convincing radiographic evidence of acute cardiopulmonary disease.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2110-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163064, "text": " 5:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute process\n Admitting Diagnosis: TRAUMA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with rib fractures\n REASON FOR THIS EXAMINATION:\n ?acute process\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rib fractures, to assess for acute lung process.\n\n FINDINGS: There appears to be a fracture of the third and possibly fourth\n ribs on the left, though there is no evidence of pneumothorax. No acute\n pneumonia or vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-12-07 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1163014, "text": " 5:16 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: eval fx/malalignment\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with MVC +LOC\n REASON FOR THIS EXAMINATION:\n eval fx/malalignment\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa SUN 6:36 PM\n no acute fracture or malalignment. no critical spinal stenosis.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle collision with loss of consciousness.\n\n TECHNIQUE: Multidetector helical CT scan of the cervical spine was obtained\n without the administration of contrast. Axial, coronal, and sagittal\n reformations were prepared.\n\n FINDINGS: No acute fracture or malalignment is seen. The atlantoaxial and\n atlanto-occipital articulations are preserved. The nasopharyngeal and\n prevertebral soft tissues are grossly symmetric and unremarkable. There are\n mild multilevel degenerative changes; however, no significant spinal stenosis\n is seen. The included portions of the lung apices are clear. The visualized\n portions of the base of the brain are normal. There is mucosal thickening of\n the bilateral maxillary sinuses.\n\n IMPRESSION: No acute fracture or malalignment.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-12-07 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1163015, "text": " 5:16 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Eval acute process after trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with MVC +LOC, tender over sternum\n REASON FOR THIS EXAMINATION:\n Eval acute process after trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa SUN 6:45 PM\n bilateral anterior rib fractures of right 4 and 5 and left 2, 4, 5.\n questionable additional upper rib fractures. all are minimally displaced. no\n sternal fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Motor vehicle collision with loss of consciousness.\n\n TECHNIQUE: Multidetector helical CT scan of the chest, abdomen and pelvis was\n obtained without the administration of contrast. Axial, coronal, and sagittal\n reformations were prepared.\n\n FINDINGS:\n\n CT CHEST: There are multiple rib fractures seen bilaterally. Fractures of\n the right second, fourth, and fifth ribs are present anteriorly. A possible\n right-sided fracture of the third rib is also present. On the left, there is\n fracture of the second, fourth, and fifth ribs with equivocal fracture of the\n left third.\n\n No pulmonary contusion or pleural effusion is seen. There is minimal\n bilateral dependent atelectasis. The airways are patent to the segmental\n level. There are coronary artery and aortic calcifications. The heart size\n is normal. No pericardial effusion is seen. No pneumothorax is identified.\n No lymphadenopathy is seen.\n\n CT ABDOMEN/PELVIS: The liver, gallbladder, spleen, kidneys, adrenal glands\n and pancreas appear grossly normal. Incidental note is made of a splenule\n (2:69). There are vascular calcifications. Loops of small and large bowel\n are of normal size and caliber. No abdominal free air, free fluid, or\n lymphadenopathy is seen.\n\n Within the pelvis, the bladder contains a small diverticulum (2:117). Distal\n loops of large bowel demonstrate scattered diverticula. The prostate gland is\n normal in size. No pelvic free air, free fluid, or lymphadenopathy is seen.\n\n BONE WINDOWS: Multiple bilateral rib fractures as noted above.\n\n IMPRESSION: Multiple bilateral upper anterior rib fractures as detailed\n above. Otherwise, no traumatic injury noted.\n (Over)\n\n 5:16 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: Eval acute process after trauma\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2110-12-07 00:00:00.000", "description": "TRAUMA #3 (PORT CHEST ONLY)", "row_id": 1163016, "text": " 5:19 PM\n TRAUMA #3 (PORT CHEST ONLY) Clip # \n Reason: eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with sternal pain after trauma\n REASON FOR THIS EXAMINATION:\n eval acute process\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 17:26 HOURS.\n\n HISTORY: Sternal pain after trauma.\n\n COMPARISON: Chest CT acquired earlier same day.\n\n FINDINGS: The patient was imaged on a trauma backboard. The lungs are clear\n without consolidation or edema. The mediastinum is grossly unremarkable with\n a well-defined descending thoracic aorta. The cardiac silhouette is within\n normal limits for size. No effusion or pneumothorax is noted on the supine\n radiograph. The visualized osseous structures reveal no displaced fractures.\n Please note nearly nondisplaced anterior bilateral rib fractures are evident\n and reported in detail on the accompanying chest CT report.\n\n IMPRESSION: No radiographic evidence of traumatic injury to the chest.\n Bilateral anterior rib fractures documented on CT scan acquired just prior to\n chest x-ray. Please refer to the separately dictated report.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-12-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1163013, "text": " 5:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval acute process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with MVC +LOC\n REASON FOR THIS EXAMINATION:\n Eval acute process\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: OXZa SUN 6:35 PM\n no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post motor vehicle collision with loss of consciousness.\n\n TECHNIQUE: Multidetector CT scan of the head was obtained without the\n administration of contrast. Axial, coronal, and sagittal reformations were\n prepared.\n\n FINDINGS: There is no evidence of acute hemorrhage, edema, mass effect, or\n recent infarction. Prominence of the ventricles and sulci likely reflects\n generalized atrophy, age related. Areas of periventricular and subcortical\n white matter hypodensity likely reflect a mild degree of chronic small vessel\n ischemic disease. No fracture or concerning osseous lesion is seen. The\n visualized paranasal sinuses are clear.\n\n IMPRESSION: No evidence of acute intracranial process.\n\n\n" }, { "category": "ECG", "chartdate": "2110-12-07 00:00:00.000", "description": "Report", "row_id": 251904, "text": "Sinus rhythm. Prolonged P-R interval. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2161-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463749, "text": "s/p thrombectomy with fasciotomy of RLE\n Thromboembolism, other\n Assessment:\n Alert, oriented x3. Denies leg pain. C/O lower back pain.\n Vpaced 70-90\ns. SBP 100-140\ns, shoots up to 180 systolically at\n times, comes right back down.\n + faint pedal pulses. Rt foot mottled, Lt foot dusky.\n Hct 27 from 32\n Lungs clear, diminished bases. Sats 96% on 3L nc.\n Abdomen soft, +bs, +flatus.\n Foley draining small amt, leaking the rest at insertion site. Clots\n noted as well.\n Right leg dressing remained intact all day with minimal drainage.\n Action:\n Tylenol 650mg given po.\n Carveidalol as ordered.\n 1 unit prbc given.\n Heparin off for 4 hrs for increased leg drainage on nights.\n Heparin back on at 10am at 1000 units/hr- Increased to 1100\n units/hr at 7pm for PTT of 35.9\n Using incentive spirometer to about 50cc. Weak cough.\n Tolerated diabetic diet today. Blood sugars covered with RISS.\n Foley changed but continues to leak at site- 18 french ordered.\n Ditropan started.\n Response:\n Back pain relieved with Tylenol.\n Plan:\n Pain control.\n Cont to monitor hemodynamics, pulses.\n Follow labs, treat prn.\n Change foley to 18 french. Monitor.\n Incentive Spirometer!\n" }, { "category": "Nursing", "chartdate": "2161-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463811, "text": "Thromboembolism, other\n Assessment:\n + compartment syndrome of right leg, OR for right leg fasciotomy\n x2, Pulses weak but palpable, foot slightly mottled/dusky but warm to\n the touch. +CSM~Patient has sensation but admits that his foot is numb.\n On heparin gtt\n Action:\n Vascular changed dressing\ns x2 in evening, heparin gtt at 1200\n Response:\n DSD , PTT non therapeutic\n Plan:\n Next PTT to be drawn @ 0830 , dressing changes to be done by\n Vascular team\n Hypotension {Not Shock}\n Assessment:\n SBP low 80\ns by cuff and A line, V paced, HCT 26.3\n Action:\n 1 unit PRBC and 250cc bolus NS given, a line and cuff pressures\n correlated, repeat HCT at 0400\n Response:\n Right cuff higher than left and generally correlates with Aline,\n HUO>20 and SBP>100\n Plan:\n Continue to monitor VS and Right arm cuff pressure with A line\n" }, { "category": "Physician ", "chartdate": "2161-06-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 463900, "text": "CVICU\n HPI:\n POD 2 s/p RLE fasciotomy\n Anticoagulant:asa, Hep gtt\n Beta-blocker/Statin:coreg/atorva\n Baseline Creatinine:0.9\n PMH: CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2,\n OSA/CPAP, h/o of syncope, htn, BPH, PVD, hiatal hernia, Menire's\n disease, psoriasis, cervical and lumbar spinal stenosis, GERD, right\n eye blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n : Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5\", Flomax 0.4',\n Actos 15', Advair 250/50', Lasix 20', Gemfibrozil 600\", Omeprazole 20\",\n Glyburide 10\", Nasonex 1\", Albuterol, Metformin 500\"', Ranitidine 150'\n Pulses: Fem DP PT\n Rt 2+ 4+ mono 1+\n Lt 2+ 4+ 2+ 2+\n Assessment:\n 72M with b/l popliteal aneurysms, RLE ischemia and RLE compartment\n syndrome.\n Plan:\n [ ] POC (CVICU)\n [ ] CXR for CVL\n [ ] Hep gtt\n [ ] bicarb gtt overnight\n [ ] serial CK's\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Albuterol 0.083% Neb Soln 5. Aspirin 6. Atorvastatin\n 7. Bisacodyl\n 8. Carvedilol 9. Docusate Sodium (Liquid) 10. Fluticasone-Salmeterol\n Diskus (250/50) 11. Furosemide\n 12. Gemfibrozil 13. GlyBURIDE 14. Heparin 15. HydrALAzine 16. Insulin\n 17. Lidocaine Jelly 2% (Urojet)\n 18. Lidocaine Jelly 2% (Urojet) 19. Magnesium Sulfate 20. Morphine\n Sulfate 21. Omeprazole 22. Oxybutynin\n 23. Pioglitazone 24. Potassium Chloride 25. Ranitidine 26. Senna 27.\n Sodium Chloride 0.9% Flush\n 28. Tamsulosin 29. Valsartan\n 24 Hour Events:\n Post operative day:\n POD 2 s/p RLE fasciotomy\n Allergies:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,200 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 03:51 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.9\nC (98.4\n HR: 68 (68 - 99) bpm\n BP: 145/80(95) {66/40(46) - 147/87(112)} mmHg\n RR: 19 (15 - 27) insp/min\n SPO2: 89%\n Heart rhythm: V Paced\n CVP: 6 (0 - 32) mmHg\n Total In:\n 4,825 mL\n 1,734 mL\n PO:\n Tube feeding:\n IV Fluid:\n 4,475 mL\n 1,009 mL\n Blood products:\n 350 mL\n 725 mL\n Total out:\n 2,346 mL\n 830 mL\n Urine:\n 1,596 mL\n 830 mL\n NG:\n Stool:\n Drains:\n 400 mL\n Balance:\n 2,479 mL\n 904 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 89%\n ABG: ///28/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular), Vpaced\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 237 K/uL\n 10.8 g/dL\n 90 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 100 mEq/L\n 137 mEq/L\n 30.8 %\n 12.4 K/uL\n [image002.jpg]\n 11:56 PM\n 01:11 AM\n 07:15 AM\n 02:22 PM\n 12:55 AM\n 04:55 AM\n 02:35 PM\n WBC\n 12.4\n 12.3\n 13.7\n 13.1\n 12.4\n Hct\n 37\n 32.8\n 27.2\n 28.8\n 26.3\n 27.2\n 30.8\n Plt\n 291\n 271\n 265\n 245\n 237\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n Glucose\n 92\n 116\n 197\n 157\n 90\n Other labs: PT / PTT / INR:17.1/47.7/1.5, CK / CK-MB / Troponin\n T:7560//, Lactic Acid:1.4 mmol/L, Ca:9.7 mg/dL, Mg:2.7 mg/dL, PO4:2.4\n mg/dL\n Assessment and Plan\n THROMBOCYTOPENIA, ACUTE, THROMBOEMBOLISM, OTHER\n Assessment and Plan: POD 2 s/p RLE fasciotomy\n Neurologic: Neuro checks Q: 4 hr, MSO4/Oxybutynin prn pain. OOB today\n for a short period per Vasc team\n Cardiovascular: Aspirin, Cont /B-Blocker/Statin/ASA. Hydralazine prn\n Pulmonary: IS, Encourage DB&c. OOB today. Cont. Advair\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Cont prophylaxis\n Renal: Foley, 3-way cath->CBI for traumatic insertion x2\n yesterday->irrigate clot/hematuria. Lasix after PRBC this AM.\n BUN/Cr=13/0.8\n Hematology: HCT= 26.2->Tx 2uPRBC this AM. Recheck post infusion\n response. Heparin GTT@ 1200 u/h. PTT goal 50-60 per Vasc->go slow. PTT\n 47->No change for now per Vasc.\n Endocrine: Humolog SS/PO oralhypoglycemics\n Infectious Disease:\n Lines / Tubes / Drains: Foley\n Wounds: Wet / Dry dressings, Fasciotomy sites\n Imaging:\n Fluids:\n Consults: Vascular surgery, CT surgery\n ICU Care\n Nutrition:\n Glycemic Control: Comments: Humolog SS\n Lines:\n Arterial Line - 01:00 AM\n Multi Lumen - 01:00 AM\n 18 Gauge - 01:00 AM\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2161-06-08 00:00:00.000", "description": "Intensivist Note", "row_id": 464131, "text": "CVICU\n HPI:\n 72M with b/l popliteal aneurysms, RLE ischemia and RLE compartment\n syndrome.\n Chief complaint:\n PMHx:\n CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2, OSA/CPAP,\n h/o of syncope, htn, BPH, PVD, hiatal hernia, Menire's disease,\n psoriasis, cervical and lumbar spinal stenosis, GERD, right eye\n blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n : Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5\", Flomax 0.4',\n Actos 15', Advair 250/50', Lasix 20', Gemfibrozil 600\", Omeprazole 20\",\n Glyburide 10\", Nasonex 1\", Albuterol, Metformin 500\"', Ranitidine 150'\n Current medications:\n 24 Hour Events:\n - On heparin gtt, goal PTT 50-60 per Vascular\n - Transfused 2 u pRBCs for Hct 26, bumped to 30, back to 27.8 this AM\n - Had hematuria in the setting of foley placement, on CBI\n Post operative day:\n POD#2 - RLE fasciotomy\n Allergies:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:15 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 (98.9\n HR: 71 (68 - 88) bpm\n BP: 0/0(69) {0/0(46) - 147/87(101)} mmHg\n RR: 21 (15 - 26) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n CVP: -4 (-4 - 14) mmHg\n Total In:\n 2,722 mL\n 151 mL\n PO:\n 600 mL\n Tube feeding:\n IV Fluid:\n 1,397 mL\n 151 mL\n Blood products:\n 725 mL\n Total out:\n 2,650 mL\n 555 mL\n Urine:\n 2,650 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 72 mL\n -404 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ///26/\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\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 243 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 27.8 %\n 13.4 K/uL\n [image002.jpg]\n 11:56 PM\n 01:11 AM\n 07:15 AM\n 02:22 PM\n 12:55 AM\n 04:55 AM\n 02:35 PM\n 02:42 AM\n WBC\n 12.4\n 12.3\n 13.7\n 13.1\n 12.4\n 13.4\n Hct\n 37\n 32.8\n 27.2\n 28.8\n 26.3\n 27.2\n 30.8\n 27.8\n Plt\n 291\n 271\n 265\n 245\n 237\n 243\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n 0.7\n TCO2\n 26\n Glucose\n 92\n 116\n 197\n 157\n 90\n 82\n Other labs: PT / PTT / INR:17.7/53.5/1.6, CK / CK-MB / Troponin\n T:5571/7/, Lactic Acid:1.4 mmol/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.7\n mg/dL\n Imaging:\n CXR: There is a right IJ line with tip in the SVC. The left\n pacemaker/AICD is unchanged. Old lateral rib fractures are unchanged.\n There is no focal infiltrate or effusion. There is some mild volume\n loss in the left lower lung.\n Microbiology: MRSA screen: P\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Hematuria, THROMBOCYTOPENIA, ACUTE, THROMBOEMBOLISM, OTHER\n Assessment and Plan: 72M with b/l popliteal aneurysms, RLE ischemia and\n RLE compartment syndrome.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled with Tylenol.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n Continue heparin gtt with goal PTT 50-60. Some oozing from RLE,\n received 2 u pRBCs yesterday, transfuse for Hct < 30. Blood pressure\n running high, will up-titrate antihypertensive agents.\n Pulmonary: IS, OOB to chair, encourage deep breathing.\n Gastrointestinal / Abdomen: + flatus. Ordered for cardiac diet.\n Nutrition: Cardiac diet\n Renal: Foley with 3 way irrigation for hematuria. Rhabdo with CK 5571\n this AM, down from 7560, continue to trend. On bicarb gtt overnight for\n renal protection, creatinine normal this AM.\n Hematology: Serial Hct, Transfuse Hct <30\n Endocrine: BS well-controlled, continue RISS, also on Glyburide.\n Infectious Disease: Afebrile, no cultures pending.\n Lines / Tubes / Drains: 3-way foley, CVL,\n Wounds: RLE\n Imaging: None\n Fluids:\n Consults:\n Billing Diagnosis: Ischemia\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 AM\n Multi Lumen - 01:00 AM\n 18 Gauge - 01:00 AM\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 29 minutes\n" }, { "category": "Physician ", "chartdate": "2161-06-08 00:00:00.000", "description": "Intensivist Note", "row_id": 464137, "text": "CVICU\n HPI:\n 72M with b/l popliteal aneurysms, RLE ischemia and RLE compartment\n syndrome.\n Chief complaint:\n PMHx:\n CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2, OSA/CPAP,\n h/o of syncope, htn, BPH, PVD, hiatal hernia, Menire's disease,\n psoriasis, cervical and lumbar spinal stenosis, GERD, right eye\n blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n : Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5\", Flomax 0.4',\n Actos 15', Advair 250/50', Lasix 20', Gemfibrozil 600\", Omeprazole 20\",\n Glyburide 10\", Nasonex 1\", Albuterol, Metformin 500\"', Ranitidine 150'\n Current medications:\n 24 Hour Events:\n - On heparin gtt, goal PTT 50-60 per Vascular\n - Transfused 2 u pRBCs for Hct 26, bumped to 30, back to 27.8 this AM\n - Had hematuria in the setting of foley placement, on CBI\n Post operative day:\n POD#2 - RLE fasciotomy\n Allergies:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 07:15 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 (98.9\n HR: 71 (68 - 88) bpm\n BP: 0/0(69) {0/0(46) - 147/87(101)} mmHg\n RR: 21 (15 - 26) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n CVP: -4 (-4 - 14) mmHg\n Total In:\n 2,722 mL\n 151 mL\n PO:\n 600 mL\n Tube feeding:\n IV Fluid:\n 1,397 mL\n 151 mL\n Blood products:\n 725 mL\n Total out:\n 2,650 mL\n 555 mL\n Urine:\n 2,650 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 72 mL\n -404 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ///26/\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\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 243 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 27.8 %\n 13.4 K/uL\n [image002.jpg]\n 11:56 PM\n 01:11 AM\n 07:15 AM\n 02:22 PM\n 12:55 AM\n 04:55 AM\n 02:35 PM\n 02:42 AM\n WBC\n 12.4\n 12.3\n 13.7\n 13.1\n 12.4\n 13.4\n Hct\n 37\n 32.8\n 27.2\n 28.8\n 26.3\n 27.2\n 30.8\n 27.8\n Plt\n 291\n 271\n 265\n 245\n 237\n 243\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n 0.7\n TCO2\n 26\n Glucose\n 92\n 116\n 197\n 157\n 90\n 82\n Other labs: PT / PTT / INR:17.7/53.5/1.6, CK / CK-MB / Troponin\n T:5571/7/, Lactic Acid:1.4 mmol/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.7\n mg/dL\n Imaging:\n CXR: There is a right IJ line with tip in the SVC. The left\n pacemaker/AICD is unchanged. Old lateral rib fractures are unchanged.\n There is no focal infiltrate or effusion. There is some mild volume\n loss in the left lower lung.\n Microbiology: MRSA screen: P\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS\n Hematuria, THROMBOCYTOPENIA, ACUTE, THROMBOEMBOLISM, OTHER\n Assessment and Plan: 72M with b/l popliteal aneurysms, RLE ischemia and\n RLE compartment syndrome.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled with Tylenol.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n Continue heparin gtt with goal PTT 50-60. Some oozing from RLE,\n received 2 u pRBCs yesterday. Blood pressure running high, increased\n Losartan, goal SBP <140. Holding Gemfibrozil while renal impairment in\n setting of rhabdo.\n Pulmonary: IS, OOB to chair, encourage deep breathing.\n Gastrointestinal / Abdomen: + flatus. Ordered for cardiac diet.\n Nutrition: Cardiac diet\n Renal: Foley with 3 way irrigation for hematuria, primary team calling\n Urology c/s. Rhabdo with CK 5571 this AM, down from 7560 (down from a\n peak of 13,000), continue to trend. On bicarb gtt overnight for renal\n protection, d/c\nd this AM, creatinine normal this AM.\n Hematology: Repeat Hct, with next PTT.\n Endocrine: BS well-controlled, continue RISS, also on Glyburide.\n Holding Metformin & Gemfibrozil for renal issues while in rhabdo.\n Infectious Disease: Afebrile, no cultures pending.\n Lines / Tubes / Drains: 3-way foley, CVL, arterial line\n Wounds: RLE\n Imaging: None\n Fluids:\n Consults: Vascular surgery\n Billing Diagnosis: Post-operative complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 AM\n Multi Lumen - 01:00 AM\n 18 Gauge - 01:00 AM\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Physician ", "chartdate": "2161-06-08 00:00:00.000", "description": "Intensivist Note", "row_id": 464142, "text": "CVICU\n HPI:\n 72M with b/l popliteal aneurysms, RLE ischemia and RLE compartment\n syndrome.\n PMHx:\n CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2, OSA/CPAP,\n h/o of syncope, htn, BPH, PVD, hiatal hernia, Menire's disease,\n psoriasis, cervical and lumbar spinal stenosis, GERD, right eye\n blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n : Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5\", Flomax 0.4',\n Actos 15', Advair 250/50', Lasix 20', Gemfibrozil 600\", Omeprazole 20\",\n Glyburide 10\", Nasonex 1\", Albuterol, Metformin 500\"', Ranitidine 150'\n Current medications:\n 24 Hour Events:\n - On heparin gtt, goal PTT 50-60 per Vascular\n - Transfused 2 u pRBCs for Hct 26, bumped to 30, back to 27.8 this AM\n - Had hematuria in the setting of foley placement, on CBI\n Post operative day:\n POD#2 - RLE fasciotomy\n Allergies:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Infusions:\n Heparin Sodium - 1,300 units/hour\n Flowsheet Data as of 07:15 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 (98.9\n HR: 71 (68 - 88) bpm\n BP: 0/0(69) {0/0(46) - 147/87(101)} mmHg\n RR: 21 (15 - 26) insp/min\n SPO2: 100%\n Heart rhythm: V Paced\n CVP: -4 (-4 - 14) mmHg\n Total In:\n 2,722 mL\n 151 mL\n PO:\n 600 mL\n Tube feeding:\n IV Fluid:\n 1,397 mL\n 151 mL\n Blood products:\n 725 mL\n Total out:\n 2,650 mL\n 555 mL\n Urine:\n 2,650 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 72 mL\n -404 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 100%\n ABG: ///26/\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\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Neurologic: (Awake / Alert / Oriented: x 3), Moves all extremities\n Labs / Radiology\n 243 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.7 mg/dL\n 26 mEq/L\n 3.6 mEq/L\n 13 mg/dL\n 102 mEq/L\n 135 mEq/L\n 27.8 %\n 13.4 K/uL\n [image002.jpg]\n 11:56 PM\n 01:11 AM\n 07:15 AM\n 02:22 PM\n 12:55 AM\n 04:55 AM\n 02:35 PM\n 02:42 AM\n WBC\n 12.4\n 12.3\n 13.7\n 13.1\n 12.4\n 13.4\n Hct\n 37\n 32.8\n 27.2\n 28.8\n 26.3\n 27.2\n 30.8\n 27.8\n Plt\n 291\n 271\n 265\n 245\n 237\n 243\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n 0.7\n TCO2\n 26\n Glucose\n 92\n 116\n 197\n 157\n 90\n 82\n Other labs: PT / PTT / INR:17.7/53.5/1.6, CK / CK-MB / Troponin\n T:5571/7/, Lactic Acid:1.4 mmol/L, Ca:8.1 mg/dL, Mg:2.1 mg/dL, PO4:2.7\n mg/dL\n Imaging:\n CXR: There is a right IJ line with tip in the SVC. The left\n pacemaker/AICD is unchanged. Old lateral rib fractures are unchanged.\n There is no focal infiltrate or effusion. There is some mild volume\n loss in the left lower lung.\n Microbiology: MRSA screen: P\n Assessment and Plan\n Hematuria, THROMBOCYTOPENIA, ACUTE, THROMBOEMBOLISM\n Assessment and Plan: 72M with b/l popliteal aneurysms, RLE ischemia and\n RLE compartment syndrome.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled with Tylenol.\n Cardiovascular: Aspirin, Full anticoagulation, Beta-blocker, Statins,\n Continue heparin gtt with goal PTT 50-60. Some oozing from RLE,\n received 2 u pRBCs yesterday. Blood pressure running high, increased\n Losartan, goal SBP <140. Holding Gemfibrozil while renal impairment in\n setting of rhabdo.\n Pulmonary: IS, OOB to chair, encourage deep breathing.\n Gastrointestinal / Abdomen: + flatus. Ordered for cardiac diet.\n Nutrition: Cardiac diet\n Renal: Foley with 3 way irrigation for hematuria, primary team calling\n Urology c/s. Rhabdo with CK 5571 this AM, down from 7560 (down from a\n peak of 13,000), continue to trend. On bicarb gtt overnight for renal\n protection, d/c\nd this AM, creatinine normal this AM.\n Hematology: Repeat Hct, with next PTT.\n Endocrine: BS well-controlled, continue RISS, also on Glyburide.\n Holding Metformin & Gemfibrozil for renal issues while in rhabdo.\n Infectious Disease: Afebrile, no cultures pending.\n Lines / Tubes / Drains: 3-way foley, CVL, arterial line\n Wounds: RLE\n Imaging: None\n Fluids:\n Consults: Vascular surgery\n Billing Diagnosis: Post-operative complication\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 AM\n Multi Lumen - 01:00 AM\n 18 Gauge - 01:00 AM\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2161-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463909, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Thromboembolism, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2161-06-08 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 464173, "text": "Thromboembolism\n Assessment:\n A/Ox3. C/o chronic back pain.\n BP labile at times. V paced with own PPM. Peripheral pulses\n dopplerable. RIJ triple lumen in place. Left radial arterial line in\n place. Right foot mottled but warm to touch with dopplerable DP+ PT\n pulses. Right leg fasciotomy. VAC dsg placed this am by Vascular\n team. Heparin Gtt infusing @ 1300Units/hr.\n Lung sounds clear. 02Sat >94% on RA.\n Abd obese (+) BS.\n Foley with hematuria. Intermittant CBI.\n Elevated FSBS.\n Action:\n Tylenol for pain.\n Fluid bolus administered for brief period of hypotension, adjusting BP\n medication dose.\n RISS coverage. PO hyperglycemic agents administered.\n Response:\n Good effect w/ PO Tylenol.\n VSS.\n Plan:\n Mobilize, monitor, support, and comfort.\n PTT @ 1200.\n Transfer to VICU.\n Demographics\n Attending MD:\n FRANK B.\n Admit diagnosis:\n LEG PAIN\n Code status:\n Full code\n Height:\n Admission weight:\n 102.7 kg\n Daily weight:\n Allergies/Reactions:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Precautions:\n PMH: Diabetes - Oral \n CV-PMH: Arrhythmias, CAD, Pacemaker, PVD\n Additional history: PMH: EF 25%, OSA apnea on CPAP, syncope,\n hypertension, BPH, Hiatal hernia, Menieres disease, psoriasis, cervical\n and lumber spine stenosis GERD, right eye blindness\n PSH: CABG x 3 \"92\n Pacemaker and AICD \n cervical and lumber laminectomies\n Surgery / Procedure and date: + compartment syndrome of right leg, \n OR for right leg fasciotomy. Post op to CVICU hypertensive no drips,\n already extubated, VAC dressing over right leg incision. Viable muscle\n in all compartments.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:93\n D:77\n Temperature:\n 98.8\n Arterial BP:\n S:113\n D:50\n Respiratory rate:\n 21 insp/min\n Heart Rate:\n 80 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n None\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 747 mL\n 24h total out:\n 1,015 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:42 AM\n Potassium:\n 3.6 mEq/L\n 02:42 AM\n Chloride:\n 102 mEq/L\n 02:42 AM\n CO2:\n 26 mEq/L\n 02:42 AM\n BUN:\n 13 mg/dL\n 02:42 AM\n Creatinine:\n 0.7 mg/dL\n 02:42 AM\n Glucose:\n 82 mg/dL\n 02:42 AM\n Hematocrit:\n 27.8 %\n 02:42 AM\n Finger Stick Glucose:\n 135\n 08:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: CVICU A\n Transferred to: VICU\n Date & time of Transfer: 11:00 AM\n" }, { "category": "Physician ", "chartdate": "2161-06-06 00:00:00.000", "description": "ICU Note - CVI", "row_id": 463700, "text": "CVICU\n HPI:\n 71M w/ bilateral popliteal aneuryms with RLE ischemia. POD 1 RLE\n fasciotomy.\n Chief complaint:\n PMHx:\n PMH: CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2,\n OSA/CPAP, h/o of syncope, htn, BPH, PVD, hiatal hernia, Menire's\n disease, psoriasis, cervical and lumbar spinal stenosis, GERD, right\n eye blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n Current medications:\n 150 mEq Sodium Bicarbonate/ 1000 mL D5W , Acetaminophen , Albuterol\n 0.083% Neb Soln , Aspirin,\n Atorvastatin , Bisacodyl , Carvedilol , Docusate Sodium (Liquid) ,\n Fluticasone-Salmeterol Diskus (250/50),\n Gemfibrozil , GlyBURIDE , Heparin , Insulin , Morphine Sulfate ,\n Omeprazole , Pioglitazone, Ranitidine , Senna , Sodium Chloride 0.9%\n Flush ,Tamsulosin , Valsartan\n 24 Hour Events:\n OR RECEIVED - At 12:55 AM\n MULTI LUMEN - START 01:00 AM\n ARTERIAL LINE - START 01:00 AM\n Post operative day:\n POD#0 - RLE fasciotomy\n Allergies:\n Procardia (Oral) (Nifedipine)\n stopped breathi\n Benadryl (Oral) (Diphenhydramine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 11:21 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: 37.5\nC (99.5\n HR: 93 (81 - 93) bpm\n BP: 187/84(112) {87/44(55) - 187/97(126)} mmHg\n RR: 21 (17 - 27) insp/min\n SPO2: 99%\n Heart rhythm: V Paced\n CVP: 11 (1 - 11) mmHg\n Total In:\n 3,485 mL\n PO:\n Tube feeding:\n IV Fluid:\n 3,485 mL\n Blood products:\n Total out:\n 0 mL\n 1,465 mL\n Urine:\n 715 mL\n NG:\n Stool:\n Drains:\n 400 mL\n Balance:\n 0 mL\n 2,020 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 99%\n ABG: 7.39/42/265/29/0\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: 2+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n No(t) Moves all extremities, (RUE: Weakness)\n Labs / Radiology\n 271 K/uL\n 9.6 g/dL\n 197 mg/dL\n 0.7 mg/dL\n 29 mEq/L\n 3.3 mEq/L\n 12 mg/dL\n 100 mEq/L\n 139 mEq/L\n 27.2 %\n 12.3 K/uL\n [image002.jpg]\n 11:56 PM\n 01:11 AM\n 07:15 AM\n WBC\n 12.4\n 12.3\n Hct\n 37\n 32.8\n 27.2\n Plt\n 291\n 271\n Creatinine\n 0.8\n 0.7\n TCO2\n 26\n Glucose\n 92\n 116\n 197\n Other labs: PT / PTT / INR:16.9/38.9/1.5, CK / CK-MB / Troponin\n T://, Lactic Acid:1.4 mmol/L, Ca:8.1 mg/dL, Mg:1.5 mg/dL, PO4:2.8\n mg/dL\n Imaging: CXR: sm L effusion\n Microbiology: neg\n Assessment and Plan\n THROMBOCYTOPENIA, ACUTE, THROMBOEMBOLISM, OTHER\n Assessment and Plan: Pt. stable post op. There was some bleeding in\n leg and heparin was held this AM. This has resolved and heparin will\n be restarted. Cont. bicarb gtt until CK comes down. Tx 1 UPRBC.\n Cont. present ICU care.\n Neurologic:\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen:\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO\n Hematology:\n Endocrine: RISS\n Infectious Disease: neg\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: Bicarb gtt at 150cc/hr\n Consults:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 01:00 AM\n Multi Lumen - 01:00 AM\n 18 Gauge - 01:00 AM\n 20 Gauge - 01:00 AM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Heparin drip)\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2161-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463767, "text": "Thromboembolism, other\n Assessment:\n + compartment syndrome of right leg, OR for right leg fasciotomy\n x2, Pulses weak but palpable, foot slightly mottled/dusky but warm to\n the touch. Patient has sensation but admits that his foot is numb. On\n heparin gtt\n Action:\n Vascular changed dressing\ns x2 in evening, heparin gtt at 1200\n Response:\n DSD , PTT non therapeutic\n Plan:\n Next PTT to be drawn @ 0830 \n Hypotension {Not Shock}\n Assessment:\n SBP low 80\ns by cuff and A line, V paced, HCT 26.3\n Action:\n 1 unit PRBC given, a line and cuff pressures correlated, repeat HCT at\n 0400\n Response:\n Right cuff higher than left and generally correlates with Aline,\n Plan:\n" }, { "category": "Nursing", "chartdate": "2161-06-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463683, "text": "Thromboembolism, S/P thromectomy with fasciotomy of RLE.\n Assessment:\n Admitted from O.R. s/p thrombectomy of RLE with VAC dsg on lateral\n aspect and open W-> D medial wound continually bleeding.Feet\n warm,mottled, (+) CSM dopplerable pulses. Awake,lethargic, following\n commands. LR with HC03 and Heparin gtts infusing. 10L median face mask.\n VSS. Afebrile, Hypotensive.\n Action:\n VAC dsg drg then became occluded on/off.. leg repositioned, VAC dsg\n taken down and replaced by MD. 3 liters LR for\n hypotension.Heparin gtt rate decreased from 1600->1300.\n Response:\n VAC dsg and Medial wound continues to bleed. VAC dsg removed by MD and\n W-> D dsg placed over both wounds.BP stabilizing. Heparin gtt shut off\n x 4hrs.\n Plan:\n Re-start heparin gtt @1000u/hr @ 11:00am. Monitor BLE pulses,labs, vs.\n" }, { "category": "Nursing", "chartdate": "2161-06-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 464022, "text": "Thromboembolism, other NEURO PT REMAINS A/O RELAXED IN GOOD SPIRITS\n MAE OOB TO CHAIR TOL WELL SLEEPS SHORT PERIODS C/O MILD H A\n TYLENOL GOOD EFFECT NOTED UNDERSTANDS AND HELPS WITH CARE GIVEN\n HEART SPLIT S2 100% PACED\n AND SENCED RATE 71 VSS PULSES POS 2 THRU OUT EDEMA REMAINS NOTE\n RIGHT LOWER LEG A;/W TOL WELL ONLY SMALL AMOUT OF DRAINAGE NOTED GOOD\n DISTAL PULSES AND CAP REFIL\n RESP CLEAR THRU OUT NO\n SOB AMBULATES WELL TO CHAIR ROOM AIR SAO2 100 TOL CPT WELL I/S GOOD\n LEVELS\n GI FOLEY MUCH URINE\n AROUND CATH FOLEY CHANGED TO 20 F 3 WAY TOL WELL GOOD RESULTS CBI\n ON/OFF TO CLEAR LESS CLOTTS\n HEPARIN DRIP AT 1300\n ORDER MD AWARE OF ALL EVENTS THIS SHIFT PER PROTOCOL\n PLAN SUPPORTIVE\n MONITOR PTT LEVEL PER ORDER T/P CPT EMOTIONAL SUPPORT\n AMBULATION WITH NWB OF RIGHT LEG\n Assessment:\n Action:\n Response:\n Plan:\n Thrombocytopenia, acute\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2161-06-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 463915, "text": "72M with b/l popliteal aneurysms, RLE ischemia and RLE compartment\n syndrome.\n PMH: CAD, CHF, EF 25%, complete heart block, pacer dependent, DM2,\n OSA/CPAP, h/o of syncope, HTN, BPH, PVD, hiatal hernia, Menire's\n disease, psoriasis, cervical and lumbar spinal stenosis, GERD, right\n eye blindness, CABGx3 ' (LGSV), Pacemaker and ICD ', laminectomy\n cervical/lumbar spine\n Problem\n Hematuria\n Assessment:\n Minimal to no UO upon initial assessment. Irrigated w/o return of\n irrigation solution\n Action:\n Foley repositioned w/immediate return of pink tinged urine of 500 ml.\n Followed by hourly bladder irrigation.\n Foley dc\nd and 3 way Foley placed and CBI initiated.\n Response:\n On going Hematuria and difficulties w/bladder irrigation solution\n returning\n CBI infusing w/o difficulties, Foley draining pink tinged irrigation\n fluid w/sediment.\n Plan:\n Continue CBI and monitor\n Thromboembolism,\n Assessment:\n A+O x\ns 3. MAE x\ns 4. c/o back pain \n BP labile w/significant difference b/t NBP and ABP. V paced. Peripheral\n pulses palpable. RIJ triple lumen. Left radial ABP line. Right foot\n mottled but warm to touch w/palpable DP+PT pulses. Right leg drsg\n . Heparin gtt 1200 units HR w/subtheraputic PTT.\n Breath sounds clear. O2 2 L/min per NC. Sats 100%\n Abd obese w/active BS.\n Foley as noted in above problem.\n 101 and 206\n Hct 27.2\n Action:\n Tylenol for pain mngt\n Reedy of difference b/t BP modalities. Blood given\n coincidently at time of hypotensive period.\n Heparin gtt ^ to 1250 after second PTT was subtheraputic. RLE drsg\n team\n Pulmonary toilet, mobilized. O2 weaned off.\n Taking diet w/o difficulties swallowing.\n RSSI SQ\n Response:\n Good effect w/Tylenol\n VSS.\n Sats 95% or >. No resp distress noted, = rise and fall of chest.\n Hct 30.8\n Plan:\n Pulmonary toilet, mobilize, monitor, tx, support, and comfort.\n PTT @ 2230\n VICU tomorrow.\n" }, { "category": "ECG", "chartdate": "2161-06-06 00:00:00.000", "description": "Report", "row_id": 260487, "text": "Regular ventricular pacing\nPacemaker rhythm - no further analysis\nSince previous tracing of , faster ventricular rate noted\n\n" } ]

[ { "category": "Radiology", "chartdate": "2146-12-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807500, "text": " 4:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: check v lead placement\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with new V lead via scl stick\n\n REASON FOR THIS EXAMINATION:\n check v lead placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69 y/o woman with new pacer lead placed via subclavian stick. Check\n for lead placement.\n\n PORTABLE SEMI-UPRIGHT CHEST AT 4:00 PM:\n\n Comparison is made to prior study two days ago. No significant change in the\n position of the ventricular lead. Cardiomegaly, left retrocardiac opacity\n obscuring the left hemidiaphragm and vascular redistribution to the apices\n are once again noed.\n\n IMPRESSION: No change.\n\n" }, { "category": "Radiology", "chartdate": "2146-12-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 807746, "text": " 8:50 AM\n CHEST (PA & LAT) Clip # \n Reason: assess lead position\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman s/p revision of LV lead - dual chamber PPM via right cephalic\n - V lead now mid-RV\n REASON FOR THIS EXAMINATION:\n assess lead position\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST:\n\n CLINICAL INDICATION: Repositioning of pacemaker leads.\n\n A permanent pacemaker is present, with a right atrial and right ventricular\n lead. The right ventricular lead has been repositioned in the interval. Its\n position is difficult to evaluate due to extreme lordotic projection on the AP\n view and due to under-penetration on the lateral view, obscuring the tip of\n the lead. No pneumothorax is identified. The cardiac and mediastinal\n contours are distorted by the lordotic projection. There are bilateral\n moderate-sized pleural effusions, seen best on the lateral view.\n\n IMPRESSION: Interval repositioning of right ventricular lead, difficult to\n accurately assess due to extreme lordotic projection on the AP view and under\n penetration on the lateral view. Repeat chest radiograph is recommended for\n more complete assessment of this lead in order to confirm appropriate\n placement. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2146-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807338, "text": " 7:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with new V lead via scl stick\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New ventricular lead.\n\n COMPARISONS: \n\n SINGLE VIEW CHEST, AP: The femoral approach swan ganz catheter has been\n removed in the interval. The presumed pericardial drain is in unchanged\n position. The right sided dual lead pacer is seen and there has been interval\n readjustment of the right ventricular wire. Where the lead once extended to\n the apical portion of the heart, it now terminates upon the more superior\n portion. No pneumothorax. There are persistent bilateral pleural effusions.\n There is also persistent left retrocardiac collapse/consolidation. The heart\n contour may have continued to slightly decrease in size in the interval.\n\n IMPRESSION: Repositioning of right ventricular lead onto the more superior\n portion of the heart. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2146-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807120, "text": " 7:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Congestion\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with Type 2 DM, CAD, renal failure and large pericardial\n effusion\n REASON FOR THIS EXAMINATION:\n Congestion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath. Large pericardial effusion.\n\n COMPARISON: .\n\n SINGLE VIEW OF THE CHEST, AP: There has been interval placement of a femoral\n approach Swan-Ganz catheter. The tip is seen within the main pulmonary\n artery. There also appears to be placement of a catheter which overlies the\n cardiac silhouette. The tip is overlying the left edge of the cardiac\n silhouette and then wraps around the heart. It is most likely in the\n pericardium. There has been slight decrease in size of the cardiac silhouette.\n It is no longer as globular in appearance when compared to the previous exam.\n There has also been increased pulmonary vasculature when compared to the\n previous exam, which is consistent with a decreased pericardial effusion.\n There are persistent bilateral pleural effusions. There is persistent left\n retrocardiac collapse/consolidation. No pneumothorax.\n\n IMPRESSION: Interval placement of pericardial drain with decrease in size and\n globular configuration of heart size. Interval increase in pulmonary\n vasculature consistent with decreased pericardial effusion.\n\n" }, { "category": "Echo", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 75124, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate pericardial effusion s/p drainage.\nHeight: (in) 62\nWeight (lb): 233\nBSA (m2): 2.04 m2\nBP (mm Hg): 113/70\nStatus: Inpatient\nDate/Time: at 11:24\nTest: Portable TTE (Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: Overall left ventricular systolic function is normal\n(LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function appears depressed. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload.\n\nTRICUSPID VALVE: Moderate [2+] tricuspid regurgitation is seen. There is mild\npulmonary artery systolic hypertension.\n\nPERICARDIUM: There is a small pericardial effusion.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). The right\nventricular cavity is dilated. Right ventricular systolic function appears\ndepressed. There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload. Moderate [2+] tricuspid regurgitation is\nseen. There is mild pulmonary artery systolic hypertension. There is a small\npericardial effusion associated with partial echo dense material consistent\nwith pericardial thickening/organization.\n\nCompared with the findings of the prior study (tape reviewed) of , the\npericardial effusion is probably slightly larger (prior study suboptimal for\ncomparison.\n\n\n" }, { "category": "Echo", "chartdate": "2146-12-24 00:00:00.000", "description": "Report", "row_id": 75098, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nBP (mm Hg): 124/51\nHR (bpm): 53\nStatus: Inpatient\nDate/Time: at 16:30\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nPERICARDIUM: There is a small pericardial effusion. The effusion appears\nloculated. There are no echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Emergency\nstudy performed by the cardiology fellow on call.\n\nConclusions:\nThere is a trivial/physiologic pericardial effusion. The effusion appears\nloculated around the right atrial free wall. There are no echocardiographic\nsigns of tamponade.\n\nCompared to previous study, probably no major change.\n\n\n" }, { "category": "Echo", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 75099, "text": "PATIENT/TEST INFORMATION:\nIndication: F/U Pericardial effusion.\nHeight: (in) 62\nWeight (lb): 233\nBSA (m2): 2.04 m2\nStatus: Inpatient\nDate/Time: at 12:11\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%).\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated. Right ventricular\nsystolic function appears depressed. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is borderline pulmonary artery systolic\nhypertension.\n\nPERICARDIUM: There is a small pericardial effusion. The effusion is echo\ndense, consistent with blood, inflammation or other cellular elements. There\nare no echocardiographic signs of tamponade.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). The right ventricular\ncavity is dilated. Right ventricular systolic function appears depressed.\nThere is abnormal septal motion/position consistent with right ventricular\npressure/volume overload. The aortic valve leaflets (3) are mildly thickened\nbut not stenotic. The mitral valve leaflets are structurally normal. There is\nborderline pulmonary artery systolic hypertension. There is a small\npericardial effusion. The effusion is echo dense, consistent with blood,\ninflammation or other cellular elements. There are no echocardiographic signs\nof tamponade.\n\nCompared with the findings of the prior study (tape reviewed) of , no major change is evident.\n\n\n" }, { "category": "Echo", "chartdate": "2146-12-20 00:00:00.000", "description": "Report", "row_id": 75167, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. ?Tamponade\nHeight: (in) 62\nWeight (lb): 220\nBSA (m2): 1.99 m2\nBP (mm Hg): 80/45\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 21:04\nTest: TTE (Focused views)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nNOTE: There is a long pause in imaging on the videotape between the pre and\npost-tap images.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the\nright atrium and/or right ventricle.\n\nLEFT VENTRICLE: Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded.\n\nRIGHT VENTRICLE: The right ventricular cavity is dilated.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nPERICARDIUM: There is a large pericardial effusion. There is right ventricular\ndiastolic collapse, consistent with impaired fillling/tamponade physiology.\n\nGENERAL COMMENTS: Suboptimal image quality due to poor echo windows. Emergency\nstudy 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 grossly\npreserved in suboptimal viewsl (LVEF>55%). The right ventricular cavity is\ndilated. The aortic valve leaflets are mildly thickened. The mitral valve\nleaflets are mildly thickened. There is a large pericardial effusion. There is\nright ventricular diastolic collapse, consistent with impaired\nfillling/tamponade physiology.\n\nFollowing pericardiocenteisis there is a very small residual partially\nechodense region around the heart consistent with probable pericaridal\nthickening or organization with minimal residual pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2146-12-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 807089, "text": " 5:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: effusion\n Admitting Diagnosis: PERICARDIAL EFFUSION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old woman with Type 2 DM, CAD, renal failure and large pericardial\n effusion\n REASON FOR THIS EXAMINATION:\n effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, ONE VIEW\n\n HISTORY: Paracardial effusion. CAD.\n\n COMPARISON: None.\n\n The heart is massively enlarged with a rounded configuration suggestive of a\n paracardial effusion. Clinical correlation is advised. There is a dual lead\n pacer. The distal aspect of the leads are not well visualized. The\n visualized lungs are clear.\n\n IMPRESSION: Massively enlarged heart with a rounded configuration suggestive\n of paracardial effusion. Minimal blunting of the right costophrenic angle,\n likely representing a small right pleural effusion.\n\n" }, { "category": "ECG", "chartdate": "2146-12-28 00:00:00.000", "description": "Report", "row_id": 195321, "text": "Electronic ventricular pacemaker with underlying atrial fibrillation. Compared\nto the previous tracing of no major change.\n\n" }, { "category": "ECG", "chartdate": "2146-12-27 00:00:00.000", "description": "Report", "row_id": 195322, "text": "Electronic ventricular pacemaker with underlying atrial fibrillation. Compared\nto the previous tracing of ventricular pacing rate is now increased.\n\n" }, { "category": "ECG", "chartdate": "2146-12-26 00:00:00.000", "description": "Report", "row_id": 195323, "text": "Atrial fibrillation with slow ventricular response and ? intermittent pacer\nspikes vs ? artifact\nRight bundle branch block\nMarked right axis deviation\nLow QRS voltage\nST-T wave abnormalities are diffuse and in part primary\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-25 00:00:00.000", "description": "Report", "row_id": 195324, "text": "Atrial fibrillation with slow ventricular response and ? intermittent pacer\nspikes vs ? artifact\nRight bundle branch block\nLow QRS voltages\nMarked right axis deviation\nST-T wave abnormalities are diffuse and in part primary\nClinical correlation is suggested\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-24 00:00:00.000", "description": "Report", "row_id": 195325, "text": "Atrial fibrillation with slow ventricular response and ? intermittent pacer\nspikes vs ? artifact\nMarked right axis deviation\nRight bundle branch block\nLow QRS voltages\nST-T wave abnormalities are diffuse and in part primary\nClinical correlation is suggested\nSince previous tracing of , ventricular pacing absent and changes as\ndiscribed seen\n\n" }, { "category": "ECG", "chartdate": "2146-12-24 00:00:00.000", "description": "Report", "row_id": 195571, "text": "Atrial fibrillation\nVentricular pacing\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-23 00:00:00.000", "description": "Report", "row_id": 195572, "text": "Ventricular paced rhythm withh 100% capture\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 195573, "text": "Ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 195574, "text": "Ventricular paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 195575, "text": "Ventricular paced rhythm. Underlying atrial mechanism may be atrial\nfibrillation. Since the previous tracing of no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2146-12-20 00:00:00.000", "description": "Report", "row_id": 195576, "text": "Ventricular paced rhythm. Underlying atrial mechanism may be atrial\nfibrillation. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2146-12-20 00:00:00.000", "description": "Report", "row_id": 1428843, "text": "PT ADMITTED IN DISTRESS C HYPOTENSION ,CO L SHOULDER PAIN, NAUSEA ,DRY HEAVES.BP 80S, FLUID BOLLUSES, DOPAMINE 5 MICS . PACED R C UNDERLYING AFIB. INR 4.6, VIT K, FFP TO BE GIVEN PRE TAP IN CATH LAB .\n\nSAT 99 ON 100% FM,BS DECREASED IN BASES .\n\nZOFRAN FOR DRY HEAVES ,DECREASED BS\n\nSCANT URINE CLOUDY.\n\nALERT ,ORIENTED ,C DAUGHTER\n\nREVERSE INR ,TO CATH LAB EMERGENTLY\n" }, { "category": "Nursing/other", "chartdate": "2146-12-24 00:00:00.000", "description": "Report", "row_id": 1428851, "text": "CCU Progress Note:\n\nThis is a 69 yr old female admitted to OSH after 1 week of flu-like symptoms- SOB, dehydrated, had epigastric pain- Hct 24- INR 4.5 on coumadin- hypotensive- RX with fluids, dobutamine- echo showed effusion ? tamponade- 2u transferred to - pericardiocentesis performed with removal of 1050cc of pericardial transferred to CCU with pericardial drain in place- stable in transferred to 3 on - pericardial drain D/C'd without incident- this afternoon @ 1:30pm, Pt noted to have failure to pace- HR 40's- STAT echo & CXR done- pacing wire found to be in correct transferred to CCU- Tele: junctional vs slow Afib- HR 38-52- no paced beats noted- SBP 130's-In O2 2L NC- lung sounds diminished @ the bases- SPO2 93-97%- saline lock R patent- labs sent @ 1830.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-25 00:00:00.000", "description": "Report", "row_id": 1428852, "text": "7p-7a\ns: ohh i have such pains in my abd\"\no/a: pt a/o, following commands, moving all extremeties on the bed.\nresp: pt on 2l nc, sats 92-95%, no c/o sob but does better with hob up. lung sounds clear, resps \ncv: pt in afib 30-40, bp stable 114-131/30-40, no c/o cp\ngi: pt able to eat toast and a drink this eve per ho then npo until ep\nsees pt this am.\ngu: pt c/o 0200 of gas discomfort, pt given simethicone then she called back and got 1 perc for abd discomfort after having lg bm and 1 small soft guiac trace pos and then still uncomfortable and req maalox\nskin: chest dsgs intact, watch heels and repos pt freq.\nid: temp max 99.6 gpt a dose of vancomycin and iv nurse started #20 in r arm\nplan:awaiting ep studies to adjust wire, has been npo after midnight cont full support\n" }, { "category": "Nursing/other", "chartdate": "2146-12-25 00:00:00.000", "description": "Report", "row_id": 1428853, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: hr 38-52 afib,no ectopy BP 144-158/34-40 not capturing\n\nResp: lings clear,sats 94-97 on 2l NP incentive spirometry\n\nGI: c/o abd cramping most of shift,lessening discomfort over course of day. received simethicone twice. vomitted once this afternoon,given zofran with relief. also given warm pack. only taking clear liqs,NPO after midnight\n\nGU: uo 25-150cc/hr. negative for the day\n\nID: afebrile\n\nEndocrine: FS 304 and 234 covered with insulin\n\nneuro: alert and oriented x3\n\nSkin: small area of redness on left antecub,irritated by BP cuff. covered with duoderm\n\nA/P: EP lab tomorrow,NPO after midnight. unable to obtain access in left arm,both IV's in right\n\n\n" }, { "category": "Nursing/other", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 1428848, "text": "CCU NSG NOTE: ALT IN CV/PERICARIDIAL EFFUSSION\nS: \"This has not been a good few months\"\nO: For complete VS see CCU flow sheet.\nID: PT t-max 99.3po at 8a, down down to 98.5 in afternoon.\nCV: PT pain free at rest, does have local discomfort at drain site with movement. HR 60 AV paced, not ectopy seen. BP stable ranging 50s/22-27. Pads decreasing to 18-20s with diuresis. RA 18-22. Groin site dry with no ooze or hematoma, and all pulses palpable. There was ~50cc bloody drainage in pericardial bag. No further drainage accumulated in afternoon. Drain flushed with saline ~Q3. She went down to EP to have pacing leads examined to find if that is the source of effusion.\nRESP: Decreased breath sounds, sating 97-99% on 2L NP. No difficulty breathing.\nGI: Pt NPO for proceedure. She had minimal abdominal discomfort in am that was gone by late morning. No BM.\nRENAL: Pt diuresed very well to lasix 20mg po. She is 2600cc neg for the day and 4000cc neg LOS.\nENDO: Blood sugars 88-110. No insulin given.\nMS: Pt slept much of the day. Very pleasant and cooperative. Her daughter called early in the day. Aware of planned EP evaluation.\nA: PT to EP at 1600\nP: Await report from lab. Monitor for change.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-23 00:00:00.000", "description": "Report", "row_id": 1428849, "text": "CCU Nursing Progress Note 7p-7a\nS: \" Everyone has been so wonderful here\"\n\nO: Please see careview for complete VS/additional objective data\n\nMS: AAOx3. Limited movement. Pleasant and cooperative w/ care. Initially complaining of pain at pericardial drain site. Managed w/ Percocet 2 tablets following departure of visitors per pt request. Also given Ambien 5mg to facilitate sleep. Pt did well overnoc. At 0500 pt c/o left shoulder pain which improved w/ position change/ massage and heat pak application. Pt returned to sleep w/o difficulty.\n\nCV: VSS. Vpaced w/ underlying rhythm of Afib. HR 60-75. No ectopy noted. ABP 99-142/45-61. Pt denies any CP. Pericardial drain remains in place. Additional 25cc bloody drainage noted since yesterday afternoon in drainage bag. Cont to flush drain q 4hrs w/o difficulty. H/H and electrolytes remain stable. PA introducer/ venous sheath remains in right groin. Swan catheter itself had been dc'd in EPS. Requested removal of groin line last pm but it is to remain in until this am per HO. Extremeties warm. CSM nml.\n\nResp: LS remain diminished in bases otherwise clear upon auscultation. RR 10-20. O2 sat 96-98% while on 2L supplemental O2 via NC. 90-91% on RA. Pt denies SOB/ difficulty breathing. Cont encouragement of incentive spirometry use. Observed vt 5-600.\n\nGI/GU: Tolerated po meds, icechips and chicken bouillon w/o difficulty. No N/V. Obese abdomen. + BS. No stool. Adequate UO. -3500cc/24hrs and remains -4900cc/ LOS. BUN/CR cont to improve 67/2.2.\n\nID: Low grade. Tmax 99.8. Received IV dose of Vanco in EPS. D/t receive dose q 48 x 2 doses. Endo: FS qid. BS 94-109. No coverage per RISS.\n\nSocial: Son in law and grandson into visit. Son in law took pts meds home w/him.\n\nA/P: EPS lab yesterday afternoon. VSS following replacemnt of V lead that had previously perforated RV . Minimal drainage noted from pericardial drain. Cont flushing q4hrs. DC PA introducer and sheath today. Advance activity and diet as tolerated. Managed pain effectively w/ Percocet. Slept well w/ Ambien dose. Cont to support pt and family as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-23 00:00:00.000", "description": "Report", "row_id": 1428850, "text": "CCU NSG NOTE: ALT IN CV/PERICARDIAL EFFUSION\nS: \"Will this shocking hurt?\"\nO: For complete VS see CCU flow sheet.\nID: Pt has low grade temp. She will receive 2nd dose of vancomycin at ~1800 .\nCV: Pt remains in paced rhythm-primarily v-paced in afib, occasionally a-spikes seen as well. HR 60s, no ectopy. interegated and everything is working well. Pericardial drain was pulled at ~12pm with minimal drainage over the past 24hrs. Tip sent for culture. Venous sheath out of R groin at 8am and a-line also out. Groin dry with no ooze or hematoma. Pulses all palpable, feet warm, CSM nl. Pt remains in a-fib, however due to problem with pacing wire that was removed pt is at risk for further bleeding into pericardium if anticoagulation is resumed. As she has been effectively anticoagulated it was decided to cardiovert her this afternoon prior to transfer. SHe has been consented and her daughter has been spoken to and agrees.\nRESP: Pt sating 95-97% on 2L NP. She has large abdomen and has greater difficulty breathing when she is not upright.\nGI: Pt ate breakfast at 10am, but is now NPO for cardioversion this afternoon. No BM. Pt has no further abdominal cramping.\nRENAL: Pt continues on daily lasix. Diuresing well thru foley. She is ~5 liters neg LOS.\nACTIVITY: Pt can be OOB this afternoon. PT consult called.\nENDO: Pt not yet started on oral . She received 4u reg insulin for BS of 210 at noon.\nMS: Pt delightful, oriented X 3. Her brother has come in to visit. FAmily aware of plans for cardioversion.\nA: Lines out/cardiovert this afternoon\nP: Keep NPO until cardioversion. Monitor for symptoms of increasing effusion. Keep careful I & O. Assist pt OOB if tolerated this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 1428844, "text": "9p-7a\ns: \"can i have a drink, my throat is burning\"\no/a: neuro: pt a/o, able to move all extremeties purposefully, follows commands.\nresp: lungs clear but decreased, last abg on 3l 7.33/37/90 improving.\nno c/o sob sats 95-98%\ncv: v paced rate 60, pacer was placed in for bradycardia and afib pt on coumadin. aline bp 115-145/51-58, pa 39-57/18-30, co 8-7.4\nci 3.65-3.38, svr 510-541, cvp 21-27, pre drain pa 65/40 wedge 43, post drain pa 60/30 wedge 35, pericardial drain being flushed with 2-4cc ns no heparin d/t high inr for pt upon admission. for drain and other specifics pls see flowsheet. pt c/o some tenderness at drain site pt has mso4 ordered but not needed pain pt slept well this shift.able to palpate pulses\ngi pt obese abd pos bs nontender, taking sips well\ngu foley placed yellow urine 65-150/hr\nfull code, skin intact,\nid: temp max 97.8 watch pt for sx of sepsis\nplan: cont full support, labs improved no intervention needed\n" }, { "category": "Nursing/other", "chartdate": "2146-12-21 00:00:00.000", "description": "Report", "row_id": 1428845, "text": "CCU NPN: please see flowsheet for objective data\n\nCardiac: pericardial drain in place,no drainage noted,unable to aspirate fluid,flushing with 2cc NS q4. HR 60 AV paced BP 108-125/48-50 PAD's 23-30 CVP's 23-28 CO/CI: 6.8/3.11 SVR 529\n\nGU/Volume: uo 60-125/hr neg 1200cc, given 20mg lasix IV at 5pm to start daily po dose tomorrow\n\nResp: lungs clear diminished at bases,using incentive spirometry, on RA ABG 79/33/7.46\n\nGI: started eating today,fair appetite. to be NPO after midnight\n\nEndocrine: FS in 80's, no insulin given.\n\nNeuro: alert and orientedx3\n\nA/P: s/p pericardial drain placement. EP lab tomorrow to check on wire placement on , be cause on pericardial effusion.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 1428846, "text": "CCU Nursing Progress Note 7p-7a\nADDENDUM: Report from cath lab\nPt on the pacemaker had perferated her RV. THe wire was removed and replaced with new V-lead that is working well. It is still a DDD and she is v-paced in a-fib. There has been no further drainage from the pericardial drain. The swan was pulled as it was interfering with proceedure. She co of discomfort at drain site and received fentanyl 225mic and 2mg versed. She received 450cc IV fluid.\nHe received dose of vanco. She tolerated proceedure well.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-22 00:00:00.000", "description": "Report", "row_id": 1428847, "text": "CCU Nursing Progress Note 7p-7a\nS: \" My breathing is much better than it was yesterday\"\n\nO: Please see careview for complete VS/ additional objective data\n\nMS: AAOx3. Extremely pleasant and cooperative w/ care. No c/o pain. Slept well overnoc.\n\nCV: AV paced @ 60 bpm. ABP 92-128/44-56. Maps> 65. PAD 21-27. CVP mid 20s. CO/CI/SVR 8.7/3.97/432 improved from 6.8/3.11/518. MVenous 71. Pericardial drain continues to be flushed q4 hrs. Still unable to aspirate. HO aware. Drained total of 130cc total from drainage bag. Right femoral groin site CDI. Did not attempt to wedge groin line. H/H and electrolytes stable. INR currently 1.3( 4.7 upon admission tx w/ Vit k and FFP). Extremeties warm. Distal pulses palpable bilaterally.\n\nResp: LS clear in upper lung fields. Diminished in bases. RR 12-20. Denies SOB. O2 sats 95-97% remains on 2L supplemental O2. 93% on RA. Encouraged use of incentive spirometry. Vt 500cc observed.\n\nGI/GU: NPO after midnight. No N/V. Abd obese. +BS. No BM. Around midnight pt c/o gas pains. Administered 80mg Simethicone w/ gd results. No further complaint overnoc. F/C to gravity. Pt c/o some discomfort r/t catheter movement. Given Lasix 20 mg on prior shift. Cont to have gd output overnoc. No additional diuresis. Currently -2700/ 24hrs and -1750/ LOS. Bun/ Cr continues to improve 67/2.2 ( had been 80/3.4).\n\nID: Afebrile. No abx treatment at this time.\n\nSocial: Daughter and son in law into visit early in evening.\n\nSkin: Some redness noted on backside. Applied barrier cream w/ some improvement noted.\n\nA/P: 69 yo female transferred from + pericardial effusions vs cardiac tamponade via ECHO. INR 4.5-> on Coumadin at home for underlying afib. Tx w/ Vit K and FFP prior to tap in cath lab. 1050cc drainage via pericardiocentesis. Drain remains in place. Able to flush drain but unable to aspirate. Plan to send to EP today to check pacemaker lead placement ? cause of pericardial effusion. Otherwise pt comfortable and night uneventful.\n" }, { "category": "Nursing/other", "chartdate": "2146-12-26 00:00:00.000", "description": "Report", "row_id": 1428854, "text": "CCU NPN 1900-0700:\nS-\"I feel much better than last night!\"\n\nSEE CAREVUE FOR ALL OBJECTIVE DATA AND TRENDS IN VSS\n\nMS:A/O/X/3. Very pleasant and cooperative. C/o of right shoulder pain when moved, given Percocet with good effect in addition to Ambien and sleeping weel overnight.\n\nCV: 30s to 40s, Afib and frequently dropping to mid 20s and coming back up. SBPs stable 100-140s. Denies chest pain and dizziness.\n to EPS this AM in addition Valium to EP as well.\n\nRESP:LSCTA. O2Sats on 2Ls, 93-95%. Denies SOB. Using IS PRN.\n\nGU/GI: Voiding adequate amounts of urine in foley, clear and yellow appearance. (-) for LOS, PO intake poor secondary to nausea on previous shift. NPO since MN.\n\nID:Low grade temps overnight.\n\nA/P:malfunctioning pacemaker\n\n Cath\nPossible call out to floor post if stable\n" }, { "category": "Nursing/other", "chartdate": "2146-12-26 00:00:00.000", "description": "Report", "row_id": 1428855, "text": "CCU NSG NOTE: ALT IN CV/PACEMEAKER FAILURE\nS: \"I hope this will finally be over.\"\nO: For complete VS see CCU flow sheet.\nID: PT has low grade temp. WBC 12.\nCV: not pacing. Pt in afib with slow vent response with rate between 27-46 with stable BP ranging 125-130/40. Pt went to EP at 1630 for revision of pacemaker. She received 5m po valium before going.\nRESP: Pt sating 94-97% on 2L NP. She has bronchial BS on L. She will use IS with encouragement.\nGI: Pt no longer has cramping. She has been NPO today taking only ice chips.\nRENAL: Creat back at baseline of 1.4. She is voiding in small amts today thru foley. SHe is getting 1/2 NS at 100cc/hr pre-cath. She is ~270cc positive for the day and 6400cc neg LOS.\nENDO: Pt is not yet on oral . FS have been in 130-140s and she has not required ss reg insulin.\nMS: Pt remains A & O X 3 and is in good spirits. Brother in to visit and her daughter will come tonight. Pt is aware she may be going to 3 if all goes well.\nA: EP for revision.\nP: Monitor for fever. Monitor for rhythm disturbance. Keep careful I & O. Mobilize pt as soon as possible.\n" } ]

[ { "category": "Radiology", "chartdate": "2184-09-20 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 800630, "text": " 9:10 AM\n CAROT/CEREB Clip # \n Reason: AVM\n Admitting Diagnosis: INTRACRANIAL BLEED;TELEMETRY\n Contrast: NON IONIC Amt: 205\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER CAROTID/CEREBRAL BILAT *\n * CAROTID/CEREBRAL BILAT EXT CAROTID UNILAT *\n * VERT/CAROTID A-GRAM VERT/CAROTID A-GRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with bleeding temporal lobe please access for AVM\n REASON FOR THIS EXAMINATION:\n AVM\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n\n 64 year old male with left temporal lobe bleeding. To rule out AV\n malformation.\n\n The previous dictation as been lost during the process of transcription and\n this is a repeat dictation.\n\n Informed consent was obtained from the patient and patient's family after\n explaining the risks, indications and alternative management. The patient is\n here for a cerebral angiogram on the request of neurologist.\n\n The patient was brought to the Neurointerventional Theater and placed on the\n table in supine position. Both groins were prepped and draped in the usual\n sterile fashion. Access to the right common femoral artery was obtained using\n a 19-gauge single-wall needle under local anesthesia with aseptic precautions.\n Initially, a 4-French vascular sheath was placed over the wire. Through the\n sheath, a 4-French Berenstein 2 catheter was placed. Using a Terumo\n Glidewire, the selected vessels were selectively catheterized and arteriograms\n were performed.\n\n 1) Right common carotid artery.\n\n 2) Right internal carotid artery.\n\n 3) Left common carotid artery.\n\n 4) Left internal carotid artery.\n\n 5) Left external carotid artery.\n\n 6) Left vertebral artery.\n (Over)\n\n 9:10 AM\n CAROT/CEREB Clip # \n Reason: AVM\n Admitting Diagnosis: INTRACRANIAL BLEED;TELEMETRY\n Contrast: NON IONIC Amt: 205\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 7) Right vertebral artery.\n\n Arteriograms from the above levels were performed. After view of films, the\n catheter and the sheath were withdrawn and pressure was applied on the right\n groin until hemostasis was obtained. The patient was then sent to the Floor\n with orders. The procedure was uneventful and the patient tolerated the\n procedure well.\n\n FINDINGS:\n\n Evaluation of the right common carotid artery demonstrates no significant\n atherosclerotic disease. The right internal carotid artery demonstrates good\n opacification of the distal branches. The anterior and middle cerebral artery\n branches are well opacified. Good cross- flow noted across anterior\n communicating artery. No evidence of vascular malformation noted.\n\n Evaluation of the left common carotid artery demonstrates no significant\n atherosclerotic disease. The left internal carotid artery and left external\n carotid artery demonstrate good opacification of the distal branches. No\n definite evidence of vascular malformation noted.\n\n Evaluation of the left vertebral artery and right vertebral artery\n demonstrates good opacification of the distal vertebral arteries,\n posteroinferior cerebellar arteries on both sides, basilar artery and\n posterior cerebral arteries on both sides. No definite evidence of vascular\n malformation noted.\n\n IMPRESSION:\n\n 1) No definite evidence of intracranial vascular malformation noted.\n\n 2) A repeat angiogram must be performed in three months after resolution of\n hemorrhage to exclude subtle vascular malformations.\n\n The findings were reviewed with Dr. , the referring neurologist,\n immediately after the examination.\n\n\n\n\n (Over)\n\n 9:10 AM\n CAROT/CEREB Clip # \n Reason: AVM\n Admitting Diagnosis: INTRACRANIAL BLEED;TELEMETRY\n Contrast: NON IONIC Amt: 205\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-09-17 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 800412, "text": " 11:37 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MRI with area in left temporal area showing circumscribed bl\n Admitting Diagnosis: INTRACRANIAL BLEED;TELEMETRY\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 64 year old man with HTN, ADHD presenting with 2 day h/o mental status change\n and seizures with CT at outside hospital showing ?L temporal hemorrhage and MRI\n here indicating L temporal lobe lesion in addition to several small lesions,\n suspicious for bleed vs. mass.\n REASON FOR THIS EXAMINATION:\n MRI with area in left temporal area showing circumscribed bleed vs. mass\n (suspicious for brain mets); please evaluate for mass in chest, abdomen, pelvis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left temporal hemorrhage, question malignancy.\n\n TECHNIQUE: Contiguous axial images though the liver were obtained prior to\n contrast followed by contiguous axial images from the thoracic inlet to the\n pubic symphysis following the administration of 150 cc of Optiray contrast.\n\n COMPARISON: There are no prior studies for comparison.\n\n CT CHEST WTIH IV CONTRAST: There is no significant axillary, mediastinal, or\n hilar lymphadenopathy. The heart, pericardium, and great vessels are normal\n in appearance. There are no pleural effusion present. There is a small\n amount of atelectasis at the right lung base. The airways appear patent to\n the level of the segmental bronchi bilaterally.\n\n CT ABDOMEN WITH IV CONTRAST: There are no masses within the liver. Two small\n stones within the gallbladder, one with a lucent center. No associated wall\n thickening or pericholecystic fluid. The spleen, adrenals, pancreas, and left\n kidney are normal. The right kidney shows a 2.8 x 2.8 cm low-attenuation\n lesion, with fluid density representing a renal cyst. There is a small\n calculus with the left kidney. There is no mesenteric or retroperitoneal\n adenopathy. There is no free fluid or free air.\n\n CT PELVIS WITH IV CONTRAST: The distal ureters, bladder, sigmoid, rectum,\n prostate, and seminal vesicles are unremarkable. There is no pelvic or\n inguinal lymphadenopathy. No free fluid.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions present.\n\n IMPRESSION: No evidence of malignancy with in the chest, abdomen, or pelvis,\n with incidental gallstones and right renal cyst.\n\n\n (Over)\n\n 11:37 AM\n CT CHEST W/CONTRAST; CT ABD W&W/O C Clip # \n CT PELVIS W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: MRI with area in left temporal area showing circumscribed bl\n Admitting Diagnosis: INTRACRANIAL BLEED;TELEMETRY\n Field of view: 44 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2184-09-15 00:00:00.000", "description": "Report", "row_id": 1346448, "text": "MICU-B NPN 0700-1900\nPT. 63 Y/O MALE WITH PMHX. SINIF. FOR UNCONTROLLED HTN, ADHD ON HIGH-DOSES RITALIN X5 YEARS. OCCAS. BEER DRINKER, QUIT SOMING 5 Y/AGO. PT. NOW WITH 2 WEEK HX. DULL H/A, WITH NOTED SPEECH DIFFICULTY, NEW ONSET CONFUSION AND H/A, WITH PERIOD WHERE PT. BECAME UNRESPONSIVE AND ROLLED EYES BACK YEST. BROUGHT TO OSH () WHERE HE UNDERWENT HEAD CT, WHICH APPRECIATED SM. (L)TEMPORAL INTRAPARANCHYMAL BLEED 1X2 CM. PT. ALSO WITH REPORTED SZ. ACTIVITY @ OSH AND IN EW. IN EW PT. STARTED IN NIPRIDE GTT. FOR BP 221/129 WITH GOAL SBP 140. GIVEN DILANTIN LOAD, AND TRANSFERRED TO MICU-B FOR FURTHER W/U. PT. WITH UNEVENTFUL EVE. H/A SUBSIDING, NIPRIDE GTT. WEANED TO OFF @ 0600 WITH SBP 150'S-170'S (GOAL SBP IN MICU-B HAS BEEN 140-160'S). ON METOPROLOL; DOSE INC. THIS SHIFT TO 50 MG , ALSO STARTED ON IV HYDRALAZINE. TO MRI/MRA THIS AM @ 1100; RESULTS PENDING.\n\nNEURO - PT. AXOX3. PLEASANT. PERRLA 3MM/3MM WITH BRISK REPONSE. +MAE WITH STRONG EQUAL STRENGTH NOTED. +CMS. CONT. ON DILANTIN. NO EEG. DILANTIN LEVEL THIS A.M. 6.8; GIVEN X1 500 MG. DOSE FOR SUB-THERAPEUTIC LEVEL AND INC. DOSE. NO SZ. ACTIVITY SONCE ADMIT TO MICU-B. PT. UP TO BEDSIDE COMMODE, WITH STEADY GAIT. SPEECH CLEAR.\n\nC/V - HR 70'S-80'S, NSR WITH NO ECTOPY NOTED. NIBP 150'S-170'S/90'S-100'S. AS ABOVE ON METOPROLOL AND HYDRALAZINE. OFF NIPRODE GTT. SINCE 0600 THIS AM.\n\nRESP - PT. WITH O2SATS 95-98% ON RA. LS CLEAR T/O. NO COUGH. NO C/O SOB.\n\nGI/GU- DIET ADVANCE TO REG/CARDIAC DIET. WELL TOL. ABD. SOFT, NTND WITH +BS. + FORMED STOOL THIS SHIFT. VOIDS INDEPENDENTLY, GOOD AMTS. CLEAR, YELLOW URINE.\n\nSOCIAL - FAMILY IN THIS SHIFT. UPDATED ON PT. STATUS AND CONT. PLAN OF CARE.\n\nDISPO - CALLED OUT. AWAITING FLOOR BED. TRANSFER NOTE DONE.\n" }, { "category": "Nursing/other", "chartdate": "2184-09-16 00:00:00.000", "description": "Report", "row_id": 1346449, "text": "MICU NPN 7P-7A\nNEURO: NO NEURO DEFICITS NOTED. AAOX3. MAE W/EQUAL STRENGTH. PERL @3MM AND BRISK. NO COMPLAITS OF H/A. NO SEIZURE ACTIVITY. DILANTIN AS ORDERED. LEVEL 13.8 THIS AM. MRI YESTERDAY SHOWED NO ACUTE INFARCTS, NO ANEURYSM. LEFT TEMPORAL HEMATOMA PRESENT. PLAN TO REIMAGE AGAIN THIS AM.\n\nCARDIAC: HR 83-101 SR/ST WITH NO ECTOPY. BP 136-171/82-105. TOLERATING LOPRESSOR AND HYDRALAZINE. GOAL IS TO KEEP SBP <160. NIPRIDE REMAINS OFF. PPP. HCT 48 WITH 1.1 INR.\n\nRESP: ON RA WITH RR 16-22 AND SATS 96-98%. LSC.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. TOLERATED SUPPER LAST EVENING. FS 111 THIS AM. VOIDING IN COMMODE, YELLOW CLEAR URINE. BUN/CRE WNL.\n\nID: TMAX 99.4 WITH WBC OF 11. NO CURRENT ID ISSUES.\n\nSKIN: INTACT.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: FULL CODE. AWAITING BED ON THE FLOOR.\n" }, { "category": "Nursing/other", "chartdate": "2184-09-16 00:00:00.000", "description": "Report", "row_id": 1346450, "text": "Micu Nursing Progress Note:\n\nNeuro: Alert and oriented x 3. Moving all extremities well. C/O mild headache, pain level . Team aware. Pupils 3mm, briskly reactive.\nSee orders for change in Dilantin. One time dose to be given today at 1600.\n\nCV: SR-ST, 70s to 103. Occasional PAC. BP somewhat elevated this am at 180s systolic. Team was notified and he was given his 10am Hydralazine one hour early. His Metoprolol was increased to 100mg po bid and 100mg was given at noon. His blood pressure did decrease to 155/92, with decrease in HR from low 100s to 70s.\n\nResp: 99-100% on room air. Lung sounds clear.\n\nGI/GU: Placed on low sodium, heart healty diet. Took only juice for breakfast and had one/half of tuna at lunch. No stool. Voiding sufficient quantities in urinal, 600cc total this shift.\n\nSkin: Intact.\n\nSocial: Wife in to visit.\n\nPlan: To be transferred out to 5.\n\n Rn\n" }, { "category": "ECG", "chartdate": "2184-09-20 00:00:00.000", "description": "Report", "row_id": 194699, "text": "Sinus rhythm\nNonspecific inferolateral ST-T changes - ? ischemia\nSince previous tracing, further T wave inversion in leads V4-6\n\n" }, { "category": "ECG", "chartdate": "2184-09-14 00:00:00.000", "description": "Report", "row_id": 194700, "text": "Sinus rhythm\nSupraventricular extrasystoles\nNonspecific inferior/lateral ST-T changes\nNo previous tracing for comparison\n\n" } ]

[ { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692803, "text": "POD #1 from CABG x3.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received intub cpap 5/5. A-paced at 88. Underlying rhythm SB 50s. On\n precedex, epi, & insulin gtts. Gagging on ETT despite max dose of\n precedex.\n Action:\n ABG wnl on , pt extub to FT. Precedex gtt shut off. Advanced to NC.\n CO wnl after extubation, epi gtt shut off. Neo gtt transiently infused\n after epi gtt shut off. Swan dc\nd. Transitioned to SC insulin. Pt\n assisted OOB. Diet advanced. A-line had fling, okay to dc NP. CTs\n dc\n by NP . Post CXR reviewed by NP. Lytes repleted.\n Response:\n Underlying now SR, no ectopy. No gtts. Steady gait. Coughing and deep\n breathing effectively. Diuresing well from ivp lasix. Pain managed with\n PO percocet.\n Plan:\n Advance diet/act. Pulm toilet. Monitor lytes with diuresis. Start PO\n lopressor when appropriate. Post-op education. Needs PT consult.\n Transfer to 6 in am.\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692804, "text": "POD #1 from CABG x3.\n Coronary artery bypass graft (CABG)\n Assessment:\n Received intub cpap 5/5. A-paced at 88. Underlying rhythm SB 50s. On\n precedex, epi, & insulin gtts. Gagging on ETT despite max dose of\n precedex.\n Action:\n ABG wnl on , pt extub to FT. Precedex gtt shut off. Advanced to NC.\n CO wnl after extubation, epi gtt shut off. Neo gtt transiently infused\n after epi gtt shut off. Swan dc\nd. Transitioned to SC insulin. Pt\n assisted OOB. Diet advanced. A-line had fling, okay to dc NP. CTs\n dc\n by NP . Post CXR reviewed by NP. Lytes repleted.\n Response:\n Underlying now SR, no ectopy. No gtts. Steady gait. Coughing and deep\n breathing effectively. Diuresing well from ivp lasix. Pain managed with\n PO percocet.\n Plan:\n Advance diet/act. Pulm toilet. Monitor lytes with diuresis. Start PO\n lopressor when appropriate. Post-op education. Needs PT consult.\n Transfer to 6 in am.\n" }, { "category": "Physician ", "chartdate": "2110-07-31 00:00:00.000", "description": "Intensivist Note", "row_id": 692922, "text": "CVICU\n HPI:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Chief complaint:\n CAD\n PMHx:\n Hypertension, Hyperlipidemia, Hypothyroidism, Gout\n lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n Current medications:\n Acetaminophen 5. Albuterol-Ipratropium 6. Aspirin EC 7. Aspirin 8.\n Calcium Gluconate\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Dextrose 50% 11.\n Docusate Sodium 12. Docusate Sodium (Liquid)\n 13. Fluticasone Propionate 110mcg 14. Furosemide 15. Insulin 16.\n Levothyroxine Sodium 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoclopramide 20. Milk of Magnesia 21.\n Morphine Sulfate 22. Nitroglycerin\n 23. Oxycodone-Acetaminophen 24. Phenylephrine 25. Potassium Chloride\n 26. Ranitidine 27. Ranitidine\n 28. Simvastatin 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9%\n Flush 31. Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 10:52 AM\n ARTERIAL LINE - STOP 11:00 AM\n CHEST TUBE REMOVED - At 04:00 PM\n ARTERIAL LINE - STOP 04:01 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 06:25 AM\n Other medications:\n Flowsheet Data as of 10:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.1\nC (98.7\n HR: 67 (63 - 79) bpm\n BP: 108/37(53) {106/36(53) - 138/56(72)} mmHg\n RR: 17 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n CVP: 6 (6 - 6) mmHg\n PAP: (24 mmHg) / (12 mmHg)\n Total In:\n 2,881 mL\n 530 mL\n PO:\n 480 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,610 mL\n 350 mL\n Blood products:\n 791 mL\n Total out:\n 6,155 mL\n 3,265 mL\n Urine:\n 5,485 mL\n 3,265 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,274 mL\n -2,735 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.46/33/243/28/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 12.6 K/uL\n [image002.jpg]\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n 08:00 AM\n 10:05 AM\n 03:46 PM\n 09:30 PM\n 02:38 AM\n WBC\n 12.6\n Hct\n 25.5\n 26.5\n 26.5\n Plt\n 195\n Creatinine\n 0.9\n TCO2\n 24\n 25\n 25\n 21\n 24\n Glucose\n 81\n 144\n 138\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 POD#2 s/p CABGx3. Doing well O/N off epi, CT\n out yesterday eve.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, conversant\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: periop vanco\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypotension Post op resp insufficiency\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 12:15 PM\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-07-31 00:00:00.000", "description": "ICU Note - CVI", "row_id": 692927, "text": "CVICU\n HPI:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Ejection Fraction:70\n Hempglobin A1c:5.5\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:0.8\n Assessment:77yoM s/p CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Hypothyroidism, Gout,\n PSH:lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n : Amlodipine 5', Atenolol 50', Ciprofloxacin 500' x7d(start )\n 4. Plavix 75', Finasteride 5', Levothyroxine 88', Lisinopril 5',\n Simvastatin 80', ASA 325', Colace 100\", Plavix- last dose \n Current medications:\n Acetaminophen 5. Albuterol-Ipratropium 6. Aspirin EC 7Calcium\n Gluconate 12. Docusate Sodium\n 13. Fluticasone Propionate 110mcg 14. Furosemide 15. Insulin 16.\n Levothyroxine Sodium 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoclopramide 20. Milk of Magnesia 21.\n Morphine Sulfate 22. Nitroglycerin\n 23. Oxycodone-Acetaminophen Potassium Chloride Ranitidine 28.\n Simvastatin Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 10:52 AM\n ARTERIAL LINE - STOP 11:00 AM\n CHEST TUBE REMOVED - At 04:00 PM\n ARTERIAL LINE - STOP 04:01 PM\n Post operative day:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 06:25 AM\n Flowsheet Data as of 10:50 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: 37.1\nC (98.7\n HR: 67 (63 - 79) bpm\n BP: 108/37(53) {106/36(53) - 138/56(72)} mmHg\n RR: 17 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n Total In:\n 2,881 mL\n 530 mL\n PO:\n 480 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,610 mL\n 350 mL\n Blood products:\n 791 mL\n Total out:\n 6,155 mL\n 3,265 mL\n Urine:\n 5,485 mL\n 3,265 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,274 mL\n -2,735 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.46/33/243/28/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 12.6 K/uL\n [image002.jpg]\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n 08:00 AM\n 10:05 AM\n 03:46 PM\n 09:30 PM\n 02:38 AM\n WBC\n 12.6\n Hct\n 25.5\n 26.5\n 26.5\n Plt\n 195\n Creatinine\n 0.9\n TCO2\n 24\n 25\n 25\n 21\n 24\n Glucose\n 81\n 144\n 138\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77yo man s/p CABG, doing well post operatively\n Neurologic: Percocet for pain control\n Cardiovascular: start BBlockers today, cont statin, ASA\n Pulmonary: IS, OOB-ambulate today\n Gastrointestinal / Abdomen: Cardiac healthy diet\n Nutrition: ADAT\n Renal: Continue diuretics to keep net negative 1-1.5 liters/day\n Hematology: stable hct\n Endocrine: RISS\n Infectious Disease:no active issues, afebrile\n Lines / Tubes / Drains: epicardial wires\n Wounds: CDI\n Imaging: none\n Fluids: KVO\n Consults: Nutrition, PT\n ICU \n Nutrition: Cardiac diet\n Glycemic Control: RISS\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT: non indicated\n Stress ulcer: H2blocker\n VAP bundle: HOB^, mouth care\n Code status: Full\n Disposition: Transfer F6\n" }, { "category": "Nursing", "chartdate": "2110-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 692929, "text": "POD #2 from CABG x3. Pt extubated POD #1 d/t hemodynamic instability\n post-op night.\n CV-PMH: CAD, Hypertension\n Additional history: Hyperlipidemia, hypothyroidism, gout, s/p lap CCY\n ; s/p colon polypectomy; s/p bl hernia repair ; s/p\n hemorroidectomy; s/p TURP . Quit smoking 20 years ago (30-pack\n year hx). ETOH 1 glass wine daily w/meals. HgA1C 5.5.\n Surgery / Procedure and date: CABG x 3 (LIMA -> LAD, SVG -> OM1,\n PVG -> PDA). MR worse off pump and PA pressures high. Epi gtt\n started. To CVICU on propofol, epi and neo gtts. CXT 47\", BPT 63\".\n EZ intubation.\n Coronary artery bypass graft (CABG)\n Assessment:\n VSS have been stable since POD #1. Pt currently following post-op\n pathway.\n Action:\n Started PO Lopressor this am. Foley dc\nd. Ambulating with one assist\n for line safety. Cortis dc\nd. Pulm toilet.\n Response:\n SR 60s and sbp 90-100. Pt voiding sufficient amts. Tolerating reg\n consistency heart healthy meals. Pulls sufficient amts with IS.\n Plan:\n Transfer to 6. Needs initial PT consult. Advance per pathway.\n Post-op education.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CHEST PAIN CATH\n Code status:\n Height:\n 67 Inch\n Admission weight:\n 90.9 kg\n Daily weight:\n 102.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:122\n D:37\n Temperature:\n 98.7\n Respiratory Rate: 17 insp/min\n Heart Rate:\n 70 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 530 mL\n 24h total out:\n 3,265 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Ventricular Demand\n Temporary pacemaker rate:\n 50 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 0.8 mV\n Temporary atrial sensitivity setting:\n 0.4 mV\n Temporary atrial stimulation threshold :\n 25 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 2.5 mV\n Temporary ventricular sensitivity setting:\n 1 mV\n Temporary ventricular stimulation threshold :\n 5 mA\n Temporary ventricular stimulation setting :\n 10 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 134 mEq/L\n 02:38 AM\n Potassium:\n 4.0 mEq/L\n 02:38 AM\n Chloride:\n 102 mEq/L\n 02:38 AM\n CO2:\n 28 mEq/L\n 02:38 AM\n BUN:\n 10 mg/dL\n 02:38 AM\n Creatinine:\n 0.9 mg/dL\n 02:38 AM\n Glucose:\n 138 mg/dL\n 02:38 AM\n Hematocrit:\n 26.5 %\n 02:38 AM\n Finger Stick Glucose:\n 102\n 06:00 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 20g piv LLarm , 2 V/2A epicardial wires attached to pacer box\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife\n / :\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: wife\n Jewelry: none\n Transferred from: cvicu a 797\n Transferred to: 6\n Date & time of Transfer: 1200\n" }, { "category": "Physician ", "chartdate": "2110-07-31 00:00:00.000", "description": "Intensivist Note", "row_id": 692910, "text": "CVICU\n HPI:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Chief complaint:\n CAD\n PMHx:\n Hypertension, Hyperlipidemia, Hypothyroidism, Gout\n lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n Current medications:\n Acetaminophen 5. Albuterol-Ipratropium 6. Aspirin EC 7. Aspirin 8.\n Calcium Gluconate\n 9. Chlorhexidine Gluconate 0.12% Oral Rinse 10. Dextrose 50% 11.\n Docusate Sodium 12. Docusate Sodium (Liquid)\n 13. Fluticasone Propionate 110mcg 14. Furosemide 15. Insulin 16.\n Levothyroxine Sodium 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoclopramide 20. Milk of Magnesia 21.\n Morphine Sulfate 22. Nitroglycerin\n 23. Oxycodone-Acetaminophen 24. Phenylephrine 25. Potassium Chloride\n 26. Ranitidine 27. Ranitidine\n 28. Simvastatin 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9%\n Flush 31. Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 10:52 AM\n ARTERIAL LINE - STOP 11:00 AM\n CHEST TUBE REMOVED - At 04:00 PM\n ARTERIAL LINE - STOP 04:01 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 06:25 AM\n Other medications:\n Flowsheet Data as of 10:18 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.1\nC (98.7\n HR: 67 (63 - 79) bpm\n BP: 108/37(53) {106/36(53) - 138/56(72)} mmHg\n RR: 17 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n CVP: 6 (6 - 6) mmHg\n PAP: (24 mmHg) / (12 mmHg)\n Total In:\n 2,881 mL\n 530 mL\n PO:\n 480 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,610 mL\n 350 mL\n Blood products:\n 791 mL\n Total out:\n 6,155 mL\n 3,265 mL\n Urine:\n 5,485 mL\n 3,265 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,274 mL\n -2,735 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.46/33/243/28/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n bases)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: (Awake / Alert / Oriented: x 3)\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 12.6 K/uL\n [image002.jpg]\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n 08:00 AM\n 10:05 AM\n 03:46 PM\n 09:30 PM\n 02:38 AM\n WBC\n 12.6\n Hct\n 25.5\n 26.5\n 26.5\n Plt\n 195\n Creatinine\n 0.9\n TCO2\n 24\n 25\n 25\n 21\n 24\n Glucose\n 81\n 144\n 138\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 POD#2 s/p CABGx3. Doing well O/N off epi, CT\n out yesterday eve.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, conversant\n Cardiovascular: Aspirin, Beta-blocker, Statins\n Pulmonary: IS\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet\n Renal: Foley, Adequate UO\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: periop vanco\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T., O.T.\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 12:15 PM\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status:\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2110-07-31 00:00:00.000", "description": "ICU Note - CVI", "row_id": 692915, "text": "CVICU\n HPI:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Ejection Fraction:70\n Hempglobin A1c:5.5\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:0.8\n Assessment:77yoM s/p CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Chief complaint:\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Hypothyroidism, Gout,\n PSH:lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n : Amlodipine 5', Atenolol 50', Ciprofloxacin 500' x7d(start )\n 4. Plavix 75', Finasteride 5', Levothyroxine 88', Lisinopril 5',\n Simvastatin 80', ASA 325', Colace 100\", Plavix- last dose \n Current medications:\n Acetaminophen 5. Albuterol-Ipratropium 6. Aspirin EC 7Calcium\n Gluconate 12. Docusate Sodium\n 13. Fluticasone Propionate 110mcg 14. Furosemide 15. Insulin 16.\n Levothyroxine Sodium 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoclopramide 20. Milk of Magnesia 21.\n Morphine Sulfate 22. Nitroglycerin\n 23. Oxycodone-Acetaminophen Potassium Chloride Ranitidine 28.\n Simvastatin Vancomycin\n 24 Hour Events:\n PA CATHETER - STOP 10:52 AM\n ARTERIAL LINE - STOP 11:00 AM\n CHEST TUBE REMOVED - At 04:00 PM\n ARTERIAL LINE - STOP 04:01 PM\n Post operative day:\n HD7 POD 2-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:30 AM\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:00 PM\n Furosemide (Lasix) - 06:25 AM\n Other medications:\n Flowsheet Data as of 10:50 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: 37.1\nC (98.7\n HR: 67 (63 - 79) bpm\n BP: 108/37(53) {106/36(53) - 138/56(72)} mmHg\n RR: 17 (14 - 21) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n Total In:\n 2,881 mL\n 530 mL\n PO:\n 480 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,610 mL\n 350 mL\n Blood products:\n 791 mL\n Total out:\n 6,155 mL\n 3,265 mL\n Urine:\n 5,485 mL\n 3,265 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n -3,274 mL\n -2,735 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 94%\n ABG: 7.46/33/243/28/1\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 195 K/uL\n 8.9 g/dL\n 138 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 10 mg/dL\n 102 mEq/L\n 134 mEq/L\n 26.5 %\n 12.6 K/uL\n [image002.jpg]\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n 08:00 AM\n 10:05 AM\n 03:46 PM\n 09:30 PM\n 02:38 AM\n WBC\n 12.6\n Hct\n 25.5\n 26.5\n 26.5\n Plt\n 195\n Creatinine\n 0.9\n TCO2\n 24\n 25\n 25\n 21\n 24\n Glucose\n 81\n 144\n 138\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L,\n Ca:8.3 mg/dL, Mg:2.1 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\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 ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 03:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2110-07-31 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 692916, "text": "POD #2 from CABG x3. Sluggish LV required epi gtt first post-op night.\n Pt extubated POD #1 d/t hemodynamic instability post-op night.\n Coronary artery bypass graft (CABG)\n Assessment:\n VSS have been stable since POD #1. Pt currently following post-op\n pathway.\n Action:\n Started PO Lopressor this am. Foley dc\nd. Ambulating with one assist\n for line safety. Cortis dc\nd. Pulm toilet.\n Response:\n SR 60s and sbp 90-100. Pt voiding sufficient amts. Tolerating reg\n consistency heart healthy meals. Pulls sufficient amts with IS.\n Plan:\n Transfer to 6. Needs initial PT consult. Advance per pathway.\n Post-op education.\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692776, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received intub cpap 5/5. A-paced at 88. Underlying rhythm SB 50s. On\n precedex, epi, & insulin gtts. Gagging on ETT despite max dose of\n precedex.\n Action:\n ABG wnl on , pt extub to FT. Advanced to NC. Precedex gtt shut off.\n CO wnl after extubation, epi gtt shut off. Neo gtt transiently infused\n after epi gtt shut off. Swan dc\nd. Transitioned to SC insulin. Pt\n assisted OOB. Diet advanced.\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692788, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received intub cpap 5/5. A-paced at 88. Underlying rhythm SB 50s. On\n precedex, epi, & insulin gtts. Gagging on ETT despite max dose of\n precedex.\n Action:\n ABG wnl on , pt extub to FT. Advanced to NC. Precedex gtt shut off.\n CO wnl after extubation, epi gtt shut off. Neo gtt transiently infused\n after epi gtt shut off. Swan dc\nd. Transitioned to SC insulin. Pt\n assisted OOB. Diet advanced. A-line had fling, okay to dc NP. CTs\n dc\n by NP . Post CXR reviewed by NP. Lytes repleted.\n Response:\n Underlying now SR, no ectopy. No gtts. Steady gait. Coughing and deep\n breathing effectively. Diuresing well from ivp lasix. Pain managed with\n PO percocet.\n Plan:\n Advance diet/act. Pulm toilet. Monitor lytes with diuresis. Start PO\n lopressor when appropriate.\n" }, { "category": "Physician ", "chartdate": "2110-07-30 00:00:00.000", "description": "Intensivist Note", "row_id": 692769, "text": "TITLE: Intensivist\n Surgical Critical Care\n CVICU\n HPI:\n HD6 POD 1-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Ejection Fraction:70\n Hempglobin A1c:5.5\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:0.8\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Hypothyroidism, Gout,\n PSH:lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n : Amlodipine 5', Atenolol 50', Ciprofloxacin 500' x7d(start )\n 4. Plavix 75', Finasteride 5', Levothyroxine 88', Lisinopril 5',\n Simvastatin 80', ASA 325', Colace 100\", Plavix- last dose \n Current medications:\n Acetaminophen 5. Albumin 5% (12.5g / 250mL) 6. Albuterol-Ipratropium 7.\n Aspirin EC Calcium Gluconate 10. Chlorhexidine Gluconate 0.12% Oral\n Rinse Docusate Sodium Epinephrine HCl 16. Fluticasone Propionate\n 110mcg\n 17. Furosemide 18. Furosemide 19. Insulin 20. Levothyroxine Sodium 21.\n Magnesium Sulfate 22. Metoclopramide\n 23. Milk of Magnesia 24. Midazolam 25. Morphine Sulfate 26.\n Nitroglycerin 27. Oxycodone-Acetaminophen\n 28. Phenylephrine 29. Potassium Chloride 30. Ranitidine Simvastatin\n Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ARTERIAL LINE - START 12:15 PM\n CORDIS/INTRODUCER - START 12:15 PM\n PA CATHETER - START 12:15 PM\n INVASIVE VENTILATION - START 12:20 PM\n Post operative day:\n HD6 POD 1-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:56 PM\n Infusions:\n Insulin - Regular - 3 units/hour\n Epinephrine - 0.02 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.7 mcg/Kg/hour\n Other ICU medications:\n Insulin - Regular - 05:49 PM\n Midazolam (Versed) - 11:19 PM\n Morphine Sulfate - 03:19 AM\n Furosemide (Lasix) - 05:23 AM\n Flowsheet Data as of 08:45 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: 88 (60 - 91) bpm\n BP: 106/45(61) {86/36(49) - 151/55(79)} mmHg\n RR: 16 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: A Paced\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n CVP: 7 (6 - 17) mmHg\n PAP: (21 mmHg) / (14 mmHg)\n CO/CI (Thermodilution): (5.01 L/min) / (2.5 L/min/m2)\n CO/CI (Fick): (5.2 L/min) / (2.6 L/min/m2)\n SVR: 910 dynes*sec/cm5\n Mixed Venous O2% sat: 56 - 56\n SV: 57 mL\n SVI: 28 mL/m2\n Total In:\n 12,022 mL\n 1,469 mL\n PO:\n Tube feeding:\n IV Fluid:\n 10,572 mL\n 678 mL\n Blood products:\n 1,450 mL\n 791 mL\n Total out:\n 2,166 mL\n 2,160 mL\n Urine:\n 715 mL\n 1,750 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 9,856 mL\n -691 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 593 (487 - 593) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: 7.43/31/109/25/-2\n Ve: 8.3 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress, Anxious, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), A-paced currently sinus bradycardia\n under paced rythym\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bases bilaterally), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 209 K/uL\n 7.4 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 135 mEq/L\n 25.5 %\n 12.1 K/uL\n 02:21 PM\n 04:26 PM\n 05:43 PM\n 11:51 PM\n 01:30 AM\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n WBC\n 12.1\n Hct\n 27.1\n 21.9\n 25.5\n Plt\n 209\n Creatinine\n 0.7\n TCO2\n 20\n 20\n 24\n 24\n 25\n 25\n 21\n Glucose\n 93\n 113\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77yo man s/p CABGx3. Extubated this AM,\n hemodynamically stable.\n Neurologic: Pain controlled, PO percocet today\n Cardiovascular: Wean epinephrine infusion to off Aspirin, start\n Beta-blocker, Statins as tolerated today. Discontinue PA monitor,\n Pulmonary: IS, hypoxia O/N resolved with precedex/anxiolysis and\n increased contractility, preload reduction. Extubated this AM.\n Breathing comfortably\n Gastrointestinal / Abdomen: no issues\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Begin diuretics to make net negative 1-1.5 liters today\n Hematology: recieved 2 units of PRBC's overnight. Appropriate Post\n transfusion hct of 25, will follow\n Endocrine: Insulin drip, Insulin infusion will transition to\n Lanatus/RISS\n Resume synthroid today\n Infectious Disease: on 7 day course of Cipro for Urethral irrigation by\n GU service @OSH\n Afebrile, continue periop Vanco\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, follow CT output likely d/c tomorrow. Pacing wires keep in\n place.\n Wounds: Dry dressings sternum c/d/i\n Consults: CT surgery, P.T., Nutrition\n ICU Care\n Nutrition: cardiac diet, advance as tolerated\n Glycemic Control: Insulin infusion, transition to Lantus\n Lines:\n Arterial Line - 12:15 PM\n Cordis/Introducer - 12:15 PM\n PA Catheter - 12:15 PM\n 18 Gauge - 12:15 PM\n 20 Gauge - 12:15 PM\n Prophylaxis:\n DVT: (OOB today)\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU Time spent : 31 min.\n" }, { "category": "Respiratory ", "chartdate": "2110-07-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 692745, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 0\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\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: Slightly Coarse\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Pt received intubated and on PSV 5/5. Subglottic suctioning done prior\n to extubation. Pt has a positive cuff leak test. Pt extubated to cool\n aerosol without incident.\n" }, { "category": "Physician ", "chartdate": "2110-07-30 00:00:00.000", "description": "ICU Note - CVI", "row_id": 692751, "text": "CVICU\n HPI:\n HD6 POD 1-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Ejection Fraction:70\n Hempglobin A1c:5.5\n Pre-Op Weight:0 lbs 0 kgs\n Baseline Creatinine:0.8\n PMHx:\n PMH: Hypertension, Hyperlipidemia, Hypothyroidism, Gout,\n PSH:lap CCY , colon polypectomy, b/l hernia repair ,\n hemorroidectomy, TURP \n : Amlodipine 5', Atenolol 50', Ciprofloxacin 500' x7d(start )\n 4. Plavix 75', Finasteride 5', Levothyroxine 88', Lisinopril 5',\n Simvastatin 80', ASA 325', Colace 100\", Plavix- last dose \n Current medications:\n Acetaminophen 5. Albumin 5% (12.5g / 250mL) 6. Albuterol-Ipratropium 7.\n Aspirin EC Calcium Gluconate 10. Chlorhexidine Gluconate 0.12% Oral\n Rinse Docusate Sodium Epinephrine HCl 16. Fluticasone Propionate\n 110mcg\n 17. Furosemide 18. Furosemide 19. Insulin 20. Levothyroxine Sodium 21.\n Magnesium Sulfate 22. Metoclopramide\n 23. Milk of Magnesia 24. Midazolam 25. Morphine Sulfate 26.\n Nitroglycerin 27. Oxycodone-Acetaminophen\n 28. Phenylephrine 29. Potassium Chloride 30. Ranitidine Simvastatin\n Vancomycin\n 24 Hour Events:\n ARTERIAL LINE - START 12:15 PM\n ARTERIAL LINE - START 12:15 PM\n CORDIS/INTRODUCER - START 12:15 PM\n PA CATHETER - START 12:15 PM\n INVASIVE VENTILATION - START 12:20 PM\n Post operative day:\n HD6 POD 1-CABGx3(LIMA-LAD,SVG-OM1,SVG-PDA)\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:56 PM\n Infusions:\n Insulin - Regular - 3 units/hour\n Epinephrine - 0.02 mcg/Kg/min\n Dexmedetomidine (Precedex) - 0.7 mcg/Kg/hour\n Other ICU medications:\n Insulin - Regular - 05:49 PM\n Midazolam (Versed) - 11:19 PM\n Morphine Sulfate - 03:19 AM\n Furosemide (Lasix) - 05:23 AM\n Flowsheet Data as of 08:45 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: 88 (60 - 91) bpm\n BP: 106/45(61) {86/36(49) - 151/55(79)} mmHg\n RR: 16 (14 - 21) insp/min\n SPO2: 97%\n Heart rhythm: A Paced\n Wgt (current): 102.3 kg (admission): 90.9 kg\n Height: 67 Inch\n CVP: 7 (6 - 17) mmHg\n PAP: (21 mmHg) / (14 mmHg)\n CO/CI (Thermodilution): (5.01 L/min) / (2.5 L/min/m2)\n CO/CI (Fick): (5.2 L/min) / (2.6 L/min/m2)\n SVR: 910 dynes*sec/cm5\n Mixed Venous O2% sat: 56 - 56\n SV: 57 mL\n SVI: 28 mL/m2\n Total In:\n 12,022 mL\n 1,469 mL\n PO:\n Tube feeding:\n IV Fluid:\n 10,572 mL\n 678 mL\n Blood products:\n 1,450 mL\n 791 mL\n Total out:\n 2,166 mL\n 2,160 mL\n Urine:\n 715 mL\n 1,750 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 9,856 mL\n -691 mL\n Respiratory support\n O2 Delivery Device: Aerosol-cool, Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 593 (487 - 593) mL\n PS : 5 cmH2O\n RR (Set): 0\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 50%\n PIP: 18 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: 7.43/31/109/25/-2\n Ve: 8.3 L/min\n PaO2 / FiO2: 218\n Physical Examination\n General Appearance: No acute distress, Anxious, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), A-paced currently sinus bradycardia\n under paced rythym\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bases bilaterally), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 209 K/uL\n 7.4 g/dL\n 113 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.5 mEq/L\n 11 mg/dL\n 109 mEq/L\n 135 mEq/L\n 25.5 %\n 12.1 K/uL\n [image002.jpg]\n 02:21 PM\n 04:26 PM\n 05:43 PM\n 11:51 PM\n 01:30 AM\n 01:34 AM\n 04:48 AM\n 05:04 AM\n 06:10 AM\n 07:32 AM\n WBC\n 12.1\n Hct\n 27.1\n 21.9\n 25.5\n Plt\n 209\n Creatinine\n 0.7\n TCO2\n 20\n 20\n 24\n 24\n 25\n 25\n 21\n Glucose\n 93\n 113\n Other labs: PT / PTT / INR:15.2/44.8/1.3, Lactic Acid:1.4 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77yo man s/p CABGx3. Extubated this AM,\n hemodynamically stable.\n Neurologic: Pain controlled, Morphine for pain control overnight will\n transition to percocet\n Cardiovascular: Aspirin, Beta-blocker, Statins, Discontinue PA monitor,\n Currently on Epinephrine infusion, will wean to off. After epi off will\n start Bblockers. Resume statins. D/c PA catheter after weans off Epi\n Pulmonary: IS, Extubate today, Extubated this AM. Breathing comfortably\n Gastrointestinal / Abdomen:\n Nutrition: Regular diet, Advance diet as tolerated\n Renal: Foley, Begin diuretics to make net negative 1-1.5 liters today\n Hematology: recieved 2 units of PRBC's overnight. Post transfusion hct\n 25, will repeat later this morning\n Endocrine: Insulin drip, Insulin infusion will transition to\n Lanatus/RISS\n Resume synthroid today\n Infectious Disease: on 7 day course of Cipro for Urethral irrigation by\n GU @OSH\n Afebrile, continue periop Vanco\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: CT surgery, P.T., Nutrition\n ICU Care\n Nutrition: cardiac diet, advance as tolerated\n Glycemic Control: Insulin infusion, transition to Lantus\n Lines:\n Arterial Line - 12:15 PM\n Cordis/Introducer - 12:15 PM\n PA Catheter - 12:15 PM\n 18 Gauge - 12:15 PM\n 20 Gauge - 12:15 PM\n Prophylaxis:\n DVT: (OOB today)\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Respiratory ", "chartdate": "2110-07-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 692710, "text": "Demographics\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\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 Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Exp Wheeze\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient required more sedationand therefore went\n on SIMV/PSV for the night. SPO2 decreased requiring an increase in\n FIO2 and PEEP levels. PEEP has since been reduced to 5 cm, but patient\n remains on SIMV/PSV.\n No RSBI measured per PA.\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692714, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated on propofol gtt\n Initiated precedex gtt for failed attempt to wake calmly x 2\n Pt woke and followed commands\n Had bursts of agitation\nhemodynamically unstable during\n PERRL, brisk\n MAE, nodding appropriately to questions\n SB-SR at start of shift; occasional to frequent PACs/PVCs\n SBP labile\n on neo gtt\n Hypothermic\n Epi gtt @ 0.03mcg/kg\n CI <2; MV sent +1 TR\n 56%\n Sternal dressing with serosang drainage\n Received on CPAP 50% 5/5\n CTs with initial dump s/p turn side to side\n + airleak\n checked system cannot find leak ???\n HUO marginal at start of shift\n Insulin gtt infusing\n Action:\n Precedex gtt titrated to keep pt calm and stable\n Morphine IV/SC given for pain management\n 1mg versed given x2 for extreme agitation\n Pt sitting up in bed\n O2 sat dropped 90-92% with no recovery\n CXR done; RLL diminished following agitation\n Vagal response with bursts of agitation\n A paced at 88 for BP augmentation\n Lytes repleted prn\n Neo/nitro for BP control SBP >90 <130\n Bair Hugger placed to warm\n ~2-3 L crystalloid given for low filling pressures & CI <2\n Albumin 5% given in addition\n 2 units PRBCs given for Hct 21.9 (previous 27)\n Suctioned for large amount of thick yellow x 2\n Placed back on SIMV\n + improvement with fluid\n Insulin gtt per protocol\n Response:\n Pt kept sedated overnight d/t instability of VS throughout shift on\n precedex gtt\n Pt more cooperative this am, following consistent commands\n Assisted with turning\n Did not vagal with last turn\n A Paced @ 88\n Underlying rhythm SB 50s with PVCs/junctional beats\n SBP labile\n Neo/nitro\n + response from cryst/colloid/blood products with CI >2\n Repeat Hct\n 25.5\n not treated; plan to recheck\n MDIs ordered for ^ wheezing throughout shift\n 20mg lasix given IV\n Plan:\n Wean to extubate slowly\n Wean epi per team\n Diuresis\n Monitor Hct\n Transition insulin gtt when pt taking POs\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692707, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated on propofol gtt\n Initiated precedex gtt for failed attempt to wake calmly x 2\n Pt woke and followed commands\n Had bursts of agitation\nhemodynamically unstable during\n PERRL, brisk\n MAE, nodding appropriately to questions\n SB-SR at start of shift; occasional to frequent PACs/PVCs\n SBP labile\n on neo gtt\n Hypothermic\n Epi gtt @ 0.03mcg/kg\n CI <2; MV sent +1 TR\n 56%\n Sternal dressing with serosang drainage\n Received on CPAP 50% 5/5\n CTs with initial dump s/p turn side to side\n + airleak\n checked system cannot find leak ???\n HUO marginal at start of shift\n Insulin gtt infusing\n Action:\n Precedex gtt titrated to keep pt calm and stable\n Morphine IV/SC given for pain management\n 1mg versed given x2 for extreme agitation\n Pt sitting up in bed\n O2 sat dropped 90-92% with no recovery\n CXR done; RLL diminished following agitation\n Vagal response with bursts of agitation\n A paced at 88 for BP augmentation\n Lytes repleted prn\n Neo/nitro for BP control SBP >90 <130\n Bair Hugger placed to warm\n ~2-3 L crystalloid given for low filling pressures & CI <2\n Albumin 5% given in addition d/t pt looking dry\n 2 units PRBCs given for Hct 21.9 (previous 27)\n Suctioned for large amount of thick yellow x 2\n Placed back on SIMV\n + improvement with fluid\n Insulin gtt per protocol\n Response:\n Pt kept sedated overnight d/t instability of VS throughout shift on\n precedex gtt\n Pt more cooperative this am, following consistent commands\n Assisted with turning\n Did not vagal with last turn\n Underlying rhythm SB with PVCs/junctional beats\n SBP labile\n Neo/nitro\n + response from cryst/colloid/blood products with CI >2\n Repeat Hct\n 25.5\n not treated; plan to recheck\n MDIs ordered for ^ wheezing throughout shift\n 20mg lasix given IV\n Plan:\n Wean to extubate slowly\n Wean epi per team\n Diuresis\n Monitor Hct\n" }, { "category": "Nursing", "chartdate": "2110-07-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692848, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt stable overnight. Sr no ectopy. C/o some incisional pain. Alert,\n oriented x3, mae\n Action:\n 1 percocet given, and lytes repleted. Pt diuresing large amounts from\n lasix on evening shift.\n Response:\n Pain controlled with 1 percocet .\n Plan:\n De-line and transfer to 6, start lopressor\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692703, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated on propofol gtt\n Initiated precedex gtt for failed attempt to wake calmly x 2\n Pt woke and followed commands\n Had bursts of agitation\nhemodynamically unstable during\n PERRL, brisk\n MAE, nodding appropriately to questions\n SB-SR at start of shift; occasional to frequent PACs/PVCs\n SBP labile\n on neo gtt\n Hypothermic\n Epi gtt @ 0.03mcg/kg\n CI <2; MV sent +1 TR\n 56%\n Sternal dressing with serosang drainage\n Received on CPAP 50% 5/5\n CTs with initial dump s/p turn side to side\n + airleak\n checked system cannot find leak ???\n HUO marginal at start of shift\n Insulin gtt infusing\n Action:\n Precedex gtt titrated to keep pt calm and stable\n Morphine IV/SC given for pain management\n 1mg versed given x2 for extreme agitation\n Pt sitting up in bed\n O2 sat dropped 90-92% with no recovery\n CXR done; RLL diminished following agitation\n Vagal response with bursts of agitation\n A paced at 88 for BP augmentation\n Neo/nitro for BP control SBP >90 <130\n Bair Hugger placed to warm\n ~2-3 L crystalloid given for low filling pressures & CI <2\n Albumin 5% given in addition d/t pt looking dry\n 2 units PRBCs given for Hct 21.9 (previous 27)\n Suctioned for large amount of thick yellow x 2\n Placed back on SIMV\n + improvement with fluid\n Insulin gtt per protocol\n Response:\n Pt kept down overnight d/t instability of VS throughout shift on\n precedex gtt\n Pt more cooperative this am, following consistent commands\n Assisted with turning\n Did not vagal with last turn\n Underlying rhythm SB with PVCs/junctional beats\n SBP labile\n Neo/nitro\n + response from cryst/colloid/blood products with CI >2\n Repeat Hct\n MDIs ordered for ^ wheezing throughout shift\n Plan:\n Wean to extubate\n Wean epi per team\n Diuresis\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692695, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2110-07-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692697, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received pt intubated sedated on propofol gtt\n Initiated precedex gtt for failed attempt to wake calmly x 2\n Pt woke and followed commands\n Had bursts of agitation\nhemodynamically unstable during\n PERRL, brisk\n MAE, nodding appropriately to questions\n SB-SR at start of shift; occasional to frequent PACs/PVCs\n SBP labile\n on neo gtt\n Epi gtt @ 0.03mcg/kg\n CI <2; MV sent +1 TR\n 56%\n Sternal dressing with serosang drainage\n Received on CPAP 50% 5/5\n CTs with initial dump s/p turn side to side\n + airleak\n checked system cannot find leak ???\n HUO marginal at start of shift\n Insulin gtt infusing\n Action:\n Precedex gtt titrated to keep pt calm and stable\n Morphine IV/SC given for pain management\n 1mg versed given x2 for extreme agitation\n Pt sitting up in bed\n O2 sat dropped 90-92% with no recovery\n CXR done; RLL diminished following agitation\n Vagal response with bursts of agitation\n A paced at 88 for BP augmentation\n Neo/nitro for BP control SBP >90 <130\n ~2-3 L crystalloid given for low filling pressures & CI <2\n Albumin 5% given in addition d/t pt looking dry\n 2 units PRBCs given for Hct 21.9 (previous 27)\n Suctioned for large amount of thick yellow x 2\n Placed back on SIMV\n + improvement with fluid\n Insulin gtt per protocol\n Response:\n Pt kept down overnight d/t instability of VS throughout shift on\n precedex gtt\n Underlying rhythm SB with PVCs/junctional beats\n SBP labile\n Neo/nitro\n + response from cryst/colloid/blood products with CI\n Plan:\n" }, { "category": "Nursing", "chartdate": "2110-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692661, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received from OR sedated on Propofol. 1^st attempt sedation\n vacation, became agitated, would not follow commands. O2 sat decreased\n to 90-92%. Re-sedated and attempted a second time.\n BP labile, requiring Neo and NTG gtts to maintain SBP <=130\n or MAP >=60. Epicardial wires sense and pace. Setting at a-demand of\n 60. SR underneath pacing, although junctional in OR. Pulses\n palpable. Trace generalized edema.\n Lungs clear bilaterally in all lobes. No secretions from\n ETT. Weaned to CPAP 5/5. O2 sat dropped during weaning of sedation.\n ABG drawn showing pO2 of 70. Conferred with NP . No no orders\n received.\n Abdomen soft, non-tender, absent BS. OGT to continuous\n suction ( sump). No drainage noted.\n Foley catheter draining clear yellow urine. Urine output\n decreased to ~35cc/hr.\n Skin intact other than surgical wounds. See Metavision for\n details.\n Insulin gtt started for post-OR glucose of 165.\n Wife, , very nervous about pt\ns condition. Emotional\n support provided. Wife spoke with Dr. and felt much better.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2110-07-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 692672, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Received from OR sedated on Propofol. 1^st attempt sedation\n vacation, became agitated, would not follow commands. O2 sat decreased\n to 90-92%. Re-sedated and attempted a second time. Pt still very\n anxious, not following commands, agitated. MD , pt has\n anxious personality. Will start on Precedex.\n BP labile, requiring Neo and NTG gtts to maintain SBP <=130\n or MAP >=60. Epicardial wires sense and pace. Setting at a-demand of\n 60. SR underneath pacing, although junctional in OR. Pulses\n palpable. Trace generalized edema. CI 2.1-2.4.\n Lungs clear bilaterally in all lobes. No secretions from\n ETT. Weaned to CPAP 5/5. O2 sat dropped during weaning of sedation.\n ABG drawn showing pO2 of 70. Conferred with NP . No no orders\n received.\n Abdomen soft, non-tender, absent BS. OGT to continuous\n suction ( sump). No drainage noted.\n Foley catheter draining clear yellow urine. Urine output\n decreased to ~35cc/hr.\n Skin intact other than surgical wounds. See Metavision for\n details.\n Insulin gtt started for post-OR glucose of 165.\n Wife, , very nervous about pt\ns condition. Emotional\n support provided. Wife spoke with Dr. and felt much better.\n Plan:\n Start Precedex, provide sedation vacation, wean from ventilator and\n extubate. Keep SBP < 130 while maintaining MAP >= 60.\n" }, { "category": "Respiratory ", "chartdate": "2110-07-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 692675, "text": "ETT:\n Position: 20 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: pt received from OR s/p CABG;\n no difficulty w/ ventilation; wean to extubate per protocol.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n" }, { "category": "Echo", "chartdate": "2110-07-29 00:00:00.000", "description": "Report", "row_id": 89445, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Coronary artery disease. Left ventricular function. Mitral valve disease. Valvular heart disease.\nStatus: Inpatient\nDate/Time: at 13:25\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nPoor transgastric echo windows. LV function could be grossly estimated and\nunable to measure wall thickness and LV cavity size.\nLEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast or thrombus\nin the LA/LAA or the RA/RAA. All four pulmonary veins identified and enter the\nleft atrium.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size.\n\nLV WALL MOTION: basal anterior - normal; mid anterior - normal; basal\nanteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal;\nmid inferoseptal - normal; basal inferior - normal; mid inferior - normal;\nbasal inferolateral - normal; mid inferolateral - normal; basal anterolateral\n- normal; mid anterolateral - normal; anterior apex - normal; septal apex -\nnormal; inferior apex - normal; lateral apex - normal; apex - normal;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Normal ascending aorta diameter. Mildly dilated descending aorta.\nSimple atheroma in descending aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve\nleaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The TEE probe was passed\nwith assistance from the anesthesioology staff using a laryngoscope. No TEE\nrelated complications. Suboptimal image quality - poor echo windows.\n\nConclusions:\nPRE-BYPASS: The left atrium is markedly dilated. No spontaneous echo contrast\nor thrombus is seen in the body of the left atrium/left atrial appendage or\nthe body of the right atrium/right atrial appendage. Left ventricular wall\nthicknesses and cavity size are normal. The right ventricular cavity is mildly\ndilated with normal free wall contractility. The descending thoracic aorta is\nmildly dilated. There are simple atheroma in the descending thoracic aorta.\nThere are three aortic valve leaflets. The aortic valve leaflets (3) are\nmildly thickened. There is no aortic valve stenosis. Mild (1+) aortic\nregurgitation is seen. The mitral valve leaflets are moderately thickened.\nMild to moderate (+) mitral regurgitation is seen. There is no pericardial\neffusion.\n\nPOST-CPB:\n\n1. Preserved biventricular systolci function (Possible underestimated due to\nMR).\n2. Moderate to severe mitral regurgitation\n3. MR severity improved with initiation of inotropic therapy (Epinephrine) and\ndecreased to moderate MR.\n4. NO change in TR or AI severity.\n5. No other change.\n\n\n" }, { "category": "Echo", "chartdate": "2110-07-25 00:00:00.000", "description": "Report", "row_id": 89446, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Preoperative assessment. Left ventricular function.\nHeight: (in) 67\nWeight (lb): 199\nBSA (m2): 2.02 m2\nBP (mm Hg): 143/64\nHR (bpm): 59\nStatus: Inpatient\nDate/Time: at 15:11\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Mild\nmitral annular calcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Normal PA\nsystolic 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.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nsymmetric left ventricular hypertrophy with normal cavity size and global\nsystolic function (LVEF>55%). Due to suboptimal technical quality, a focal\nwall motion abnormality cannot be fully excluded. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. Trace aortic regurgitation is\nseen. The mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is no pericardial effusion.\n\nIMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global\nbiventricular systolic function.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate prophylaxis is NOT recommended. Clinical decisions regarding the need\nfor prophylaxis should be based on clinical and echocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2110-07-29 00:00:00.000", "description": "Report", "row_id": 233553, "text": "Sinus rhythm. Low anterolateral lead T wave amplitude is non-specific. Tracing\nmay be within normal limits but clinical correlation is suggested. No previous\ntracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2110-07-29 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1093995, "text": " 11:15 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: s/p CABG w/hypoxia r/o PTX check ETT placement\n Admitting Diagnosis: CHEST PAIN\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with as above\n REASON FOR THIS EXAMINATION:\n s/p CABG w/hypoxia r/o PTX check ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 11:38 P.M., \n\n HISTORY: Hypoxia after CABG. Rule out pneumothorax and check ET tube\n placement.\n\n IMPRESSION: AP chest compared to and 18:\n\n Left lower lobe collapse unchanged. New perihilar opacification in the left\n mid lung could represent asymmetric edema or developing pneumonia. Careful\n followup advised. Right lung volume, but grossly clear. Interval increase in\n caliber of the postoperative cardiac silhouette and mild increase in\n mediastinal venous caliber suggest volume overload. Mediastinal fluid\n accumulation cannot be excluded. Swan-Ganz catheter ends in the right\n pulmonary artery, ET tube at the thoracic inlet, and a nasogastric tube can be\n traced as far as the GE junction, but the tip is indistinct. Midline and left\n pleural drains in place. No pneumothorax. was paged.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 985453, "text": " 7:30 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: left PTX?\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with hypoxia and hypotension require central line placment -\n unsucessful lt subclavian.\n REASON FOR THIS EXAMINATION:\n left PTX?\n ______________________________________________________________________________\n WET READ: DMFj MON 9:51 PM\n No left pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia and hypotension requiring central line placement;\n unsuccessful but need to assess for pneumothorax.\n\n FINDINGS: In comparison with earlier films of this date, there has been\n little change other than placement of a nasogastric tube that extends to the\n antrum of the stomach, then coils back in itself so that the tip lies just\n beneath the left hemidiaphragm. Specifically, no evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985660, "text": " 5:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Assess for interval change.\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with hypercarbic respiratory arrest.\n REASON FOR THIS EXAMINATION:\n Assess for interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hypercarbic respiratory arrest.\n\n Portable AP chest radiograph compared to , and CT torso from\n .\n\n The ET tube tip is 4.0 cm above the carina. The right internal jugular line\n tip is in mid low SVC. The NG tube passes below the diaphragm with the loop\n in the stomach with its tip at the inferior margin of the film, most likely in\n the distal stomach. The lung volumes have decreased in the meantime interval.\n The bibasilar opacities represent bilateral atelectasis. Significant\n interstitial widespread abnormality is unchanged since the previous study and\n is consistent with interstitial pulmonary edema in a setting of underlying\n abnormalities such as emphysema. There is no sizeable pleural effusion.\n There is no pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2191-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985971, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA, effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CHF, intubated on mechanical ventiallation\n REASON FOR THIS EXAMINATION:\n PNA, effusion\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient intubated and mechanically\n ventilated.\n\n Portable AP chest radiograph compared to .\n\n Current chest radiograph demonstrates extubation. There is no change in\n aortic calcifications and mild cardiomegaly. The lungs are essentially clear\n except for bibasal areas of atelectasis. There is no pleural effusion or\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-25 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 985264, "text": " 3:09 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: SOB, TACHYPNEA, ARF, ? INTERSTITIAL LUNG DISEASE, ? PULMONARY HYPERTENSION\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with sob, tachypnea, wide mediastinum on cxr and pulmonary\n hypertension on recent echo.\n REASON FOR THIS EXAMINATION:\n Evaluate pulmonary hypertension, r/o interstitial lung disease\n CONTRAINDICATIONS for IV CONTRAST:\n CKD and ARF\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST, \n\n HISTORY: Hypertension. Rule out interstitial lung disease.\n\n TECHNIQUE: Multidetector helical scanning of the chest was performed at full\n inspiration, reconstructed as contiguous 5 and 1.25 mm thick axial and 5 mm\n thick coronal images and expiration as 1.25 mm and 5 mm thick images. There\n are no prior chest CTs for comparison purposes.\n\n FINDINGS: Moderately extensive pulmonary fibrosis is not distributed in the\n typical pattern of UIP, but instead produces the most severe honeycombing in\n the upper lungs, in some areas following a peribronchovascular distribution,\n producing traction bronchiectasis, particularly the anterior segment of the\n left upper lobe, 3:22, lingula, 3:26, and the right apex 3:9, while extending\n subpleurally elsewhere, such as along the subpleural zone of the minor fissure\n in the upper lobe. Interstitial abnormality in the subpleural regions of both\n lower lobes has less extensive honeycombing and more ground glass\n opacification but may be exaggerated by dependent atelectasis. Inspiration\n views show heterogeneity in pulmonary perfusion and expiratory views document\n air trapping. There is no consolidation or any lung nodule present.\n\n Several enlarged mediastinal lymph nodes range in size to 15 mm in the right\n lower paratracheal station adjacent to calcified nodes and 22 mm in the\n subcarinal and paraesophageal stations. Hilar adenopathy, if present, is not\n as impressive. The intrapericardial right pulmonary artery is 35 mm wide\n (compared to 42 mm of the ascending thoracic aorta), an indication of severe\n pulmonary hypertension.\n\n There is no pleural or pericardial effusion. Atherosclerotic coronary\n calcification is seen in the left main and anterior descending coronary\n arteries. Atherosclerotic calcification in the thoracic aorta is heavy in the\n arch extending into the innominate artery, which is dilated at 21 mm in\n diameter, and in the descending thoracic aorta that continues\n into the abdominal portion, which is not dilated on the levels imaged. Study\n is not designed for other subdiaphragmatic diagnosis except to note normal\n size adrenal glands and no heterogeneity or obvious mass in the liver to\n suggest malignancy.\n\n IMPRESSION:\n (Over)\n\n 3:09 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: SOB, TACHYPNEA, ARF, ? INTERSTITIAL LUNG DISEASE, ? PULMONARY HYPERTENSION\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Moderately extensive interstitial lung disease with fibrosis in a pattern\n not typical for UIP suggesting fibrosing NSIP or, given the presence of\n enlarged, partially calcified lymph nodes, sarcoidosis. Langerhans cell\n histiocytosis is another possibility.\n\n 2. Severe pulmonary hypertension. Moderate air trapping, probably due to\n small airways obstruction.\n\n 3. Generalized atherosclerosis including left coronary and its branches.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 985469, "text": " 10:52 PM\n CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST Clip # \n CT PELVIS W/O CONTRAST\n Reason: eval for effusion, worsening disease, bowel distension\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with ?IPF now with worsening O2 sats, getting intubated with\n rigid abdomen, pain with palpation\n REASON FOR THIS EXAMINATION:\n eval for effusion, worsening disease, bowel distension\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old man with question IPF, worsening O2 saturation, post-\n intubation, and abdominal pain.\n\n TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and pelvis were\n obtained without the administration of intravenous contrast . Multiplanar\n reformation images are reconstructed. Intravenous contrast was not\n administered due to elevated creatinine.\n\n COMPARISON: CT Chest \n\n FINDINGS: The evaluation of major vessels and organs are limited due to lack\n of intravenous contrast .\n\n CHEST: Again note is made of markedly enlarged pulmonary arterial trunk and\n bilateral main pulmonary arteries, measuring 5 cm at the trunk. Findings are\n suggestive of pulmonary arterial hypertension in this patient with chronic\n interstitial lung disease as noted previously. Thoracic aorta is tortuous and\n atherosclerotic. Esophagus is dilated and filled with oral contrast,\n surrounding the nasogastric tube, suggestive of reflux. There are calcified\n lymph nodes in the mediastinum. Evaluation for lymphadenopathy is somewhat\n limited due to lack of intravenous contrast . There is no pericardial\n effusion. Coronary arteries are calcified, and there is moderate cardiomegaly.\n The patient is post-intubation, with endotracheal tube terminating just below\n the thoracic inlet, and right IJ line terminating in the SVC.\n\n Lung windows demonstrate diffuse interstitial lung disease with peripheral\n distribution which is grossly stable from study performed 1 day prior. There\n has been increase in bibasilar atelectasis. No pleural effusions are present.\n\n ABDOMEN: The evaluation of major organs and vessels are limited due to lack\n of intravenous contrast as well as streak related to patient position\n with arms by his sides.\n\n There is no evidence of free air, free fluid, fluid collection, or bowel\n dilatation. Stomach is somewhat distended with contrast and nasogastric tube\n is terminating in the antrum. Gallbladder is distended with layering\n hyperattenuating material. No definite liver, splenic or pancreatic lesion is\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: eval for effusion, worsening disease, bowel distension\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n Field of view: 36\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n noted. Adrenal glands are unremarkable. Vascular calcifications are noted in\n renal hilum. There is no evidence of hydronephrosis. Atherosclerotic disease\n of the aorta is noted, with two infrarenal aneurysms, measuring 3.8 x 3.8 cm\n and 3.4 x 3 0.2 cm. There is ectatic appearance of the iliac arteries with\n calcification.\n\n PELVIS: There is no evidence of free air, free fluid, or fluid collection.\n Appendix is normal. Formed stool is noted within the rectum. There are\n bilateral fat-containing inguinal hernias. Extensive vascular calcifications\n are noted.\n\n There are extensive degenerative changes of thoracolumbar spine. There is no\n evidence of suspicious lytic or blastic lesion.\n\n IMPRESSION:\n\n 1. Diffuse interstitial lung disease stable from CT chest performed 1 day\n prior with interval increase in bibasilar atelectasis.\n\n 2. Enlarged pulmonary arteries likely related to underlying pulmonary\n hypertension.\n\n 3. Moderate cardiomegaly.\n\n 4. Infrarenal aortic aneurysms and iliac artery ectasia with underlying\n marked atherosclerotic disease.\n\n 6. Distended gallbladder containing sludge. Ultrasound may be obtained if\n there is concern for acute gallbladder disease.\n\n 7. Limited assessment due to lack of intravenous contrast and artifact\n from the arms.\n\n Preliminary report provided by Dr. and discussed with Dr. at\n 3:50 a.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985064, "text": " 8:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CHF exacerbation now s/p diuresis for several days,\n with lower O2 Sat\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST.\n\n REASON FOR EXAM: CHF exacerbation, now S/P diuresis and persistent low\n oxygenation.\n\n Comparison is made with prior study dated .\n\n The aorta is elongated. Mild cardiomegaly is stable. There are low lung\n volumes. There is persistent increase in the interstitial markings that still\n suggests mild interstitial pulmonary edema. There is small bilateral pleural\n effusion.\n\n jr\n\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2191-09-25 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 985236, "text": " 9:07 AM\n CHEST (PA & LAT) Clip # \n Reason: Evaluate for pleural effusions and infiltrates\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with acute diastolic CHF, CKD\n REASON FOR THIS EXAMINATION:\n Evaluate for pleural effusions and infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST, \n\n HISTORY: Acute diastolic CHF. Possible pleural effusion or pneumonia.\n\n IMPRESSION: PA and lateral chest compared to :\n\n Mild multifocal interstitial pulmonary abnormality unchanged. Small region of\n consolidation at the base of the right lung is new or newly apparent could be\n pneumonia or aspiration. Heart is top normal size. Thoracic aorta is\n generally large. Pleural effusion, if any, is minimal. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 985467, "text": " 10:28 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: eval line placement r/o pneumothorax\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with hypoxia now s/p RIJ cath placement\n REASON FOR THIS EXAMINATION:\n eval line placement r/o pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia with right IJ catheter placement.\n\n FINDINGS: In comparison with earlier studies of this date, there has been\n placement of a right IJ catheter that extends to the mid superior vena cava at\n the level of the carina. No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 984468, "text": " 6:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: 89 yo malwe with cc sob\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CHF exacerbation now s/p diuresis for several days\n\n REASON FOR THIS EXAMINATION:\n 89 yo malwe with cc sob\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: CHF exacerbation status post diuresis.\n\n COMPARISON: CXR and multiple priors.\n\n UPRIGHT PORTABLE CHEST: A mildly enlarged heart size and dilated, calcified\n aorta are unchanged allowing for technique. Compared to , there\n are more prominent interstitial markings, bilaterally, suggesting edema.\n Bilateral small pleural effusions are likely. Subtle opacity at left base may\n represent atelectasis. No pneumothorax is seen.\n\n IMPRESSION: Interstitial pulmonary edema. Recommend follow-up radiographs\n after diuresis to exculde pneumonic consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 985437, "text": " 5:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CHF exacerbation, in resp distress now intubated.\n REASON FOR THIS EXAMINATION:\n ET tube placement\n ______________________________________________________________________________\n WET READ: DMFj MON 9:31 PM\n ETT 4 cm above carina in good position.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with earlier films of this date, there has been\n placement of an endotracheal tube with its tip approximately 4 cm above the\n carina. Otherwise little change.\n\n\n" }, { "category": "Radiology", "chartdate": "2191-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 984628, "text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA, pleural effusion\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with CHF exacerbation now s/p diuresis for several days\n\n REASON FOR THIS EXAMINATION:\n PNA, pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 89-year-old male with CHF exacerbation status post diuresis for\n several days. Evaluate for pneumonia or pleural effusion.\n\n COMPARISON: .\n\n AP UPRIGHT CHEST RADIOGRAPH: The patient's head overlies the medial right and\n left lung apices. There has been a slight decrease in bilateral interstitial\n opacity consistent with improved pulmonary edema. There are probably small\n bilateral effusions.\n\n IMPRESSION: Slight improvement in mild pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2191-09-22 00:00:00.000", "description": "RENAL U.S.", "row_id": 984890, "text": " 5:24 PM\n RENAL U.S. Clip # \n Reason: EVAL FOR HYDR/ BPH.ARF\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 89 year old man with ARF on CKD stage 3, BPH, CHF, HTN, atrial fibrillation\n REASON FOR THIS EXAMINATION:\n Evaluate kidneys, ureters, bladder and prostate for obstruction,\n hydronephrosis, or BPH\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure.\n\n No prior studies for comparison.\n\n RENAL ULTRASOUND: This study is technically limited. The right kidney\n measures 8.0 cm. The left kidney measures 8.5 cm. There is no hydronephrosis\n bilaterally. A Foley catheter is seen within a collapsed bladder.\n\n IMPRESSION:\n 1. Limited evaluation. No hydronephrosis.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-10-01 00:00:00.000", "description": "Report", "row_id": 1646685, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: DISCHARGE PLANNING IN PROGRESS. UPDATED PT.'S FAMILY REGUARDING POOR PROGNOSIS AND THEY AGREED TO HOSPICE CARE PER PT.'S WISHES. AGREED TO TAKE PT. BACK FOR HOSPICE CARE, HOWEVER, FAMILY STATED, \"HE IS TOO SICK TO GO BACK YET.\" MD'S TO SPEAK TO PT.'S FAMILY TODAY REGUARDING PLAN OF CARE. UNABLE TO REACH THIS SHIFT.\n\nNEURO: PT. AROUSES TO VOICE. DOES ANSWER QUESTIONS APPROPRIATELY. FOLLOWS SIMPLE COMMANDS. NO C/O PAIN. APPEARED COMFORTABLE THIS SHIFT.\n\nRESP: PT. ON 5L NASAL CANNULA AND 40% FACE TENT WITH SATS >95%. CONTINUES ON NEBS Q4H. BREATH SOUNDS COARSE THROUGHOUT ALL LUNG FIELDS. PT. DOES COUGH UP COPIOUS AMOUNTS OF THICK GREEN SPUTUM BUT CANNOT CLEAR. SUCTIONED BACK OF THROAT NUMEROUS TIMES. NO NT SUCTIONING DONE AS PT.'S INR ELEVATED TO 6.2.\n\nCV: PT. REMAINS IN NSR/ST WITH FREQUENT PVC'S. (UNCHANGED) SBP 120'S TO 140'S. + PULSES. GENERALIZED EDEMA NOTED. TMAX 99.8. REMAINS ON VANCO Q48H. K+ 3.3 REPLETED WITH 20MEQ LAST EVENING. AM LABS PENDING.\n\nGI: ABD. SOFT. BS+. NOT TOLERATING PO'S. PT.'S FAMILY REFUSING PEG PLACEMENT. ? START TPN. PT. HAD SMALL BM THIS SHIFT. GUIAC NEGATIVE.\n\nGU: FOLEY IN PLACE DRAINING BLOOD TINGED URINE. (MD'S AWARE) GOOD OUTPUT\n\nSKIN: STAGE I ON COCCYX. DUODERM CHANGED THIS SHIFT.\n\nACCESS: R IJ TL\n\nPLAN: CONTINUE WITH CURRENT . LEANING MORE TOWARDS PT.'S COMFORT. HE IS A DNR/DNI. DATE OF TRANSFER BACK TO UNKNOWN AT THIS TIME. MD'S TO SPEAK WITH PT.'S FAMILY. UNABLE TO CONTACT THIS SHIFT. CONTINUE WITH AGGRESSIVE PULMONARY TOILET AND ANTIBIOTIC THERAPY. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2191-10-01 00:00:00.000", "description": "Report", "row_id": 1646686, "text": "ADDENDUM TO NPN 7P-7A\nAM K+ 2.8. REPLETED WITH 40MEQ KCL. MD'S WOULD LIKE K+ RECHECKED PRIOR TO FURTHER K REPLETION AS PT. IS IN RENAL FAILURE\n" }, { "category": "Nursing/other", "chartdate": "2191-10-01 00:00:00.000", "description": "Report", "row_id": 1646687, "text": "Discharged at 16:00 to --hospice in stable condition w/ DNR/DNI formed completed. Reported called to RN. Family in to visit per to discharge and updated.\u0013\n" }, { "category": "Nursing/other", "chartdate": "2191-09-27 00:00:00.000", "description": "Report", "row_id": 1646673, "text": "0700-1500\nneuro: sedated on fentanyl/versed gtts, opens eyes to stimuli, no response to command, agitated @ times needing versed bolus, moving all extremites\n\ncv: hr nsr, no ectopy, sbp stable(104-135)\n\nresp: on 40% cpap ps, bs+ all lobes, course, diminished to bases, sux sm amt thick tan sputum, sat 96-100, inhalers by R.T.\n\ngi: npo, ogt clamped, no N/V, incont mod amt formed brown guiac negative stool, po prevacid\n\ngu: foley patent, clear yellow urine, good uo, U/A sent\n\nother: sister called & updated on pt's condition, LG amt bleeding noted from site of R ij mlc, ho aware, stitch & pressure applied, bleeding stopped, no pain noted\n\nplan: continue with ventilatory support, wean as tolerated, iv antibiotics as ordered\n\n" }, { "category": "Nursing/other", "chartdate": "2191-09-27 00:00:00.000", "description": "Report", "row_id": 1646674, "text": "BS fine crackles bibasilar/posterior; otherwise 2+ diminshed; no change with MDI's. Weaned to PSV 5/5. Pt exhibits periodic respiration - no apnea but Vt's increasing from 150-450 and then decreasing.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-28 00:00:00.000", "description": "Report", "row_id": 1646675, "text": "Nursing Note:\n\nNeuro: pt remains sedated, versed gtt 2mg/hr, fentanyl 50mcs/hr. pt opens eyes to voice, denied pain nonverbally (nodding head). sqeezed hands per command.\n\nResp: remains intubated. vent CPAP FIO2 0.40. sats 96-97. lungs diminished bilaterally. suction sm amt thick tan.\n\nCV: HR 90-100 SR, freq PVC's, vent trigemeny noted during night. BP 100-115/50-60. afebrile. significant edema lower extremities, weak distal pulses.\n\nGU/GI: foley intact, urine output marginal (see careview). abd soft, pos BS, no BM overnight. OGT clamped.\n\nIV: r IJ TLC intact, r radial aline intact.\n\nSocial: no calls/visits from pts family overnight.\n\nPlan: continue to wean vent as tolerated, cont to monitor/assess for pain, cont to monitor vitals, urine output, and labs. cont to provide emotional support for pt.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-09-28 00:00:00.000", "description": "Report", "row_id": 1646676, "text": "resp care\nPt initially on psv5/peep5 and 40%. Changed to psv10 due to volumes to 200cc and rr inc to 30's. Current volumes are 350cc and rr 25. BS coarse bil. Suct for sml-mod amts of thick tan sput.Alb/atro mdi given as ordered.RSBI=93. Will cont to follow and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-28 00:00:00.000", "description": "Report", "row_id": 1646677, "text": "Nursing progress note: DNR/DNI (not to be reintubated).\n\nPlease see flowsheet for more details\n\nNeuro: Sedated on fent/versed gtts. Responsive to light touch and voice. Stiffens w/ touching and repositioning.\n\nPulm: CPAP 5/10/40%. Lungs coarse/diminished. Suctioned for small amt of thick yellow secretions q3-4hrs. RR regular and unlabored.\n\nCV: NSR-ST w/ frequent ectopy at times. HR 89-116. BP 92/51 - 121/66. Afebrile. CVP 6-10. R L ext lymphedema > L L ext.\n\nGI/GU: + bs noted. Abd is soft, NT, ND. No BM for my shift. Oral sump in place. NPO except meds. Foley in place w/ low uo.\n\nAccess: RIJ central line. L rad a-line.\n\nPlan: Monitor per protocol. Replete lytes as needed. Cont. to wean vent as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-28 00:00:00.000", "description": "Report", "row_id": 1646678, "text": "BS coarse crackles; no change with MDI's. Suctioned for moderate amount tan secretions. No vent changes or ABG's. DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-29 00:00:00.000", "description": "Report", "row_id": 1646679, "text": "RESPIRATORY CARE\nPt remains intubated on vent support. Vent settings unchanged this shift. Unable to tol decrease on PSV, Vt too small. AM RSBI 109. No ABG values this shift. Sx for large amounts tenacious tan and yellow secretions.\nPlan Wean from vent support as tol.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-21 00:00:00.000", "description": "Report", "row_id": 1646665, "text": "NPN 1900-0700:\nNeuro: alert, oriented x3, calm, cooperative, follows commands consistently, MAEs.\n\nResp: breathing regularly on O2 NC 4 LPM, RR 22-29, Sat 92-100%, LS CTA to coarse at bases, coughing but not expectorating.\n\nCV: Frequent PVCs NSR, BP 118-133/52/83, with one PIV line, edematous lower extremities elevated over pillow, potassium in pm was 3.4 repleted with 60 meQ KCL PO increased to 5.9 with am labs, cardiac enzymes CK decreased from 180 to 129, CKMB decreased from 4 to 3.\n\nGI/GU: abdomen soft, BS present, passed one golden color soft BM, with Foley cath drained adequate U/O, tolerated crushed meds with apple sauce and water.\n\nInteg: T max 97.6, FS 115, all washed out.\n\nSocial: family visited and updated on , pt is /DNR.\n\nPlan: continue same tx, most likely to be called out, transfer note written, needs to be updated.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-29 00:00:00.000", "description": "Report", "row_id": 1646680, "text": "MICU NPN\nNEURO: CONTINUES TO BE SEDATED WITH FENTANYL 25MCG AND VERSED 1MG. RESPOND TO TOUCH AND PAIN.\n\nRESP: NO CHANGES TO VENT, SX FOR LARGE AMTS. OF THICK YELLOW PLUGS. VENT ON CPAP/PS 10, PEEP OF 5, FIO2 40%.\n\nCV: HR 90-120'S ST, FREQ.PVC'S HAD 10 BEAT RUN OF V-TACH, BP STABLE SEE CAREVUE FOR MOST UP TO DATE VITAL SIGNS.\n\nGI/GU: CONTINUES TO BE NPO, OGT IN PLACE, U/O DK. CLOUDY AND REMAIN LOW.\n\nSOCIAL: FAMILY IN VISITING LAST NIGHT, TEAM SPOKE TO FAMILY ABOUT PT'S CONDITION.\n\nPLAN: PT. IS A DNR/ NOT REINTUBATE, ? EXTUBATE TODAY AND MAKE COMFORT CARE.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-29 00:00:00.000", "description": "Report", "row_id": 1646681, "text": "RESPIRATORY CARE: PT EXTUBATED TODAY W/ AN RSBI\nOF 70-75 TO AN AEROSOL MASK .40. SPO2 98 %. RR\n18-26 BPM. WILL MONITOR RESPIRATORY STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-29 00:00:00.000", "description": "Report", "row_id": 1646682, "text": "Nursing progress note: DNR/DNI\n\nNeuro: Responsive to voice and nodding y/n questions. Conts to deny pain/discomfort. Opens eyes only to commands.\n\nPulm: Weaned to 6L NC w/ stable 02 sats. Lungs coarse w/ noted crackles to bases. Nonproductive cough noted. RR regular and unlabored.\n\nCV: NSR-ST w/ mulitfocal PVC's. HR 95-127. BP 95/61 -- 135/72. T. max 100.4 (ax). Left leg lymphedema noted. + weak pulses x 4.\n\nGI/GU: + bs noted. Abd is soft, nt, nd (obese). No bm noted. Foley in place w/ amber cloudy urine.\n\nID: vancomycin q48hrs.\n\nAccess: RIJ central line.\n\nPlan: Cont. to monitor per protocol. Replete lytes as needed. Family scheduled to come in to visit this afternoon. Pt. remains DNR/DNI, but not moved to comfort care at present.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-30 00:00:00.000", "description": "Report", "row_id": 1646683, "text": "MICU NPN\nNEURO: RESPONDS TO VOICE, NODDING Y/N TO QUESTIONS. FOLLOWS SIMPLE COMMANDS.\n\nRESP: IN O2 VIA N/C AT 6L, SATS 96-98%. LUNG SOUNDS UNCHANGED,\n\nCV: HR 90-120'S CONTINUES TO HAVE FREQUENT PVC'S. CONTINUES WITH BILATERAL LOWER LEG EDEMA LEFT LEG BIGGER THAN RIGHT.\n\nGI/GU: NO BM, FOLEY PATENT DRAINING CLOUDY AMBER COLERED URINE.\n\nSOCIAL: FAMILY IN VISITING LAST NIGHT.\n\nPLAN: DNR/DNI, ? CALLOUT OT FLOOR OR BACK TO NURSING HOME.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-30 00:00:00.000", "description": "Report", "row_id": 1646684, "text": " 4 ICU NPN 0700-1900\nOpens eyes to voice. Appears to nod & shake head appropriately to \"yes, no\" questions. Follows simple commands. No verbal response. Unable to take PO meds. Positive cough reflex. Minimal gag reflex. Mouth care Q4 hrs. Yankauer suctioned back of oropharanyx several X's. Initially copious amts thick, yellow secretions. Currently small to mod amts of same. Afeb. SBP 125/56-161/90, HR 92-120 Sr, St with frequent VEA.\nReceiving D5W for NA 153.\nCoags elevated\nUO adequate. Family phoned & updated.\n , case manager, investigating if Cooldge House would accept pt back for palliative care. If so, this option needs to be discussed with family\nA/P;\nNo sig. change.Remains DNR/DNI. Continue oral/mouth care. Yankaur suction PRN. NPO Aspiration precautions.\nDispo pnd- ? callout to floor.\nSupport to pt & family\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-09-21 00:00:00.000", "description": "Report", "row_id": 1646666, "text": "Nursing Note:\n\nNeuro: pt 3, pleseant, calm, cooperative. denies pain. OOB to chair for several hours during day, required full two person assist r/t very weak gait.\n\nResp: sats 90-96 on 4L NC, RR 25-35, lungs clear upper, crackles lower bases. dry non productive cough.\n\nCV: HR 75-90 SR w/ freq PVC's. BP stable (see careview). afebrile. repleated w/ 40meq PO KCL r/t lasix dosing.\n\nGI/GU: abd soft, pos bowel sounds, no BM. tolerating full liquid diet, took meds mixed in pudding today. foley cath intact, UO adequate (see careview), cont PO lasix dosing.\n\nIV: pts PIV infiltrated today and was D/C'd. pt has no IV access and is difficult venipuncture. IV RN evaluated pt for PICC placement on and pt would need to go to IR. medical team aware of lack of access but holding on placing PICC r/t pts clinical condition and need.\n\nSkin: skin dry and intact, significant edema in lower extremities.\n\nPlan:\npt presently C/O to medical floor and awaiting bed, transfer note updated. pt is DNR/DNI. cont to update pt on plan of care.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-09-22 00:00:00.000", "description": "Report", "row_id": 1646667, "text": " 4 NURSING PROGRESS NOTE 0900\nFOR NURSING PROGRESS NOTE PLEASE REFER TO NURSING TRANSFER NOTE IN \"NURSING TRANSFER NOTE\" SECTION OF CAREVIEW. THANK YOU.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-26 00:00:00.000", "description": "Report", "row_id": 1646668, "text": "Respiratory care\nPt pea arrest on floor, intubated with 8.0 taped at 20 at lip transfered to unit placed on a/c vent.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-26 00:00:00.000", "description": "Report", "row_id": 1646669, "text": "NPN\n\n Pt with a past med hx of CHF, HTN, chronic lyphadema/venous stasis, BPH, pulm fibrosis, multiple falls, he was a DNR/DNI but he reversed this on the floor. He was on 11R where he vomited then dropped his SATs to the low 80s, able to maintain his SAT in the high 90s on 100% but was intubated on the floor and taken to the MICU. He arrived on a dopa gtt, told that they did do \"some\" compressions on him.\n\nNeuro: Pt has woken periodically, given 2 mg of IV versed with good effect.\n\nCV: Remains on dopa periferally, the team is trying to place a CL now. His BP has ranged 75-130s, WAP with frequent PVCs, his HR does go up to the 130s with an increased dose of dopa.\n\nResp: Exp wheezes throughout, no changes were made on the vent.\n\nGI: His abd is soft and distended, per the team it was firm while on the floor. He has had 2 stools since admit OB neg, sent for cdif. An OGT was placed, it is draining pink fluid which is also OB neg - about 300cc has drained so far. After his CL is placed and he is stable he will have a CT of his abd.\n\nGU: Poor u/o, foley in place.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2191-09-27 00:00:00.000", "description": "Report", "row_id": 1646670, "text": "MSICU NPN 7P-7A\nTHIS IS AN 89Y/O MALE WITH H/O CHF WITH DIASTOLIC DYSFUNCTION, PULM HTN, HTN, VENOUS STASIS, CKD WITH BASELINE CREAT 1.7-2.\n\nPT WAS INITIALLY ADMITTED TO FOR HYPOXIA THAT WAS FELT TO BE D/T CHF EXACERBATION. DIURESED AND R/O'D FOR MI. TRANSITIONED TO 50% FACE MASK WITH STABLE O2 SATS. CHEST CT SIGN FOR MODERATELY EXTENSIVE ILD WITH FIBROSIS AND SEVERE PULM HTN. WAS TRANSFERRED TO THE FLOOR ON . AT THE TIME WAS DNR/DNI.\n\nON IN THE AFTERNOON WAS NOTED TO HAVE A DISTENDED ABD AND C/O MILD ABD PAIN. WAS BEING EVALED BY S&S AND WAS FOUND TO BE TACHYPNEIC ON 5L N/C WITH SATS 90%. GURGLING AIRWAY AND SXTED. HE THEN VOMITED AND SATS DROPPED TO 81%. GIVEN LASIX, PLACED ON NRB WITH RR ~40 AND WORSENING RESP DISTRESS. ABD NOW FIRM AND DISTENDED. WAS INTUBATED FOR PROGRESSIVE HYPOXIC RESP FAILURE. GIVEN PROPOFOL AND SUCCS AND AFTER INTUBATION HAD PEA ARREST. CPR AND EPI X1MIN BEFORE RECOVERY OF PULSE. NOT SURE WHEN HE REVERSED HIS CODE STATUS. DURING INTUBATION HAD LGE VOLUME BROWN STOOL.\n\nRECEIVED PT ON DOPA GTT (6MCG) WITH SBP IN THE 140'S AND HR 120' ATTEMPTING TO PLACE CVL IN LSC.\n\nNEURO: RECEIVED ADDITIONAL 2MG VERSED X2 FOR ATTEMPTED LINE PLACEMENT. LATER WAS BRIEFLY ON PROPOFOL FOR ART LINE INSERTION, BUT REMOVED AS BP FALLING. LATER PLACED ON FENTANYL AND VERSED GTTS. FENT @25MCG AND VERSED @2MG. PT CALM WHEN LEFT ALONE BUT WILL AROUSE TO VOICE OR MINIMAL STIMULUS AND WILL ATTEMPT TO REACH FOR ETT AND THRASH HEAD TO MOUTH CARE. SOFT WRIST RESTRAINTS IN PLACE FOR SAFETY OF LINES AND TUBES. WILL OPEN EYES, MAE, AND FOLLOWING COMMANDS INCONSISTENTLY.\n\nCARDIAC: AS MENTIONED RECEIVED PT ON 6MCG OF DOPA. ABLE TO TITRATE TO OFF WITHIN THE HOUR WITH IMPROVED HR AND MAINTAINED SBP 90-110'S. HE 75-120'S SR/ST WITH FREQUENT ECTOPY. BP 85-143/49-69 VIA ART LINE. HCT 38.4/36.8 STOOL OB (-). EVENING INR 2.3. BLEEDING FROM CVL SITE.\n\nRESP: RECEIVED ON A/C 500X16 100% +5PEEP. RR 16-20 BUT UNABLE TO OBTAIN SATS. ABG 7.46/49/380/36. FIO2 DECREASED TO 50%. LS COARSE WITH BIBASILAR CRACKLES TO CLEAR/COARSE WITH DIMINISHED BASES. SXTED FOR VERY LITTLE. AM RSBI 92, PLACED ON WITH ABG 7.41/59/120/39. RR 24-25. DECREASED FIO2 TO 40%.\n\nGI/GU: ABD SOFT AND DISTENDED WITH HYPOACTIVE TO +BS. BROWN LOOSE TO BROWN SOFT STOOL. OGT IN PLACE AND PATENT. RECEIVED PT WITH OGT TO LWS AND AND IT WAS DRAINING PINKISH COLORED FLUID. HAD TOTAL OF 350CC. WHEN PT TURNED DURING THE NIGHT FOR CARE HE BECAME AGITATED AND VOMITED BARICAT. HAD CT OF TORSO WHICH HAS NOT BEEN READ BUT PER RESIDENT AND SURGICAL TEAM IT WAS UNREMARKABLE. UOP BRISK 60-160CC/HR. CREAT REMAINS 2.7.\n\nFEN: RECEIVED 1L IVF AT START OF SHIFT FOR LOW BP. +~1L. PERIPHERAL EDEMA PRESENT. LYTES PER CAREVUE. NEEDING TO REPLETE POTASSIUM. WILL CHECK FS Q6HRS WITH SS COVERAGE. NPO FOR NOW.\n\nID: TMAX 97.5 WITH WBC . HAVE SENT ONE SET OF BLOOD CX AND STOOL FOR CDIFF. HAS RECEIVED VANCO AND ZOSYN X1 EACH AND FLAGYL. NEED ID APPROVAL FOR ZOSYN TO CONTINUE.\n\nSKIN: 3 SMALL ABRASIONS/\n" }, { "category": "Nursing/other", "chartdate": "2191-09-27 00:00:00.000", "description": "Report", "row_id": 1646671, "text": "MSICU NPN 7P-7A\n(Continued)\nULCERS ON LEFT BUTTOCK. DUODERM APPLIED. LEFT LEG LARGER THAN RIGHT PVD, THIS IS NOT NEW.\n\nACCESS: PIV, RIGHT ART LINE, RIJ CVL THAT CONTINUES TO OOZE.\n\nSOCIAL/DISPO: FULL CODE. SISTER, BROTHER, AND VISITING LAST NOC. ALL UPDATED BY MD. PLAN TO CONTINUE TO WEAN VENT AS TOLERATED, FINAL READS ON CT'S, ABX THERAPY, FOLLOW LYTES AND REPLETE PRN, SURGERY FOLLOWING.\n" }, { "category": "Nursing/other", "chartdate": "2191-09-27 00:00:00.000", "description": "Report", "row_id": 1646672, "text": "Respiratory Care\nPt intubated on vent support. Transport to and from CAT Scan w/o incident. AM RSBI 93. Mode of ventilation changed to PS. ABG metabolically compensated respiratory acidosis with hyperoxia, FiO2 decreased.\nPlan: continue to wean to extubation when stable.\n" }, { "category": "ECG", "chartdate": "2191-09-19 00:00:00.000", "description": "Report", "row_id": 191167, "text": "Baseline artifact precludes definite assessment. Rhythm appears to be resting\nsinus tachycardia with frequent ventricular premature beats and occasional\natrial premature beats. Borderline left axis deviation. Relatively low limb\nlead voltage. Possible underlying anteroseptal myocardial infarction.\nNon-specific ST-T wave changes. Possible prior inferior wall myocardial\ninfarction. Compared to previous tracing of heart rate is faster.\nDecreased R wave in lead V2 is noted. Clinical correlation is suggested.\nRepeat tracing is recommended to confirm atrial mechanism.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2191-09-26 00:00:00.000", "description": "Report", "row_id": 190944, "text": "A-V dissociation with sinus rhythm and atrial premature beats. Sinus\nrate is about 70. There is a narrow escape, just slightly slower than\nthat. The escape has a low limb lead voltage leftward configuration.\nSince previous tracing of A-V dissociation is now present.\nClinical correlation is suggested. The narrow complex rhythm here is\nthe same as during conducted sinus rhythm on . Clinical correlation is\nsuggested.\n\n" }, { "category": "ECG", "chartdate": "2191-09-24 00:00:00.000", "description": "Report", "row_id": 190945, "text": "Sinus tachycardia, rate 90. Left anterior hemiblock. Left atrial abnormality.\nOccasional ventricular premature beats. Probable anteroseptal myocardial\ninfarction of indeterminate age. Cannot exclude inferior myocardial\ninfarction.\n\n" }, { "category": "ECG", "chartdate": "2191-09-20 00:00:00.000", "description": "Report", "row_id": 191166, "text": "Baseline artifact precludes definite assessment. Underlying atrial mechanism\ncannot be determined with certainty and could be sinus rhythm with atrial\npremature beats, although atrial fibrillation should be excluded with\nhigher quality recording. Frequent ventricular premature beats are also noted\nwith two consecutive ventricular premature beats at the very end of the\nrecording. Compared to the previous tracing of multiple other\nabnormalities are as reported. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1260539, "text": " 6:49 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: RESPIRATORY DISTRESS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Respiratory distress.\n\n FINDINGS: In comparison with the study of , the patient has taken a\n somewhat poorer inspiration. Again, the heart is at the upper limits of\n normal in size and there is diffuse prominence of interstitial markings\n consistent with vascular congestion. Opacifications at the bases are\n suggestive of aspiration pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2191-09-26 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1260540, "text": " 6:50 PM\n PORTABLE ABDOMEN Clip # \n Reason: RESPIRATORY DISTRESS\n Admitting Diagnosis: CONGESTIVE HEART FAILURE\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Respiratory distress.\n\n A SINGLE SUPINE PORTABLE ABDOMINAL RADIOGRAPH\n\n Comparison is made to CT examination of the torso subsequently obtained on\n same date.\n\n FINDINGS: The large bowel is diffusely gas filled and mildly prominent in\n caliber measuring approximately 5.8 cm in diameter at the level of the\n sigmoid. No evidence of pneumatosis or free air. No abnormally dilated loops\n of small bowel are present. Multilevel degenerative changes are present within\n the lower lumbar spine.\n\n IMPRESSION:\n\n Gas distended and mildy prominent large bowel. Please refer to subsequent CT\n abdomen/pelvis for further evaluation.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2136-03-15 00:00:00.000", "description": "Intensivist Note", "row_id": 527168, "text": "CVICU\n HPI:\n 77 year old male POD # 1 from CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag,\n SVG>PLV). Extubated successfuly. Post-op hypotension requiring\n neosynephrine. AV paced (junctional rhythm post-op with a 4 sec pause)\n Chief complaint:\n PMHx:\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n Current medications:\n 24 Hour Events:\n NASAL SWAB - At 01:58 PM\n OR RECEIVED - At 01:58 PM\n INVASIVE VENTILATION - START 01:58 PM\n ARTERIAL LINE - START 02:50 PM\n PA CATHETER - START 02:51 PM\n CORDIS/INTRODUCER - START 02:51 PM\n EKG - At 03:08 PM\n INVASIVE VENTILATION - STOP 04:06 PM\n EXTUBATION - At 07:32 PM\n PA CATHETER - STOP 06:31 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:00 AM\n Infusions:\n Phenylephrine - 0.5 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:58 PM\n Ranitidine (Prophylaxis) - 04:32 PM\n Midazolam (Versed) - 04:43 PM\n Morphine Sulfate - 02:22 AM\n Other medications:\n Flowsheet Data as of 09:53 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: 37.1\nC (98.7\n HR: 69 (69 - 90) bpm\n BP: 98/47(63) {61/36(47) - 162/97(126)} mmHg\n RR: 19 (0 - 27) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 76.7 kg (admission): 65.7 kg\n Height: 68 Inch\n CVP: 10 (1 - 10) mmHg\n PAP: (37 mmHg) / (14 mmHg)\n CO/CI (Thermodilution): (5.83 L/min) / (3.3 L/min/m2)\n SVR: 878 dynes*sec/cm5\n SV: 73 mL\n SVI: 41 mL/m2\n Total In:\n 6,918 mL\n 392 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,393 mL\n 392 mL\n Blood products:\n 500 mL\n Total out:\n 1,935 mL\n 970 mL\n Urine:\n 1,645 mL\n 700 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,983 mL\n -578 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 525 (525 - 525) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 97%\n ABG: 7.38/42/158/28/-2\n Ve: 8.9 L/min\n PaO2 / FiO2: 316\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular), (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, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), (Responds to: Verbal\n stimuli), Moves all extremities\n Labs / Radiology\n 204 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 107 mEq/L\n 137 mEq/L\n 29.7 %\n 8.0 K/uL\n [image002.jpg]\n 11:35 AM\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n WBC\n 12.9\n 8.0\n Hct\n 31\n 32\n 32\n 30.7\n 29.5\n 29.7\n Plt\n 172\n 204\n Creatinine\n 0.6\n 0.6\n TCO2\n 30\n 27\n 26\n 25\n 24\n Glucose\n 110\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 year old male POD # 1 from CABG x4 (LIMA>LAD,\n SVG>RAMUS, SVG>Diag, SVG>PLV). Extubated successfuly. Post-op\n hypotension requiring neosynephrine. AV paced (junctional rhythm\n post-op with a 4 sec pause)\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Percocet and\n morphine with adequate pain control.\n Cardiovascular: Aspirin, Statins, Still requires neosynephrine for BP\n control. Wean as tolerated. Start b-blocker once off neosynephrine\n Pulmonary: IS, Get OOB --> chair\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Hold off on diuresis for now. start once\n off neosynephrine drip. Autodiuresing\n Hematology: Serial Hct, Post-op anemia. Monitor for now\n Endocrine: RISS, BG well controlled. Goal BG < 150\n Infectious Disease: Periop cefazolin. No evidence of infection\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Imaging:\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:50 PM\n Cordis/Introducer - 02:51 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: ICU\n Total time spent: 25 minutes\n" }, { "category": "Physician ", "chartdate": "2136-03-15 00:00:00.000", "description": "ICU Note - CVI", "row_id": 527169, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag, SVG>PLV)\n Ejection Fraction:45\n Hemoglobin A1c:5.6\n Pre-Op Weight:145.28 lbs 65.9 kgs\n Baseline Creatinine:0.8\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n PMHx: HTN, hypercholesterolemia, prostate adenocarcimona, depression,\n anxiety, osteoarthritis, tonsillectomy, hernia repair\n Current medications:\n 2. 3. 250 mL D5W 4. Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN 8. Dextrose 50% 9. Docusate Sodium 10. Insulin 11. Magnesium\n Sulfate 12. Metoclopramide 13. Milk of Magnesia 14. Morphine Sulfate\n 15. Nitroglycerin 16. Oxycodone-Acetaminophen 17. Phenylephrine 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Ranitidine 21. Simvastatin 22. Sodium Chloride 0.9% Flush 23.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 01:58 PM\n OR RECEIVED - At 01:58 PM\n INVASIVE VENTILATION - START 01:58 PM\n ARTERIAL LINE - START 02:50 PM\n CORDIS/INTRODUCER - START 02:51 PM\n PA CATHETER - START 02:51 PM\n EKG - At 03:08 PM\n INVASIVE VENTILATION - STOP 04:06 PM\n EXTUBATION - At 07:32 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:22 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:58 PM\n Ranitidine (Prophylaxis) - 04:32 PM\n Midazolam (Versed) - 04:43 PM\n Morphine Sulfate - 02:22 AM\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: 37.5\nC (99.5\n T current: 37.3\nC (99.1\n HR: 80 (80 - 90) bpm\n BP: 117/54(75) {61/36(47) - 162/97(126)} mmHg\n RR: 20 (0 - 27) insp/min\n SPO2: 100%\n Heart rhythm: A Paced\n Height: 68 Inch\n CVP: 7 (1 - 10) mmHg\n PAP: (34 mmHg) / (12 mmHg)\n CO/CI (Thermodilution): (5.83 L/min) / (3.3 L/min/m2)\n SVR: 851 dynes*sec/cm5\n SV: 73 mL\n SVI: 41 mL/m2\n Total In:\n 6,918 mL\n 245 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,393 mL\n 245 mL\n Blood products:\n 500 mL\n Total out:\n 1,935 mL\n 580 mL\n Urine:\n 1,645 mL\n 400 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,983 mL\n -335 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 525 (525 - 525) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 100%\n ABG: 7.38/42/158/28/-2\n Ve: 8.9 L/min\n PaO2 / FiO2: 316\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 204 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 107 mEq/L\n 137 mEq/L\n 29.7 %\n 8.0 K/uL\n [image002.jpg]\n 11:35 AM\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n WBC\n 12.9\n 8.0\n Hct\n 31\n 32\n 32\n 30.7\n 29.5\n 29.7\n Plt\n 172\n 204\n Creatinine\n 0.6\n 0.6\n TCO2\n 30\n 27\n 26\n 25\n 24\n Glucose\n 110\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L\n Assessment and Plan\n Neurologic: Neuro checks Q: 4 hr, Pain controlled on percocet\n Cardiovascular: Aspirin, Statins, beta-blocker being held while on\n neo. Plan to wean neo with goal MAP >60. SR 60 being paced for\n output/blood pressure.\n Pulmonary: IS, cough and deep breath, OOB to chair once off neo.\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO, diurese once blood pressure can tolerate it.\n Hematology: stable anemia\n Endocrine: Insulin drip overnight, transitioned to sliding scale\n insulin, goal BG < 150\n Infectious Disease: for periop antibiotics (cefazolin), wbc 8 thou -\n no evidence of infection\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition: Heart healthy\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 02:50 PM\n Cordis/Introducer - 02:51 PM\n PA Catheter - 02:51 PM\n 16 Gauge - 02:53 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor if weaned, ICU otherwise\n" }, { "category": "Nursing", "chartdate": "2136-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527281, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Initially pt with no underlying HR. A and V wires capture and\n sense. C/O incisional pain with marginal relief from Percocet. C/DB/IS\n q 1HR, IS to 750cc.\n Action:\n Rechecked pacer at 9am, SR with HR 60\n Pain med switched to Dilaudid with improved effect.\n CT draining s/s, no leak noted.\n Periperal IV started.\n Response:\n Pt more comfortable.\n Pt regained rthymn\n Plan:\n Offer pain med.\n Monitor lytes/bs\n Pulm hygiene.\n D/C ct in am.\n Pacer in Ademand.\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527338, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pleasant, cooperative, A&Ox3\n c/o incisional pain , especially with coughing and movement\n SR 60s-70s\n SBP >90 on 0.5mcg neo\n LS clear, using IS on own\n + nonproductive cough\n CT + , serosang drainage\n Adequate HUO\n Action:\n Dilaudid 4mg given Q3-4 hours\n Turned Q2 in bed\n Encouraged pt to continue with sternal precautions to help with pain\n Weaned Neo slowly 0.3mcg\n Response:\n Pt with adequate pain relief\n Slept on and off throughout the night\n Marginal BP with neo gtt weaned off\n Plan:\n Restart neo if SBP <90\n Pain management\n Pulmonary toilet\n ^ Activity\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527521, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain that was worse with\n coughing\n Action:\n -Medicated patient with 2 Percocet tabs every 4 hours and IVP Torodal\n 15 mg every 6 hours x24hrs\n Response:\n -Pain score after pain meds given\n Plan:\n -Manage incisional pain with Percocet tabs and Torodal\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair and dizziness\n resolved..\n -Lungs clear bilaterally and sats>95% on room air. He used IS to 750ml\n and he had a weak nonproductive cough\n -Chest tubes were d/c\nd and CXR done\n -Foley d/c\nd and he voided dark yellow urine\n -FS 154 max\n -OOB to chair most of the day\n Action:\n -Gave 1L LR over 1 hour. Told PA, who ordered repeat HCT to\n be drawn.\n -Gave regular insulin per unit sliding scale\n Response:\n -SBP initially low 100\ns then dropped back down to80\ns-90\ns-> Notified\n PA. It was decided to A pace at 90 to keep SBP>100.\n HCT 31.2\n -Patient voided small amounts dark yellow urine x1.\n Plan:\n -Pulmonary toileting with IS every hour\n -Slowly increase activity\n A pace at 90 to keep SBP>100\n -Manage FS with SSI per unit protocal\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527524, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain that was worse with\n coughing\n Action:\n -Medicated patient with 2 Percocet tabs every 4 hours and IVP Torodal\n 15 mg every 6 hours x24hrs\n Response:\n -Pain score after pain meds given\n Plan:\n -Manage incisional pain with Percocet tabs and Torodal\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair and dizziness\n resolved.\n -Lungs clear bilaterally and sats>95% on room air. He used IS to 750ml\n and he had a weak nonproductive cough\n -Chest tubes were d/c\nd and CXR done\n -Foley d/c\nd and he voided dark yellow urine\n -FS 154 max\n -OOB to chair most of the day\n Action:\n -Gave 1L LR over 1 hour. Told PA, who ordered repeat HCT to\n be drawn.\n -Infusing 500ml of 5% Albumin over 2 hours\n -Gave regular insulin per unit sliding scale\n Response:\n -SBP initially low 100\ns then dropped back down to80\ns-90\ns-> Notified\n PA. It was decided to A pace at 90 to keep SBP>100.\n HCT 31.2\n -Patient voided small amounts dark yellow urine x1.\n Plan:\n -Pulmonary toileting with IS every hour\n -Slowly increase activity\n A pace at 90 to keep SBP>100\n -Manage FS with SSI per unit protocal\n" }, { "category": "Physician ", "chartdate": "2136-03-16 00:00:00.000", "description": "Generic Note", "row_id": 527446, "text": "TITLE:\n CVICU\n HPI:\n 77 year old male POD # 2 from CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag,\n SVG>PLV). Extubated successfuly post-op but complicated by hypotension\n requiring neosynephrine, which was weaned off overnight. Post-op AV\n paced (junctional rhythm post-op with a 4 sec pause), now in SR in the\n 70s\n Chief complaint:\n PMHx:\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n Current medications:\n 24 Hour Events:\n : Weaned off Neo . HD stable.\n ARTERIAL LINE - STOP 06:22 PM\n CHEST TUBE REMOVED - At 06:46 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:00 PM\n Ranitidine (Prophylaxis) - 08:01 AM\n Other medications:\n Flowsheet Data as of 08:39 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: 37.1\nC (98.8\n HR: 72 (61 - 79) bpm\n BP: 109/56(69) {89/44(53) - 133/72(86)} mmHg\n RR: 22 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.9 kg (admission): 65.7 kg\n Height: 68 Inch\n Total In:\n 1,820 mL\n 377 mL\n PO:\n 1,200 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 620 mL\n 257 mL\n Blood products:\n Total out:\n 1,910 mL\n 515 mL\n Urine:\n 1,400 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -90 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic), Cardiac rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffuse, Diminished: -basilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 190 K/uL\n 9.9 g/dL\n 87 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 135 mEq/L\n 29.7 %\n 12.0 K/uL\n [image002.jpg]\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n 01:46 AM\n WBC\n 12.9\n 8.0\n 12.0\n Hct\n 32\n 32\n 30.7\n 29.5\n 29.7\n 29.7\n Plt\n 172\n 204\n 190\n Creatinine\n 0.6\n 0.6\n 0.7\n TCO2\n 27\n 26\n 25\n 24\n Glucose\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n 87\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L,\n Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 year old male POD # 2 from CABG x4 (LIMA>LAD,\n SVG>RAMUS, SVG>Diag, SVG>PLV). Extubated successfuly post-op but\n complicated by hypotension requiring neosynephrine, which was weaned\n off overnight. Post-op AV paced (junctional rhythm post-op with a 4 sec\n pause), now in SR in the 70s.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain well controlled\n on dilaudid PO and morphine. Will change to percocet. Try to minimize.\n Will start toradol for pain control and the rub on auscultation. Resume\n home zoloft\n Cardiovascular: Aspirin, Beta-blocker, Statins, HD stable. Heart block\n resolved in SR currently. B-blocker started.\n Pulmonary: IS, Get OOB --> chair.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Continue to diurese to keep 1-2 L negative\n today, BUN/Cr=18/0.7\n Hematology: Serial Hct, Stable anemia. Monitor for now\n Endocrine: RISS, BG well controlled. Goal BG < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today-post pull shows No PTX\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 02:51 PM\n 20 Gauge - 06:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2136-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527680, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt into afib at 0100, sbp decreased to 84/ urine ouput inaccurate\n secondary to incontinent times 2\n Action:\n Piv # 18 placed in right lower forearm, amioderone bolus 150 mg at\n 0130 followed by amioderone drip at 1mg/min for 6 hours and then\n decrease to .5 mg/min times 18 hours. Lr bolus 500 cc. lytes drawn.\n Bladder scan at 0530 =125 cc\n Response:\n Sbp initially responded to bolus sbp 107/ but sbp later drifted down\n to 86/ neo started at 1 mg/min,titrated down to .8 mg/min. lytes\n returned mag =2.2,K=4.4, hct = 26.5 ( decreased from 31.2)\n Plan:\n Keep sbp> 100 with neo, monitor and check with ho regarding need for\n more volume.\n" }, { "category": "Nursing", "chartdate": "2136-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527113, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert, orientedx3, c/o incisional pain with deep breathe/turning in\n bed. Pt A paced at 80, no underlying rhythm. On neo most of noc for\n goal sbp 90, map 60. chest tubes with sang\nserosang drainage no leak\n +minimal crepitus. Lungs sound diminished bilat. Pedal pulses palp,\n skin warm and dry. Good urine output. HCT stable. On cefazolin\n Action:\n Monitored, treated pain with morphine IV, pulm hygiene. Insulin gtt\n per cvicu protocol. Insulin minimal dose this AM with blood glucose\n trending down so gtt shut off with no RISS admin. Positioned for\n comfort. PA line d/c this AM PA. pulm hygiene coached.\n Response:\n Stabilizing blood pressure overnoc. Stable HCT. Good pain control\n with minimal morphine dose. Stable with paced rhythm,\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527118, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pt alert, orientedx3, c/o incisional pain with deep breathe/turning in\n bed. Pt A paced at 80, no underlying rhythm. On neo most of noc for\n goal sbp 90, map 60. chest tubes with sang\nserosang drainage no leak\n +minimal crepitus. Lungs sound diminished bilat. Pedal pulses palp,\n skin warm and dry. Good urine output. HCT stable. On cefazolin\n Action:\n Monitored, treated pain with morphine IV, pulm hygiene. Insulin gtt\n per cvicu protocol. Insulin minimal dose this AM with blood glucose\n trending down so gtt shut off with no RISS admin. Positioned for\n comfort. PA line d/c this AM PA. pulm hygiene coached.\n Response:\n Stabilizing blood pressure overnoc. Stable HCT. Good pain control\n with minimal morphine dose. Stable with paced rhythm.\n Plan:\n Continue to monitor. Remains paced. Pain control and pulm hygiene.\n ?maintain central access while pacer dependent. Encourage PO\n tolerating liquids.\n" }, { "category": "Physician ", "chartdate": "2136-03-16 00:00:00.000", "description": "Intensivist Note", "row_id": 527403, "text": "CVICU\n HPI:\n 77 year old male POD # 2 from CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag,\n SVG>PLV). Extubated successfuly post-op but complicated by hypotension\n requiring neosynephrine, which was weaned off overnight. Post-op AV\n paced (junctional rhythm post-op with a 4 sec pause), now in SR in the\n 70s\n Chief complaint:\n PMHx:\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n Current medications:\n 24 Hour Events:\n ARTERIAL LINE - STOP 06:22 PM\n CHEST TUBE REMOVED - At 06:46 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:00 PM\n Ranitidine (Prophylaxis) - 08:01 AM\n Other medications:\n Flowsheet Data as of 08:39 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: 37.1\nC (98.8\n HR: 72 (61 - 79) bpm\n BP: 109/56(69) {89/44(53) - 133/72(86)} mmHg\n RR: 22 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.9 kg (admission): 65.7 kg\n Height: 68 Inch\n Total In:\n 1,820 mL\n 377 mL\n PO:\n 1,200 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 620 mL\n 257 mL\n Blood products:\n Total out:\n 1,910 mL\n 515 mL\n Urine:\n 1,400 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -90 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///30/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic), Cardiac rub\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n diffuse, Diminished: -basilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 190 K/uL\n 9.9 g/dL\n 87 mg/dL\n 0.7 mg/dL\n 30 mEq/L\n 4.2 mEq/L\n 18 mg/dL\n 103 mEq/L\n 135 mEq/L\n 29.7 %\n 12.0 K/uL\n [image002.jpg]\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n 01:46 AM\n WBC\n 12.9\n 8.0\n 12.0\n Hct\n 32\n 32\n 30.7\n 29.5\n 29.7\n 29.7\n Plt\n 172\n 204\n 190\n Creatinine\n 0.6\n 0.6\n 0.7\n TCO2\n 27\n 26\n 25\n 24\n Glucose\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n 87\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L,\n Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 year old male POD # 2 from CABG x4 (LIMA>LAD,\n SVG>RAMUS, SVG>Diag, SVG>PLV). Extubated successfuly post-op but\n complicated by hypotension requiring neosynephrine, which was weaned\n off overnight. Post-op AV paced (junctional rhythm post-op with a 4 sec\n pause), now in SR in the 70s.\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain well controlled\n on dilaudid PO and morphine. Will change to percocet. Try to minimize.\n Will start toradol for pain control and the rub on auscaltation. On\n zoloft\n Cardiovascular: Aspirin, Beta-blocker, Statins, HD stable. Heart block\n resolved in SR currently. B-blocker started.\n Pulmonary: IS, Get OOB --> chair.\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Continue to diurese to keep 1-2 L negative\n today\n Hematology: Serial Hct, Stable anemia. Monitor for now\n Endocrine: RISS, BG well controlled. Goal BG < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 02:51 PM\n 20 Gauge - 06:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status:\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2136-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527010, "text": "Extremely labile bp with low filling pressures,brisk dilute appearing\n huo treated with warming,volume,neo titration & pacing rate adjustments\n with improvremrnt. Ci remains > 2. underlying rhythm sb 50\ns,remains a\n paced for chronotropy.mild crepitus noted anterior chest bilaterally,no\n air leak observed. Scant sero sang ct dng.\n" }, { "category": "Physician ", "chartdate": "2136-03-15 00:00:00.000", "description": "ICU Note - CVI", "row_id": 527085, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag, SVG>PLV)\n Ejection Fraction:45\n Hemoglobin A1c:5.6\n Pre-Op Weight:145.28 lbs 65.9 kgs\n Baseline Creatinine:0.8\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n Chief complaint:\n PMHx:\n Current medications:\n 2. 3. 250 mL D5W 4. Acetaminophen 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN 8. Dextrose 50%\n 9. Docusate Sodium 10. Insulin 11. Magnesium Sulfate 12. Metoclopramide\n 13. Milk of Magnesia 14. Morphine Sulfate\n 15. Nitroglycerin 16. Oxycodone-Acetaminophen 17. Phenylephrine 18.\n Pneumococcal Vac Polyvalent 19. Potassium Chloride\n 20. Ranitidine 21. Simvastatin 22. Sodium Chloride 0.9% Flush 23.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n NASAL SWAB - At 01:58 PM\n OR RECEIVED - At 01:58 PM\n INVASIVE VENTILATION - START 01:58 PM\n ARTERIAL LINE - START 02:50 PM\n CORDIS/INTRODUCER - START 02:51 PM\n PA CATHETER - START 02:51 PM\n EKG - At 03:08 PM\n INVASIVE VENTILATION - STOP 04:06 PM\n EXTUBATION - At 07:32 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:22 AM\n Infusions:\n Phenylephrine - 0.3 mcg/Kg/min\n Other ICU medications:\n Dextrose 50% - 02:58 PM\n Ranitidine (Prophylaxis) - 04:32 PM\n Midazolam (Versed) - 04:43 PM\n Morphine Sulfate - 02:22 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: 37.5\nC (99.5\n T current: 37.3\nC (99.1\n HR: 80 (80 - 90) bpm\n BP: 117/54(75) {61/36(47) - 162/97(126)} mmHg\n RR: 20 (0 - 27) insp/min\n SPO2: 100%\n Heart rhythm: A Paced\n Height: 68 Inch\n CVP: 7 (1 - 10) mmHg\n PAP: (34 mmHg) / (12 mmHg)\n CO/CI (Thermodilution): (5.83 L/min) / (3.3 L/min/m2)\n SVR: 851 dynes*sec/cm5\n SV: 73 mL\n SVI: 41 mL/m2\n Total In:\n 6,918 mL\n 245 mL\n PO:\n Tube feeding:\n IV Fluid:\n 6,393 mL\n 245 mL\n Blood products:\n 500 mL\n Total out:\n 1,935 mL\n 580 mL\n Urine:\n 1,645 mL\n 400 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 4,983 mL\n -335 mL\n Respiratory support\n O2 Delivery Device: Face tent\n Ventilator mode: Standby\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 525 (525 - 525) mL\n PS : 5 cmH2O\n RR (Set): 10\n RR (Spontaneous): 0\n PEEP: 0 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 100%\n ABG: 7.38/42/158/28/-2\n Ve: 8.9 L/min\n PaO2 / FiO2: 316\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 204 K/uL\n 10.0 g/dL\n 82 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 15 mg/dL\n 107 mEq/L\n 137 mEq/L\n 29.7 %\n 8.0 K/uL\n [image002.jpg]\n 11:35 AM\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n WBC\n 12.9\n 8.0\n Hct\n 31\n 32\n 32\n 30.7\n 29.5\n 29.7\n Plt\n 172\n 204\n Creatinine\n 0.6\n 0.6\n TCO2\n 30\n 27\n 26\n 25\n 24\n Glucose\n 110\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L\n Assessment and Plan\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, effective\n Cardiovascular: Aspirin, Statins,\n Pulmonary: IS, cough and deep breath, OOB to chair\n Gastrointestinal / Abdomen: bowel regimen\n Nutrition: Clear liquids, Advance diet as tolerated\n Renal: Foley, Adequate UO,\n Hematology: stable anemia\n Endocrine: Insulin drip, goal BG < 150\n Infectious Disease: for periop antibiotics, wbc 15 increased post op\n recheck in am - no evidence of infection\n Lines / Tubes / Drains: Foley, Surgical drains (hemovac, JP), Chest\n tube - pleural , Chest tube - mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion\n Lines:\n Arterial Line - 02:50 PM\n Cordis/Introducer - 02:51 PM\n PA Catheter - 02:51 PM\n 16 Gauge - 02:53 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2136-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527825, "text": "POD #4\n Coronary artery bypass graft (CABGx4)\n Assessment:\n PT A&Ox3, MAE, appropriate, pleasant. HR NSR sbp 120-150\ns, no ectopy\n noted this shift on amio gtt. Lungs clear UL, dim LL on 2 L NC. Pulses\n palpable, bowel sounds present, skin intact, UOP adequate. Wires\n attached\n Action:\n Pt had post-op afib, on amio gtt\n Has exp wheezing noted with exertion i.e. coughing, out of bed to\n chair, resolves with rest\n Turned per protocol\n Glucose treated per ss\n One assist out of bed\n A and V wires sense and capture\n Pt up to commode x1\n Pain treated with percocet\n MD placed coude catheter. Pt has h/o TURP\n Response:\n Amio transitioned to PO this am, gtt discontinued one hour later\n Pt remains on 2L NC\n No BM this shift, passing gas\n Wires set for AAI backup 50\n UOP adequate, no issues with catheter post placement\n Pt bathed this evening, dressings changed\n Plan:\n Transfer to 6 this AM. Coude catheter to stay in per urology\n" }, { "category": "Nursing", "chartdate": "2136-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527827, "text": "POD #4\n Coronary artery bypass graft (CABGx4)\n Assessment:\n PT A&Ox3, MAE, appropriate, pleasant. HR NSR sbp 120-150\ns, no ectopy\n noted this shift on amio gtt. Lungs clear UL, dim LL on 2 L NC. Pulses\n palpable, bowel sounds present, skin intact, UOP adequate. Wires\n attached\n Action:\n Pt had post-op afib, on amio gtt\n Has exp wheezing noted with exertion i.e. coughing, out of bed to\n chair, resolves with rest\n Turned per protocol\n Glucose treated per ss\n One assist out of bed\n A and V wires sense and capture\n Pt up to commode x1\n Pain treated with percocet\n MD placed coude catheter. Pt has h/o TURP\n Tolerating lasix 20IV \n Lytes monitored\n Response:\n Amio transitioned to PO this am, gtt discontinued one hour later\n Pt remains on 2L NC\n No BM this shift, passing gas\n Wires set for AAI backup 50\n UOP adequate, no issues with catheter post placement\n Pt bathed this evening, dressings changed\n Pt continues to Diurese well from lasix\n Lytes repleated\n Plan:\n Transfer to 6 this AM. Coude catheter to stay in per urology\n" }, { "category": "Nursing", "chartdate": "2136-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527891, "text": "POD #4\n Coronary artery bypass graft (CABGx4)\n Assessment:\n PT A&Ox3, MAE, appropriate, pleasant. HR NSR sbp 120-150\ns, no ectopy\n noted this shift on amio gtt. Lungs clear UL, dim LL on 2 L NC. Pulses\n palpable, bowel sounds present, skin intact, UOP adequate. Wires\n attached\n Action:\n Pt had post-op afib, on amio gtt\n Has exp wheezing noted with exertion i.e. coughing, out of bed to\n chair, resolves with rest\n Turned per protocol\n Glucose treated per ss\n One assist out of bed\n A and V wires sense and capture\n Pt up to commode x1\n Pain treated with percocet\n MD placed coude catheter. Pt has h/o TURP\n Tolerating lasix 20IV \n Lytes monitored\n Response:\n Amio transitioned to PO this am, gtt discontinued one hour later\n Pt remains on 2L NC\n No BM this shift, passing gas\n Wires set for AAI backup 50\n UOP adequate, no issues with catheter post placement\n Pt bathed this evening, dressings changed\n Pt continues to Diurese well from lasix\n Pt has not received any lopressor as of yet\n Lytes repleated\n Glucose of 127 treated @ 0400 with 2 units of regular sc\n Plan:\n Transfer to 6 this AM. Coude catheter to stay in per urology\n Pt requests pastoral care to be called.\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527517, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair.\n -Lungs clear bilaterally and sats>95% on room air. He used IS to 750ml\n and he had a weak nonproductive cough\n -Chest tubes were d/c\nd and CXR done\n -Foley d/c\nd and he voided dark yellow urine\n -FS 154 max\n -OOB to chair most of the day\n Action:\n -Gave 1L LR over 1 hour. Told PA, who ordered repeat HCT to\n be drawn.\n -Gave regular insulin per unit sliding scale\n Response:\n -SBP initially low 100\ns then dropped back down to80\ns-90\n -Patient voided small amounts dark yellow urine x1.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527501, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair.\n -Lungs clear bilaterally and sats>95% on room air. He used IS to 750ml\n and he had a weak nonproductive cough\n -Chest tubes were d/c\nd and CXR done\n -Foley d/c\nd and he voided dark yellow urine\n -FS 154 max\n -OOB to chair most of the day\n Action:\n -Gave 1L LR over 1 hour. Told PA, who ordered repeat HCT to\n be drawn.\n -Gave regular insulin per unit sliding scale\n Response:\n -SBP initially low 100\ns then dropped back down to80\ns-90\n -Patient voided small amounts dark yellow urine x1.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527493, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527496, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527547, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n -Patient c/o sternotomy incisional pain that was worse with\n coughing\n Action:\n -Medicated patient with 2 Percocet tabs every 4 hours and IVP Torodal\n 15 mg every 6 hours x24hrs\n Response:\n -Pain score after pain meds given\n Plan:\n -Manage incisional pain with Percocet tabs and Torodal\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair and dizziness\n resolved.\n -Lungs clear bilaterally and sats>95% on room air. He used IS to 750ml\n and he had a weak nonproductive cough\n -Chest tubes were d/c\nd and CXR done\n -Foley d/c\nd and he voided dark yellow urine\n -FS 154 max\n -OOB to chair most of the day\n Action:\n -Gave 1L LR over 1 hour. Told PA, who ordered repeat HCT to\n be drawn.\n -Infusing 500ml of 5% Albumin over 2 hours\n -Gave regular insulin per unit sliding scale\n Response:\n -SBP initially low 100\ns then dropped back down to80\ns-90\ns-> Notified\n PA. It was decided to A pace at 90 to keep SBP>100. SBP\n improved after receiving the Albumin and A pacing\n -HCT 31.2\n -Patient voided small amounts dark yellow urine x1.\n Plan:\n -Pulmonary toileting with IS every hour\n -Slowly increase activity\n -A pace at 90 to keep SBP>100\n -Manage FS with SSI per unit protocal\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527498, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Coronary artery bypass graft (CABG)\n Assessment:\n NSR 70\ns-80\ns and occasional PAC\ns. Epicardial pacer set at 50 A-demand\n backup. A and V wires sense and pace appropriately.\n -Sbp hypotensive 80\ns and 90\ns. The SBP was orthostatic 76 when he\n stood up with the physical therapist and he c/o feeling dizzy. SBP\n rapidly increased to 82 after being seated in the chair.\n -Lungs clear bilaterally and sats>95% on room air.\n -Chest tubes were d/c\nd and CXR done\n -\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2136-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527801, "text": " c x 4 lima->lad,vg->ramus,diag,plvb heavily calcified vessels\n noted otherwise uneventful. av paced for junctional.\n POD #3 Coronary artery bypass graft (CABG)\n Assessment:\n Atrial fibrillation this A.M. on Amiodarone gtt. Later A. flutter noted\n with 4:1 ratio for a short duration, then NR followed by NSR (60s).\n SBP continued to require Neosynephrine till mid day. SBP to 160 with\n simultaneous, brief wheezing with exertion (getting in and out of bed).\n HCT ~ 26. Breath sounds with bilateral crackles this A.M. Intermittent\n use of nasal oxygen as noted. Taking heart healthy diet. Unable to void\n substantial amount of urine in bed, sitting on commode or standing at\n commode. Pt reports TURP in the past and needing a catheter for 1\n month. Pt focused on trying to move bowels today. OOB to commode and\n on bedpan. No stool today. Pt requested and took Bisacodyl po. Oriented\n x 3. Ambulated in with physical therapist (while on monitor). c/o\n minimal chest discomfort. SSRI for glucose > 120.\n Action:\n Atrial wire EKG done but converted to NR from A. Flutter\n just as atrial wire EKG about to record\n 1 unit PRBC given\n #16 Fr catheter placed in bladder but unable to advance,\n unable to inflate balloon (pt c/o pain)\n small amount of bloody\n drainage with catheter insert attempt\n PA to attempt foley catheter insertion\n Continue of Amiodarone .5mg/min till 0330\n Start Amiodarone po at 0230\n see \n Response:\n Able to wean off Neosynephrine\n Rash noted at the time PRBC completing. Pt denied urticaria. Macular\n rash noted at back, lower abd and thighs.\n Converted from atrial fibrillation to NSR.\n Unable to empty bladder.\n Plan:\n Monitor blood pressure\n Reassess rash\n Check for bowel movement\n Check I&O\n Bladder catheter insert this evening\n" }, { "category": "Physician ", "chartdate": "2136-03-17 00:00:00.000", "description": "Generic Note", "row_id": 527753, "text": "TITLE:\n TITLE:\n CVICU\n HPI:\n 77 year old male POD # 3 from CABG x4 (LIMA>LAD, SVG>RAMUS, SVG>Diag,\n SVG>PLV). Extubated successfuly post-op but complicated by hypotension\n requiring neosynephrine, which was weaned off overnight. Post-op AV\n paced (junctional rhythm post-op with a 4 sec pause), now in SR in the\n 70s\n Chief complaint:\n PMHx:\n PMH: HTN, ^chol, Prostate adenocarcinoma, Depression, Anxiety,\n Osteoarthritis, ? prior MI on EKG, degenerative disk disease L4-5,\n Tonsillectomy, Bilateral inguinal hernia repair >10 yrs ago\n : HCTZ 25', lisinopril 10', Toprol XL 100', Zoloft 50', simvastatin\n 40', Cialis 20 prn, ascorbic acid 500', ASA 81', COMPLEX VITAMINS\n [B-50], CALCIUM CARBONATE-VITAMIN D3, GLUCOSAMINE, FISH OIL\n Current medications:\n 24 Hour Events:\n :On/off Neo. AF overnight.->Amio drip.HD stable\n ARTERIAL LINE - STOP 06:22 PM\n CHEST TUBE REMOVED - At 06:46 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 08:00 AM\n Infusions:\n Other ICU medications:\n Hydromorphone (Dilaudid) - 03:00 PM\n Ranitidine (Prophylaxis) - 08:01 AM\n Other medications:\n Flowsheet Data as of 08:39 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: 37.1\nC (98.8\n HR: 72 (61 - 79) bpm\n BP: 109/56(69) {89/44(53) - 133/72(86)} mmHg\n RR: 22 (12 - 25) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.9 kg (admission): 65.7 kg\n Height: 68 Inch\n Total In:\n 1,820 mL\n 377 mL\n PO:\n 1,200 mL\n 120 mL\n Tube feeding:\n IV Fluid:\n 620 mL\n 257 mL\n Blood products:\n Total out:\n 1,910 mL\n 515 mL\n Urine:\n 1,400 mL\n 375 mL\n NG:\n Stool:\n Drains:\n Balance:\n -90 mL\n -138 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 96%\n ABG: ///30/\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: Crackles :\n diffuse, Diminished: -basilar), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 166 K/uL\n g/dL\n 114 mg/dL\n 0.9 mg/dL\n 29 mEq/L\n 4.4 mEq/L\n 25 mg/dL\n 99 mEq/L\n 133 mEq/L\n 26.5 %\n 8 K/uL\n [image002.jpg]\n 12:22 PM\n 01:08 PM\n 02:10 PM\n 02:30 PM\n 04:28 PM\n 05:02 PM\n 06:11 PM\n 03:43 AM\n 03:51 AM\n 01:46 AM\n WBC\n 12.9\n 8.0\n 12.0\n Hct\n 32\n 32\n 30.7\n 29.5\n 29.7\n 29.7\n Plt\n 172\n 204\n 190\n Creatinine\n 0.6\n 0.6\n 0.7\n TCO2\n 27\n 26\n 25\n 24\n Glucose\n 176\n 115\n 64\n 106\n 126\n 75\n 82\n 87\n Other labs: PT / PTT / INR:15.8/44.2/1.4, Lactic Acid:2.7 mmol/L,\n Ca:7.8 mg/dL, Mg:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 77 year old male POD # 2 from CABG x4 (LIMA>LAD,\n SVG>RAMUS, SVG>Diag, SVG>PLV). .\n :On/off Neo. AF overnight.->Amio\n drip.HD stable\n Neurologic: Neuro checks Q: 4 hr, Pain controlled, Pain well controlled\n on percocet.,Zoloft\n Cardiovascular: Aspirin, Beta-blocker, Statins, HD stable. Cont Amio,\n convert to PO when drip protocol finished->converted to NSR\n Pulmonary: IS, Get OOB --> chair. CXR today to eval tamponade\n w/+/-Neo/oliguria\n Gastrointestinal / Abdomen: Bowel regimen\n Nutrition: Regular diet\n Renal: Failed to void->straight cathed. Lasix. Repeat lytes PND.\n Hematology: Serial Hct, Tx 1uPRBC for HCT=26.5, PLTs stable=166\n Endocrine: RISS, BG well controlled. Goal BG < 150\n Infectious Disease: No evidence of infection\n Lines / Tubes / Drains: Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today-no widening mediastinum evident\n Fluids: KVO\n Consults: CT surgery, P.T.\n Billing Diagnosis: Arrhythmia, Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Cordis/Introducer - 02:51 PM\n 20 Gauge - 06:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: full code\n Dispo :Remains in CVICU today for pressor requirement/oliguria\n" }, { "category": "Nursing", "chartdate": "2136-03-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527725, "text": " c x 4 lima->lad,vg->ramus,diag,plvb heavily calcified vessels\n noted otherwise uneventful. av paced for junctional.\n POD #3 Coronary artery bypass graft (CABG)\n Assessment:\n Atrial fibrillation this A.M. on Amiodarone gtt. Later A. flutter noted\n with 4:1 ratio for a short duration, then NR followed by NSR (60s).\n SBP continued to require Neosynephrine. HCT ~ 26.\n Action:\n Atrial wire EKG done but converted to NR from A. Flutter just at EKG\n about to record\n 1 unit PRBC given\n Response:\n Able to wean off Neosynephrine\n Rash noted at the time PRBC completing. Pt denied urticaria. Macular\n rash noted at back, lower abd and thighs.\n Plan:\n" }, { "category": "Rehab Services", "chartdate": "2136-03-17 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 527730, "text": "Subjective:\n good spirits\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for patient education\n Updated medical status: hgb 9.2, hct 26.5; afib overnoc, brief aflutter\n this a.m., currently in SR; on Neo .7; received blood\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n NA\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n Head of bed up, used bedrail\n\n\n\n T\n\n\n Transfer:\n NA\n\n\n\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n Pushing w/c\n\n\n T\n\n\n\n Stairs:\n NA\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 Sitting 2 min\n Sitting 7 min\n 60\n 66\n 115/63\n 91/55\n 116/73\n 16\n 21\n 93% RA\n Activity\n Stand\n 72\n unable to obtain\n 25\n 92% RA\n Recovery\n Supine\n 65\n 126/59\n Total distance walked: 125'\n Minutes:\n Gait: amb 125' pushing w/c with CG-- slow cadence, wide BOS\n Education / Communication: patient ed: sternal precautions, plan of\n care\n Other: reports pain in sternum - well controlled\n IS x10 to 1250mL\n cough with cough pillow-- strong, effective\n Assessment: 77m POD3 CABG x4. Patient initially hypotensive sitting\n edge of bed but improved with time. Able to tolerate ambulation\n pushing w/c. Anticipate will be able to progress to safe for d/c home\n with 1-2 more treatments.\n Anticipated Discharge: Home without PT\n : Continue per plan\n Face time: 12:15-13:00\n" }, { "category": "Nursing", "chartdate": "2136-03-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 527908, "text": "POD #4\n Coronary artery bypass graft (CABGx4)\n Assessment:\n PT A&Ox3, MAE, appropriate, pleasant. HR NSR sbp 120-150\ns, no ectopy\n noted this shift on amio gtt. Lungs clear UL, dim LL on 2 L NC. Pulses\n palpable, bowel sounds present, skin intact, UOP adequate. Wires\n attached\n Action:\n Pt had post-op afib, on amio gtt\n Has exp wheezing noted with exertion i.e. coughing, out of bed to\n chair, resolves with rest\n Turned per protocol\n Glucose treated per ss\n One assist out of bed\n A and V wires sense and capture\n Pt up to commode x1\n Pain treated with percocet\n MD placed coude catheter. Pt has h/o TURP\n Tolerating lasix 20IV \n Lytes monitored\n Response:\n Amio transitioned to PO this am, gtt discontinued one hour later\n Pt remains on 2L NC\n No BM this shift, passing gas\n Wires set for AAI backup 50\n UOP adequate, no issues with catheter post placement\n Pt bathed this evening, dressings changed\n Pt continues to Diurese well from lasix\n Pt has not received any lopressor as of yet\n Lytes repleated\n Glucose of 127 treated @ 0400 with 2 units of regular sc\n Plan:\n Transfer to 6 this AM. Coude catheter to stay in per urology\n Pt requests pastoral care to be called.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Height:\n 68 Inch\n Admission weight:\n 65.7 kg\n Daily weight:\n 77 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,prostate ca s/p\n brachytherapy,depression,anxiety,oa,djd l4-5,+ ett cath->mvd.\n tte->ef50-55%,mild mr,ar A1c 5.6%,creat. 0.8\n Surgery / Procedure and date: c x 4\n lima->lad,vg->ramus,diag,plvb heavily calcified vessels noted\n otherwise uneventful. av paced for junctional.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:73\n Temperature:\n 98.3\n Arterial BP:\n S:126\n D:57\n Respiratory rate:\n 11 insp/min\n Heart Rate:\n 63 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 98% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 448 mL\n 24h total out:\n 1,455 mL\n Pertinent Lab Results:\n Sodium:\n 133 mEq/L\n 01:44 AM\n Potassium:\n 4.6 mEq/L\n 01:44 AM\n Chloride:\n 96 mEq/L\n 01:44 AM\n CO2:\n 30 mEq/L\n 01:44 AM\n BUN:\n 23 mg/dL\n 01:44 AM\n Creatinine:\n 0.7 mg/dL\n 01:44 AM\n Glucose:\n 127 mg/dL\n 01:44 AM\n Hematocrit:\n 30.0 %\n 01:44 AM\n Finger Stick Glucose:\n 171\n 05:00 PM\n Valuables / Signature\n Patient valuables: Glasses\n Other valuables: pt has bag with clothing, no 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: \n Transferred to: 6\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2136-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527028, "text": "Extremely labile bp with low filling pressures,brisk dilute appearing\n huo treated with warming,volume,neo titration & pacing rate adjustments\n with improvement. Ci remains > 2. underlying rhythm sb 50\ns,remains a\n paced for chronotropy.mild crepitus noted anterior chest bilaterally,no\n air leak observed. Scant sero sang ct dng. Mae x 4,nods to questions\n but very lethargic,unable to lift head or extremities of the bed.will\n extubate when more awake. Multiple family members in,questions\n answered. Wife is designated spokesperson & received icu guidelines.\n Glucoses managed per protocol,see flow sheet.\n ------ Protected Section ------\n Extubated without incident. Cooperative with deep breathing,instructed\n in sternal splinting with good return . Pain well controlled with\n low dose morphine.\n ------ Protected Section Addendum Entered By: , RN\n on: 21:05 ------\n" }, { "category": "Nursing", "chartdate": "2136-03-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527025, "text": "Extremely labile bp with low filling pressures,brisk dilute appearing\n huo treated with warming,volume,neo titration & pacing rate adjustments\n with improvement. Ci remains > 2. underlying rhythm sb 50\ns,remains a\n paced for chronotropy.mild crepitus noted anterior chest bilaterally,no\n air leak observed. Scant sero sang ct dng. Mae x 4,nods to questions\n but very lethargic,unable to lift head or extremities of the bed.will\n extubate when more awake. Multiple family members in,questions\n answered. Wife is designated spokesperson & received icu guidelines.\n Glucoses managed per protocol,see flow sheet.\n" }, { "category": "Nursing", "chartdate": "2136-03-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 527295, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Pleasant, cooperative, A&Ox3\n c/o incisional pain , especially with coughing and movement\n SR 60s-70s\n SBP >90 on 0.5mcg neo\n LS clear, using IS on own\n + nonproductive cough\n CT + , serosang drainage\n Adequate HUO\n Action:\n Dilaudid 4mg given Q3-4 hours\n Turned Q2 in bed\n Encouraged pt to continue with sternal precautions to help with pain\n Weaned Neo slowly 0.3mcg\n Response:\n Pt with adequate pain relief\n Slept on and off throughout the night\n Plan:\n" }, { "category": "Rehab Services", "chartdate": "2136-03-16 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 527486, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: CAD / 414.00\n Reason of referral: eval & treat\n History of Present Illness / Subjective Complaint: 77yoM c EKG changes\n found on routine exam, had stress, echo and catheterization revealing\n 3V CAD. Pt asymptomatic. U/w CABGx4 on , extubated POD #1, chest\n tubes removed and neo weaned this morning.\n Past Medical / Surgical History: Htn, HLD, prostate adenocarcinoma,\n depression, anxiety, OA, ?MI shown on eKG, L4-5 DJD\n Medications: nitro, phenylnephrine, morphine, asa, tylenol, insulin,\n simvistatin, percocet\n Radiology: CXR: no PTX, low lung volumes, bilat atelectasis, L\n pleural effusion, no pulm edema\n Labs:\n 29.7\n 9.9\n 190\n 12.0\n [image002.jpg]\n Other labs:\n K 3.8\n Activity Orders: as tolerated per cardiac rehab\n Social / Occupational History: Lives with wife, part-time researcher\n (non-strenuous), former smoker (1 cigar/year), 1 drink/week\n Living Environment: One story home c 3 stairs to enter\n Prior Functional Status / Activity Level: Indep c all amb, ADLs/IADLs s\n use of AD, swims, tennis and bikes >/= 2x/week, very active, drives\n Objective Test\n Arousal / Attention / Cognition / Communication: A&Ox3, pleasant,\n cooperative, receptive, appropriate\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 76\n 117/55\n 20\n 100% 4L\n Rest\n /\n Sit\n 78\n 109/49\n 24\n 98%2L\n Activity\n 76/45\n Stand\n 80\n 81/51\n Recovery\n 101/44\n 99% RA\n Total distance walked: n/a\n Minutes:\n Pulmonary Status: RML & RLL diminished breath sounds o/w CTA, mod\n non-productive cough, minimal cueing for PLB c activity, able to wean\n 4L o2 down to RA throughout session\n Integumentary / Vascular: B foot edema L>R, (+) drainage proximal\n sternal dressing, tele, supplemental O2 via nasal cannula, pacing wires\n intact (A sensing), L ace wrap intact\n Sensory Integrity: Intact to light touch t/o, no c/o numbness or\n tingling\n Pain / Limiting Symptoms: 0/10 at rest, at most with coughing\n Posture: rounded shoulders & forward head\n Range of Motion\n Muscle Performance\n BUEs and \n B grip strong\n BUEs >/= (resistance not tested sternal precautions)\n BLEs \n Motor Function: able to move all extremities in isolation, no tremors\n noted\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Verbal cueing given for all mobility for technique\n and safety, no bed rail used\n Maintained sternal precautions with sit-stand\n C/o lightheadedness with position change and standing\n Stand step transfer perfommed c light UE support on w/c\n Deferred amb hypotension\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n T\n\n\n\n Sit to Stand:\n\n T\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Sitting eob unsupported c S, immediate standing balance\n steady, light UE support on w/c\n Education / Communication: c RN re: pt status, plan of care re:\n amb if BP stabilizes, vitals and O2\n Pt education re: role and goal of PT, sternal precautions, activity\n guidelines, pacing, PLB, safety in room, sx recogition\n Diagnosis:\n 1.\n Balance, Impaired\n 2.\n Aerobic Capacity / Endurance, Impaired\n 3.\n Circulation, Impaired\n 4.\n Knowledge, Impaired\n 5.\n Gait, Impaired\n Clinical impression / Prognosis: 77yoM s/p CABGx4 now POD #2 presents\n today c the above impairments c/w cardiovascular pump dysfunction.\n Session limited by orthostatic hypotension and inability to assess gait\n and endurance adequately. Pt most limited by lightheadedness and\n fatigue. Pt will benefit from continued PT intervention and increased\n activity c nsg once orthostatic hypotension is resolved. It is\n anticpated that Pt will progress to safe level for d/c to home in \n PT sessions.\n Goals\n Time frame: 1-2 sessions\n 1.\n Indep bed mobility\n 2.\n Sit-stand and transfer indep no AD\n 3.\n Amb 500' indep no use of AD\n 4.\n Ascend/descend 1 flight of stairs indep\n 5.\n Stable HDR to all activity\n 6.\n Demonstrate indep use of sternal precautions with all activity\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 1-2 sessions/1 week\n bed mobility, transfer and gait training, endurance activity\n Pt education\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face Time: \n" }, { "category": "Echo", "chartdate": "2136-03-14 00:00:00.000", "description": "Report", "row_id": 95339, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop CABG. Evaluate wall motion, aortic contours, valves\nHeight: (in) 68\nWeight (lb): 145\nBSA (m2): 1.78 m2\nBP (mm Hg): 110/50\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 12:14\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 RA size. Normal interatrial septum. No\nASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild regional LV systolic dysfunction.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; mid inferior - hypo;\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic function.\n\nAORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. Focal\ncalcifications in ascending aorta. Normal aortic arch diameter. Simple\natheroma in aortic arch. Mildly dilated descending aorta. Simple atheroma in\ndescending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. Mild PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nPre Bpass: The left atrium is normal in size. No thrombus is seen in the left\natrial appendage. No atrial septal defect is seen by 2D or color Doppler. The\nright ventricular cavity is mildly dilated with normal free wall\ncontractility. There is moderate inferior hypokinesis LVEF 45-50%. The aortic\nroot is mildly dilated at the sinus level. The ascending aorta is mildly\ndilated. There are simple atheroma in the aortic arch. The descending thoracic\naorta is mildly dilated. There are simple atheroma in the descending thoracic\naorta. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve leaflets are\nmildly thickened. Mild (1+) mitral regurgitation is seen. There is no\npericardial effusion.\n\nPost Bypass: Patient is AV paced on phenylenpherine infusion. Septum appears\ndyskinetic c/w pacing. Remaing wall motion is unchanged. Aortic contours\nintact. PI is now more pronounced. Remaining exam is unchanged. All findings\ndiscussed with surgeons at the time of the exam.\n\n\n" }, { "category": "ECG", "chartdate": "2136-03-14 00:00:00.000", "description": "Report", "row_id": 251902, "text": "Sinus bradycardia with slight A-V conduction delay. Consider left atrial\nabnormality. Consider prior inferior myocardial infarction, although it is\nnon-diagnostic. Delayed R wave progression with late precordial\nQRS transition. Modest ST-T wave changes. Findings are non-specific.\nSince the previous tracing of precordial lead QRS voltage is less\nprominent and late precordial QRS transition is now present.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2110-01-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1260508, "text": " 6:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: DECREASED O2 STATS\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreased O2 saturation.\n\n The original report of the study was lost. It is therefore being redictated.\n\n COMPARISON: .\n\n Compared to the prior study, there has been no interval change. Tip of the\n right subclavian catheter remains in the distal SVC. The lungs are clear.\n\n IMPRESSION: No interval change from prior study.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 810609, "text": " 4:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumothorax. please call results to PACU-East\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F s/p R Hkmn catheter placement\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax. please call results to PACU-East\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess line placement, pneumothorax.\n\n PORTABLE UPRIGHT FRONTAL RADIOGRAPH\n\n FINDINGS: Cardiac and mediastinal contours are normal. A right-sided\n subclavian venous catheter is seen with its tip terminating in the region of\n the cavoatrial junction. There is no pneumothorax. The lungs are otherwise\n clear with no effusions, focal consolidations, or congestive heart failure.\n\n IMPRESSION: Right-sided subclavian central venous catheter terminating in the\n region of the cavoatrial junction. No pneumothorax. These findings were\n communicated to the PACU.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-18 00:00:00.000", "description": "CHEST FLUORO WITHOUT RADIOLOGIST", "row_id": 810608, "text": " 4:27 PM\n CHEST FLUORO WITHOUT RADIOLOGIST Clip # \n Reason: INSERTION HICKMAN LINE\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n FINAL REPORT\n Chest fluoroscopy was performed in the OR without a radiologist present. No\n films were taken for interpretation. 20 seconds of fluoroscopy time was\n utilized.\n\n" }, { "category": "Radiology", "chartdate": "2109-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 811584, "text": " 6:39 PM\n CHEST (PORTABLE AP) Clip # \n Reason: neutropneic pt with spike to 101.4 and cough; r/o pna\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML 4 d s/p chemo with fever, neutropenia and cough\n REASON FOR THIS EXAMINATION:\n neutropneic pt with spike to 101.4 and cough; r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM\n\n HISTORY: AML with fever and neutropenia and cough.\n\n CV line is in distal SVC. The lungs are clear. No pleural effusion. No change\n since prior study of .\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-16 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 813524, "text": " 5:05 PM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: ?occult sinusitis\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AML s/p induction chemo with recent intubation for\n hypoxia now with ongoing fevers\n REASON FOR THIS EXAMINATION:\n ?occult sinusitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Ongoing fevers, immunosuppressed. Evaluate for sinusitis.\n\n TECHNIQUE: Axial images of the paranasal sinuses were acquired helically\n without IV contrast. Coronal reformations were made.\n\n NON-CONTRAST SINUS CT: There is a small mucus retention cyst in the right\n maxillary floor. The left maxillary sinus, sphenoid sinuses, frontal sinuses,\n and ethmoid air cells are clear. The coronal views are extremely limited.\n There is no aeration of the anterior clinoid processes, or the optic struts.\n Lamina papyracea appears intact, but evaluation is severely limited. The\n septum deviates slightly to the right anteriorly. The sphenoid septum inserts\n on the right carotid sulcus. The cribriform plates were not definitely\n visualized, but are likely level. The infundibula and ostea of the\n ostiomeatal complexes could not be properly evaluated.\n\n IMPRESSION: No evidence of acute sinusitis.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 813063, "text": " 9:23 AM\n CHEST (PA & LAT) Clip # \n Reason: ?pneumonia\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AML s/p induction chemo s/p recent extubation for\n volume overload who has fever and right basilar rales\n REASON FOR THIS EXAMINATION:\n ?pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML, status postchemotherapy, assess fluid overload, fever and\n right basilar rales.\n\n Comparison made to the prior chest x-ray on .\n\n PA AND LATERAL OF THE CHEST: The heart and mediastinum are stable. There is\n slight upper zone vascular redistribution and small bilateral pleural\n effusions possibly related to fluid overload. This appears somewhat improved\n since the prior chest x-ray. There is persistent left lower lobe atelectasis\n and right lower lobe collapse/consolidation.\n\n IMPRESSION:\n 1. Bilateral lower lobe collapse/consolidation.\n 2. Slighly improved pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-13 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 813064, "text": " 9:23 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: 55 YEAR OLD FEMALE WITH AML leukemia with transaminitis. Rul\n Admitting Diagnosis: LEUKEMIA\n ICD9 code from order: 205.0\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AML leukemia and transaminitis. Rule out leukemic\n involvement of liver.\n REASON FOR THIS EXAMINATION:\n 55 YEAR OLD FEMALE WITH AML leukemia with transaminitis. Rule out hepatic\n involvement of liver or underlying anatomic liver disorder. AST 130,\n ALT 354, LDH 977, Alk Phos 223, T Bili 0.6.\n\n Approved for early am by Dr. radiologist.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML leukemia with transaminitis.\n\n COMPARISON: None.\n\n FINDINGS: The liver is enlarged, and the echotexture is heterogeneous without\n focal mass. There is no intrahepatic ductal dilatation. The common duct\n measures 1 to 2 mm. The gallbladder appears normal, and is free of stones.\n The portal vein is open, and flow is hepatopetal. The head and body of the\n pancreas are within normal limits. The pancreatic tail is not well\n visualized. The right kidney measures 12.1 cm in length. There is no\n evidence of stone, mass, or hydronephrosis. The spleen measures 8.8 cm in\n length and is not enlarged. The left kidney measures 11.1 cm in length and\n contains a small echogenic focus within the cortex at the mid-pole, of\n doubtful significance. There is no stone or hydronephrosis on the left.\n Bilateral pleural effusions are noted. The aorta is of normal caliber.\n\n IMPRESSION:\n 1. Heterogeneous, nonspecific appearance of the liver. No evidence of\n splenomegaly.\n 2. Bilateral pleural effusions.\n 3. Small echogenic focus within the left renal parenchyma, possibly a small\n angiomyolipoma or scar, of doubtful significance.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812856, "text": " 8:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assesss for pulmonary edema vs pneumonia\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F AML s/p chemo with fever/neutropenia, desats\n REASON FOR THIS EXAMINATION:\n please assesss for pulmonary edema vs pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 55 year old woman with AML, s/p chemotherapy, now with new fever and\n neutropenia and desats. Please assess for pulmonary edema vs. pneumonia.\n\n AP PORTABLE CHEST AT 9:20 A.M.:\n\n Since prior study on , the patient has been extubated. There appears to\n be some clearing of the pulmonary edema at both bases with better definition\n of the left hemidiaphragm on today's exam. There is still residual\n interstitial opacity bilaterally.\n\n IMPRESSION: Patient has been extubated. Some clearing of the bibasilar\n opacities. Residual edema remains.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-06 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 812356, "text": " 6:21 PM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: ?interstitial process\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AML s/p chemo induction with febrile neturopenia and new\n hypoxia with diffuse interstitial markings on chest x-ray\n REASON FOR THIS EXAMINATION:\n ?interstitial process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST CT:\n\n INDICATION: 55 y/o woman with history of AML, status post chemotherapy\n induction, with febrile neutropenia and hypoxia. Evaluate for interstitial\n process.\n\n TECHNIQUE: A high resolution CT scan of the chest was performed without the\n admnistration of IV contrast. Images were obtained at end inspiration and end\n expiration.\n\n COMPARISONS: There are no prior CTs for comparison.\n\n FINDINGS: Evaluation of the lung parenchyma reveals the presence of a small\n focal area of consolidation in the right lower lobe posteriorly. There is\n some associated atelectasis at the right base. A very small focal alveolar\n opacity is also present at the left lung base. There are a few small\n scattered pulmonary nodules seen. The largest of these is located in the\n lingula and measures 4-5 mm in diameter. This nodule contains lucency\n centrally. Similarly, there is a small rather dense nodule at the extreme\n left apex which has a central low attenuation. There is no evidence of\n thickening of the interstitium.\n\n Soft tissue windows demonstrate small bilateral pleural effusions, right\n greater than left. There are numerous small lymph nodes seen in both axillary\n regions as well as in the mediastinum. None of these nodes individually reach\n CT criteria for pathologic enlargement. There is a central venous line\n present with tip in the lower SVC. There is a trace paracardial effusion.\n Note is made of a small hiatal hernia.\n\n A limited number of images to the upper abdomen demonstrate no gross\n abnormalities of the partially visualized liver, spleen, adrenal glands or\n kidneys. There is a small bone island at the superior most aspect of the L1\n vertebral body. The osseous structures are otherwise unremarkable.\n\n IMPRESSION:\n\n 1) Right lower lobe pneumonia with small bilateral pleural effusions, right\n greater than left.\n 2) A few scattered pulmonary nodules identified which could be infectious in\n nature. If clinically indicated, a repeat chest CT could be performed after\n (Over)\n\n 6:21 PM\n CT CHEST W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: ?interstitial process\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the patient has been treated.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812439, "text": " 1:26 PM\n CHEST (PORTABLE AP) Clip # \n Reason: acute desaturation\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML s/p chemo with fever/neutropenia now with rigors,\n desats, and crackles on exam. Now with acute desaturation.\n REASON FOR THIS EXAMINATION:\n acute desaturation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: AML with fever, neutropenia, rigors and crackles.\n\n ET tube is 2 cm above the carina. Right subclavian CV line is in region of\n cavoatrial junction. No pneumothorax. There are bilateral layering pleural\n effusions on this supine film; unable to compare in size because of difference\n in technique from the prior film of the same date. There are probable\n associated bibasilar atelectases. Consolidation in the left lower lobe cannot\n be ruled out.\n\n IMPRESSION: Bilateral pleural effusions. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812489, "text": " 4:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: desaturation. Please rule out pneumothorax\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML s/p chemo with fever/neutropenia now with rigors,\n desats, and crackles on exam. Now with acute desaturation.\n REASON FOR THIS EXAMINATION:\n desaturation. Please rule out pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML, chemotherapy rigors crackles and desaturation.\n\n Comparison is made to the prior AP chest on .\n\n SUPINE AP OF THE CHEST: An endotracheal tube, right internal jugular and\n right subclavian central venous line are again present and stable in position.\n The heart and mediastinal contours are unchanged in appearance. There are\n bilateral symmetric interstitial and alveolar opacities which are slightly\n more prominent. The left lower lobe collapse and consolidation also appear\n slightly worse. There is likely bilateral pleural effusions. There is no\n evidence of pneumothorax.\n\n IMPRESSION: Slightly worsened interstitial and alveolar symmetric opacities\n which may be suggestive of heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-14 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 813176, "text": " 1:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ? pneumonia of right lower , ?liver/gallbladder patholo\n Admitting Diagnosis: LEUKEMIA\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with AML s/p induction chemotherapy with non-cardiogenic\n pulmonary edema and continued RLL consolidation/collapse on chest x-ray who\n also has LFT elevations of unclear etiology. Please assess for pnemonia and\n for liver/GB process.\n REASON FOR THIS EXAMINATION:\n ? pneumonia of right lower , ?liver/gallbladder pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: AML, status post induction chemotherapy with noncardiogenic\n pulmonary edema and LFT elevations of unclear etiology.\n\n COMPARISON: Comparison is made with prior ultrasound of the abdomen dated\n . No prior comparable CTs of the abdomen and pelvis are\n available.\n\n TECHNIQUE: Contiguous helically acquired axial images from the lung apices to\n the pubic symphysis were obtained following the administration of 150 cc of\n Optiray intravenously.\n\n CONTRAST: Oral and intravenous nonionic contrast were administered due to the\n rapid rate of bolus injection required for this examination.\n\n CT OF THE CHEST WITH INTRAVENOUS CONTRAST: There are stable patchy ground-\n glass opacities within the lung parenchyma bilaterally, more prominent in the\n central location. There are small bilaterally pleural effusions and bibasilar\n atelectasis. No nodules or masses are identified within the lung parenchyma.\n There are tiny bilateral axillary lymph nodes, which do not meet criteria for\n pathologic enlargment. No pathologic mediastinal or hilar lymphadenopathy is\n identified.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver enhances uniformally\n and there are no focal lesions within the liver parenchyma. There is a small\n amount of fluid surrounding the liver inferiorly. There is no intra or\n extrahepatic biliary ductal dilatation. The gallbladder is not dilated and\n there is no abnormal gallbladder wall thickening. The pancreas, spleen, and\n adrenal glands appear unremarkable. Within the left kidney is a 9 x 9 mm low-\n attenuation rounded lesion consistent in appearance with a cyst. There are no\n masses or cysts within the right kidney. There is a small amount of fluid\n stranding within the fat plane around both kidneys and at the paracolic\n gutters. There are symmetric nephrograms and excretion of contrast\n bilaterally without evidence of hydronephrosis. The ureters appear\n unremarkable. The large and small bowel loops are normal in caliber and there\n is no abnormal wall thickening. There are tiny mesenteric and retroperitoneal\n lymph nodes, without evidence of pathologic lymphadenopathy.\n (Over)\n\n 1:56 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT CHEST W/CONTRAST; CT 150CC NONIONIC CONTRAST\n Reason: ? pneumonia of right lower , ?liver/gallbladder patholo\n Admitting Diagnosis: LEUKEMIA\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The bladder, distal ureters, and\n rectum appear unremarkable. There is no pathologic appearing pelvic\n lymphadenopathy. Several small inguinal nodes are present, and a single soft\n tissue collection in the right inguinal region measuring 14 x 20 mm probably\n represents several nodes matted together. The uterus is surgically absent.\n\n There is no free fluid within the pelvis.\n\n Bone windows demonstrate no evidence of suspicious lytic or sclerotic bony\n lesions.\n\n IMPRESSION: 1) Bilateral patchy ground-glass opacities, with pleural\n effusions and atelectasis. Probable mild cardiac decompensation.\n\n 2) No evidence of nodules or masses within the liver.\n\n 3) Probable simple cyst within the left kidney.\n\n 4) Small amount of perihepatic and perirenal fluid may relate to cardiac\n decompensation.\n\n 5) Bilateral small lymph nodes within the inguinal regions with one\n collection of nodes measuring 2 x 1.4 cm.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-12-23 00:00:00.000", "description": "SVC GRAM", "row_id": 811076, "text": " 11:32 AM\n HICK LINE PLACE Clip # \n Reason: Evaluate for flow in a port that is burning when chemotherap\n Admitting Diagnosis: LEUKEMIA\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * SVC GRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with new AML, whose port is burning with infusion of chemo.\n REASON FOR THIS EXAMINATION:\n Evaluate for flow in a port that is burning when chemotherapy is administered.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: The port was recently placed and the patient has a burning\n sensation with chemotherapy infusion.\n\n Contrast was injected by hand under direct fluoroscopic guidance into both\n ports of the indwelling Hickmnann catheter and multiple spot films of the SVC\n were obtained.\n\n Findings: There is free antegrade and retrograde flow of contrast through both\n ports. There is no evidence of obstruction. The SC is widely patent, and there\n is no evidence of narrowing, thrombus, or collateral flow.\n\n Please note however, that as the catheter goes under the right clavicle, there\n is indentation on the cephalad aspect of the catheter. There is no evidence of\n extravasation but there is a slight impingement of the catheter at this level.\n\n IMPRESSION:\n 1. Extrinsic impression of the superior aspect of the line as it travels\n under the right clavicle.\n 2. No evidence of obstruction to antegrade or retrograde flow and no evidence\n of extravasation.\n 3. Widely patent SVC, without evidence of obstruction, stenosis , or\n collateral flow.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812166, "text": " 12:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates.\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML s/p chemo with fever/neutropenia.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: AML status post chemotherapy now with fever.\n\n Chest. The position of the central line remains unchanged the heart is not\n enlarged no infiltrates are seen the costophrenic angles are sharp. There has\n been no significant change since the prior film.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812477, "text": " 7:01 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R IJ, please assess placement\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML s/p chemo with fever/neutropenia now with rigors,\n desats, and crackles on exam. Now with acute desaturation.\n REASON FOR THIS EXAMINATION:\n s/p R IJ, please assess placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of AML, status post chemotherapy with fever and hypoxia.\n Status post right internal jugular line placement.\n\n CHEST X-RAY, PORTABLE AP:\n\n Comparison is made to a prior study of six hours previously. There has been\n interval placement of a right internal jugular central venous line. The tip\n is in the mid-superior vena cava. There is no pneumothorax. An endotracheal\n tube is again visualized. The tip is positioned slightly low, lying 2 cm from\n the carina. There is a right subclavian central venous line which is\n unchanged in position. The cardiomediastinal silhouette is unchanged in\n appearance. There are bilateral layering pleural effusions. Opacity is\n present in both the right lower lobe and left lower lobe, which may represent\n atelectasis or infiltrate. This is not significantly changed in the interval.\n\n IMPRESSION:\n 1. New right internal jugular central venous line with tip in the mid-\n superior vena cava.\n 2. Exam unchanged from six hours previously with bilateral pleural effusions\n and bilateral lower lobe atelectasis versus infiltrate.\n\n" }, { "category": "Radiology", "chartdate": "2110-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812631, "text": " 9:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change in volume status\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F AML s/p chemo with fever/neutropenia, intubated, subjected to diuresis\n REASON FOR THIS EXAMINATION:\n assess for interval change in volume status\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55 year old female patient with AML. Fever, neutropenia.\n\n COMMENT: Portable AP radiograph of the chest was reviewed, and compared with\n the previous study of yesterday.\n\n The tip of endotracheal tube is identified 1 cm above the carina. The right\n jugular IV catheter terminates at the cavoatrial junction. There is\n improvement of the pulmonary edema compared with the previous study.\n\n Again note is made of calcification in both lower lobes, which is indicating\n pneumonia. There is small bilateral pleural effusions. The tip of the right\n subclavian IV catheter is also identified in the superior vena cava. No\n pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2110-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 812383, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: DESATS, CRACKLES\n Admitting Diagnosis: LEUKEMIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55F with newly dx'd AML s/p chemo with fever/neutropenia now with rigors,\n desats, and crackles on exam.\n REASON FOR THIS EXAMINATION:\n assess for worsening pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Febrile neutropenia, desaturations, AML on chemotherapy.\n\n Comparison is made to the prior chest x-ray on .\n\n FINDINGS: There is a right-sided central venous catheter present in stable\n position. The heart again appears slightly enlarged. There is again\n demonstrated diffuse interstitial prominence. There has been interval\n progression with worsened appearance of atelectasis and probable effusion of\n the right lung base. There has also been interval development of left lower\n lobe atelectasis and retrocardiac collapse/consolidation.\n\n IMPRESSION:\n\n 1) Worsened right lower lobe atelectasis and effusion.\n\n 2) Interval development of left lower lobe atelectasis/consolidation.\n\n 3) Increase in interstitial prominence which could also represent slight left\n ventricular failure.\n\n" }, { "category": "Echo", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 76563, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Congestive heart failure.\nHeight: (in) 61\nWeight (lb): 115\nBSA (m2): 1.49 m2\nBP (mm Hg): 92/53\nStatus: Inpatient\nDate/Time: at 11:13\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (tape not available)\nof .\n\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. Regional left ventricular wall motion is normal. Left\nventricular systolic function is hyperdynamic (EF>75%). There is no resting\nleft ventricular outflow tract obstruction.\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The 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. There is no\nmitral valve prolapse. There is no systolic anterior motion of the mitral\nvalve leaflets. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild to moderate\n[+] tricuspid regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nPERICARDIUM: There is a small pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. The echocardiographic results were reviewed by\ntelephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Regional left ventricular wall motion is\nnormal. Left ventricular systolic function is hyperdynamic (EF>75%) without\nevidence for valvular or resting LVOT gradient. Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve leaflets are structurally normal. There is no mitral valve\nprolapse. There is no systolic anterior motion of the mitral valve leaflets.\nMild (1+) mitral regurgitation is seen. There is moderate pulmonary artery\nsystolic hypertension. There is a small pericardial effusion without evidence\nfor hemodynamic compromise.\n\nIMPRESSION: Symmetric left ventricular hypertrophy with excellent systolic\nfunction. Mild mitral regurgitation. Pulmonary artery systolic hypertension.\nSmall pericardial effusion.\nCompared with the prior report (tape unavailable for review) of , mild\nmitral and tricuspid regurgitation is now present and the left ventricular\nsystolic function is described as more dynamic. Pulmonary artery systolic\nhypertension is now identified.\nIs there a history to suggest high-output syndrome (anemia, fever,\nthyrotoxicosis, thiamine deficiency, etc.) or pulmonary embolism?\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": "Echo", "chartdate": "2109-12-19 00:00:00.000", "description": "Report", "row_id": 76564, "text": "PATIENT/TEST INFORMATION:\nIndication: Chemotherapy.\nHeight: (in) 61\nWeight (lb): 115\nBSA (m2): 1.49 m2\nBP (mm Hg): 127/70\nStatus: Inpatient\nDate/Time: at 14:07\nTest: TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis 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) appear structurally normal with\ngood leaflet excursion and no aortic regurgitation.\n\nMITRAL VALVE: The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. 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 no pericardial effusion.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a low risk (prophylaxis not recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is normal (LVEF>55%). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no pericardial effusion.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 195650, "text": "Sinus tachycardia\nNormal ECG except for rate\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-07 00:00:00.000", "description": "Report", "row_id": 1439625, "text": " 4 ICU NPN 1200-1900\n\n 55 YO with HX AML s/p chemo induction admitted from 4S with increased worsening SOB, desaturation, new RLL infiltrate, CHF\nPlease see NSG FHPA/admission for HPI.\n Intubated on admission. Bronch done BAL obtained. Findings c/w pulm edema. BS with diffuse crackles. suctioned X2 for small to mod amt thick, bloody secretions.\n ID: T-max 104.2ax. Tylenol PR given. Had been spiking high fevers on 4S. On gent, acyclovir, flagyl, vanco, aztreonam. Last cultured . All cultures negative to date.\n HEME: ? bleeding around peri-oribital area. Received bag plts this AM for plt ct 14. Repeat 12K. Received second bag on arrival to ICU. Repeat plt 23k. Bolused & started on amicar. Crit 19. to receive 1U PRBC's. Has been pre-medicated with demerol & benedryl prior to plts but pt rigors approx 20 min after infusion requiring additional demerol. Quad lumen site oozing. Gel foam, pressure & dsg re-inforced.\n SKIN: diffuse rash across chest, face, legs- red, papular, plaques ? r/t drug rash.\n CV: HR 120's130's ST. No VEA. SBP 90-150. Lasix given. To have cardiac echo .\n GI: NPO. No stool. Needs NGT. Positive BS\n GU; Foley placed.\n Access: Quad lumen placed.\n SOCIAL: So, , cell . SO, Mother, siblings in to visit. Questions answered\n\nA/P; Resp failure. Awaiting results of BAL. Pulm hygiene. Assess response to lasix.\n neutropenia; Awaiting cultures.\n AML; Supportive care\n Thrombocytopenia; Blood Bank attempting to find HLA matched plts.\n Transfuse 1U PRBC's once line placement confirmed.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 1439630, "text": " 4 ICU NPN 0700-1900\n\n Presently on A/C 40%/ 450/14 spont resp, PEEP 5 with ABG 7.47/39/132/29/5. BS clear, diminished at bases. Suctioned ~q3-4hrs for scant to small amts thin, bloody secretions. Occas c/o feeling slightly SOB. Sats, ABG stable. Pt subjectively felt better after suctioning.\n Crit 25.4, plts 22k. Per Dr will hold off with transfusions in light of pt's, HX of transfusion reaction with plts with minimal to no bump & persistent high fevers. Min bloody secretions via ETT. Otherwise no evidence to active bleeding. ANc slightly improved.\n Fevers >102.2 (max 103 PO). Given tylenol Q4hrs. No antibx changes.\n Received lasix X2 with excellant response. Negative fld balance 350 cc's since MN.\n C-echo done. Results pnd. HR 110-120's ST. SBP low 90's to 120's\n On fentanyl & ativan gtts. Awake or easily arousable. Mouthing or writing appropriate ?'s. Follows commands. Wrist restraints off aal day.\n Rash does not appear to be progressing. Skin more red where body rash. is BX for DX. Skin creams applied to affected areas.\n Abd soft. No stool. No NGT. Started on TPN.\n Mother, sister, brother, SO as well as several other visitors in to see pt. Mother is having surgery tomorrow. Both pt and mother are appropriately upset, concerned. SS in to see pt & family.\n\nA/P: Stable on vent. ? decrease rate, VT\n Cont tylenol for fevers, antibx\n Cont to assess fld volume status.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-07 00:00:00.000", "description": "Report", "row_id": 1439626, "text": "Resp.Care\nPatient transferred from floor, because of hypoxia ,resp fatique. Electively intubated by anesthetia with # 7.0 oett taped at 22 at lips. Equal BS.Placed on vent A/C mode,see carevue for specifics. Patient needed heavy sedation for bronchoscopy, patient biting on oett. BAL procedure done. A-line placed. Fio2 titrated down to 70% fio2.Continue to monitor and follow abg's\n" }, { "category": "Nursing/other", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 1439627, "text": "NPN 1900-0700\n\nEVENTS: PT HAD REACTION 15 MINUTES AFTER PLTS FINISHED. BECAME HYPOXIC , RIGOROUS, FOAMING AT MOUTH W/ INCREASE IN HR AND BP.PT WAS GIVEN 40 MG IV LASIX AND BOLUSES IN HER SEDATION.HER VENT SETINGS WERE CHANGED TO PS 18/8.INITIAL GAS WAS 7.20/68/82.PT ~ 500CC'S RECIEVED TOTAL OF 25 MG DEMEROL, AND SETTLED OUT BACK TO HER HEMDYNAMIC BASELINE. HER GAS RETURNED TO 7.37/46/127 SHE WAS SWITCHED BACK TO HER A/C SETTINGS OF 450X14 60% 8 OF PEEP.TRANSFUSION REACTION PAPERWORK FILED .\n\nNEURO: SEDATED ON FENTYNAL @ 75 MCG'S /HR.WHEN LIGHTLY SEDATED VERY COMPLIANT , COMMUNICATES W/ NON VERBAL CUES.RECIEVED 2.5 VERSED, 25 MG DEMEROL FOR RIGORS.\n\nRESP: CURRENTLY ON SETTINGS AS STATED ABOVE. SATS ARE 97-100% . LUNGS ARE CLEAR BUT DIMINISHED.\n\nC/V: ST , BP NOW STABLIZED. RECIEVED 2 UNITS PRBC, ONE BAG OF PLATLETS, SUB Q CGSF .HCT NOW 25.4 .BLEEDING AT RIJ INSERTION SITE\nDECREASED CONSIDERABLY.\n\nF/E/N: RECIEVED 15 MML KPHOS FOR K OF 3.2, AND 2 MG MAG.HAD BRISK RESPONSE TO LASIX, W/ IMPROVED OVERALL CONDITI0N.UO AT BASELINE 50-80CC/HR. BS HYPOACTIVE / NO STOOLS OVERNOC.\n\nPLAN: CONT SUPPORTIVE CARE , MONITOR HCT , PLT, TRANSFUSE PRN, MONITOR HEMODYNAMICS, CONT AB TX.\n" }, { "category": "Nursing/other", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 1439628, "text": "Resp Care: Pt continues intubated and on ventilatory support, mult vent changes overnoc d/t dys-synchrony with vent with resultant hypercarbia, fall in oxygenation, improved with psv until sedated; BS coarse/occ wheeze, sxn pink loose secretions, rx with mdi albuterol, will cont full support and wean when ready.\n" }, { "category": "Nursing/other", "chartdate": "2110-01-08 00:00:00.000", "description": "Report", "row_id": 1439629, "text": "Resp Care\nPatient remains intubated, alert, vented on A/c mode. abg's normal with high PaO2 , decreased FiO2. Sx small blood tinge secretions. RSB done this early eve. 38. tolerated well. Plan to rest pt. til am. plan to extubate.\n" }, { "category": "Nursing/other", "chartdate": "2110-01-09 00:00:00.000", "description": "Report", "row_id": 1439631, "text": "neuro Alert and appropriate . mae to command. remains on fentanyl and versed gtt.\ncv/resp nsr. No ectopy. bp stable. temp spike to 102.9 p.o. tylenol give,. vent chages at aprox 12 midnight to 20ips and 5 peep. fio2 40%. Pt. tol this well. This am placed on 0peep 5ips ? plan extubation today\ngi/gu npo. foley to gravity. q.s. uop no stools.\ninteg total body rash/redness noted benmadryl as ordered.\nam labs pending. temp coming down with tylenol.\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-09 00:00:00.000", "description": "Report", "row_id": 1439632, "text": "Respiratory Care\nChanged from a/c to pressure support overnight as patient was breathing out of synch with the vent. She appeared more comfortable and was able to sleep without any more episodes of distress. RSBI this morning = 37 and a spontaneous breathing trial was started at 6am. Plan is to extubate later this morning.\n" }, { "category": "Nursing/other", "chartdate": "2110-01-09 00:00:00.000", "description": "Report", "row_id": 1439633, "text": "NURSING NOTE 7A-7P Review of Systems:\nNEURO: Arouses to voice alert and oriented. Fentanyl and Versed drips D/cd after extubation. MAEW, follows commands well.\nC/V: SR-ST rate 90-120's. KPhospate 15mmol infused over 6hours.\nRESP: Patient extubated at 1100, currently on 6LNC O2 Sat= 96-98%.\nID: Tmax 103.9 tylenol given. Urine and blood cultures sent. Cont on Antibiotics genta D/cd. Infuse ABX slowly Vanco over 4 hours.\nGI: Abd soft nontender positive BS, no stools this shift. Taking po clear liquids g-ale and Italian Ice tol well.\nGU: Foley patent draining clear yellow urine, Lasix 40mg given with good diuresis.\nSKIN: Continues with red rash over entire body med with benedryl 25mg prior to Vanco. Hydrocortisone cream applied.\nENDO: 1800 FS 223 covered with SSI.\nSOCIAL: Family into visit very suppportive to patient.\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-10 00:00:00.000", "description": "Report", "row_id": 1439634, "text": "NPN 1900-0700\n T MAX 103 TREATED W/ TYLENOL PO NOW W/ LOW GRADE TEMP 99.2\n\nNEURO: AXOX3, REQUESTED ATIVAN .5MG X 2 FOR SLEEP . CONTINUED TO HAVE DIFFACULTY SLEEPING , ATIVAN 5MG , W/ GOOD EFFECT.\n\nRESP: PT C/O DYSPNEA ,NOTED DROP IN SAT DOWN TO 90% ON 6 L NC.WAS FOUND TO HAVE RALES 1/3 UP.HO NOTIFIED. PT 20MG LASIX W/ GOOD EFFECT.\nPRESENTLY @ 93 -95% ON 5 L NC\n\nC/V: BP STABLE , HR ST NO ECTOPY.\n\nF/E/N : ~ 600CC POS, FOLEY D/C'D LAST EVE AS PER DR REQUEST.BS POS NO STOOL OVERNOC.\n\nHEME: CONT ON NUETROPENIC PREC. WBC BUMP TO 1.7 TODAY.DRINKS ONLY BOTTLED WATER.HAS BAKING SODA AND GELCLEAR FOR ORAL RINSE/CARE.\n\n\nPLAN: CONT AB TX, MONITOR RESP STATUS MONITOR HEMODYNAMICS, RETURN TO 4S ?\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2110-01-10 00:00:00.000", "description": "Report", "row_id": 1439635, "text": "RESP: CRACKLES NOTED THIS AM. DOE. O2 SATS LOW 90'S. DIURESED. RESP. IMPROVEMENT DURING THE DAY. LESS TACHPNEIC.\nGI: DIET INCREASED TO HOUSE. CARNATION INSTANT BREAKFAST AND LACTATE MILD ORDERED FROM KITCHEN. UP TO COMMODE X2. DIARRHEA. CONT. ON TPN\nRENAL: VOIDING IN GOOD AMTS FROM LASIX. GIVEN ANOTHER 20MG THIS PM.\nENDOC: K+ AND K+ PHOS REPLETED. LYTES DRAWN THIS AFTERNOON. BS COVERED BY SSI.\nHEM: PLTS AND HCT STABLE. WBC'S IMPROVED. LESS NEUTROPENIC.\nNEURO: ALERT AND ORIENTATED. PT. FEELS LOSS OF CONTROL. WANTS TO GET UP AND WALK AROUND.\nCV: SEE CAREVUE FOR PRESSURES.\nID: FEBRILE THIS AM. NO MORE FEBRILE EPISODES AFTER TYLENOL GIVEN. ALL ANTIBIOTICS D/C'ED. ALL CX'S NEG SO FAR.\nSKIN INTEGRITY: RASH HAS IMPROVED PER PT. LESS RED. LOTION APPLIED.\nMOUTH CARE: USING BAKING SODA AND GEL RINSE. MOUTH SOMEWHAT LESS SORE, BUT STILL FINDS IT DIFFICULT TO CHEW.\nSOCIAL: FRIENDS AND FAMILY INTO VISIT.\nPLAN: HO TO REMOVE A-LINE. TRANSFER BACK TO 4 SOUTH TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2110-01-11 00:00:00.000", "description": "Report", "row_id": 1439636, "text": "NPN (NOC): PT WAS OOB TO THE CHAIR UNTIL ~ 8:30 PM. ABLE TO TAKE A FEW STEPS AROUND HER ROOM AND TOL WELL. RR 28, REG, NONLABORED AT REST. + DOE, + OCC COUGH, SPEC SENT TO LAB. TMAX 100.4. ANTIBIOTICS ARE NOW ONLY PO ACYCLOVIR AND IV AMBISOME. RASH CONTINUES. PT TOOK THAT HER S.O. BROUGHT IN SUCH AS YOGURT. SINCE SHE IS BEGINNING TO TAKE PO'S, TPN D/C'D SO AS TO NOT GIVE HER TOO MUCH FLUID. PM FS 300 RX'D WITH SQ INSULIN 4U. DIARRHEA IS SLOWING DOWN, ONLY ONE SM EPISODE OVERNOC. DIURESED WELL AFTER LASIX, WAS ~ 700 CC'S - AT MN.\n" } ]

[ { "category": "Nursing", "chartdate": "2190-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420890, "text": "Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420892, "text": "Alcohol abuse\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2190-10-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 420894, "text": "This is a 38 year-old male with a history of EtOH abuse who presents to\n the ED after being found unresponsive at his home. Per the reports of\n his friend (roommate), he appeared normal when she returned from work\n and went outside to smoke a cigarette. On returning she found him\n slumped in a chair and then fell onto the carpeted floor. She was\n unable to arouse him, was able to find a pulse, but wasn't sure if he\n was breathing and called EMS. He was found to have respiratory\n depression and was given Narcan at that time, and per report became\n more responsive with spontaneous respirations, never requiring\n intubation.\n .\n According to his friend, he has had a long term alcohol problem and has\n been in detox on multiple occasions, the most recent sometime late\n , early . He has been seen at for alcohol intoxication in\n the past. He most recently has been very depressed (though she denies\n his mention of suicidal ideation), after his father was diagnosed with\n rhabdomyosarcoma of the ?lung. Also recently divorced 2/.\n .\n On arrival to the ED, his vitals were AF, 73 126/65 19 97% on RA. He\n did not require intubation, but had end-tidal CO2 monitoring which was\n normal. CT Head and C-spine were performed and showed no acute injury,\n bleed or fracture. EtOH level was found to be 522. Per ED report he was\n awake and alert x 3 at the time of transfer.\n .\n Upon arrival to the ICU, the patient is alert and oriented x 3. He\n denies symptoms of withdrawal, states that he feels well. Denies\n suicidal ideation. States that he drank approx 1 pint of vodka today.\n Otherwise he has intermittent binges, but usually only has 1 glass of\n wine with dinner. He denies any prior hospitalizations for alcohol\n intoxication. He denies ever having sx of withdrawal, including\n seizures.\n Alcohol abuse\n Assessment:\n Pt. A&Ox3. Occasionally forgets name of hospital but consistently\n states he is in a hospital. VSS. No tremors or signs of ETOH w/d at\n this time. Denies suicidal ideations. States he has been depressed\n after his father was dx\nd with lung CA.\n Action:\n CIWA scale q4hrs. Received 0.5mg po ativan to help him sleep at 0230\n per his request. Given MVI, thiamine and folate po.\n Response:\n CIWA <10.\n Plan:\n Continue to assess for s&s of withdrawl- ativan prn as needed.\n Probably d/c to floor in near future.\n Pt. lives with his work colleague named Dr. . Her\n # and cell #. Dr. accompanied pt. on\n arrival and spoke in length to Dr. .\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 420880, "text": "Chief Complaint: Reason for MICU Admission: Alcohol\n intoxication/respiratory arrest\n .\n Primary Care Physician: . \n HPI:\n This is a 38 year-old male with a history of EtOH abuse who presents\n to the ED after being found unresponsive at his home. Per the reports\n of his friend (roommate), he appeared normal when she returned from\n work and went outside to smoke a cigarette. On returning she found him\n slumped in a chair and then fell onto the carpeted floor. She was\n unable to arouse him, was able to find a pulse, but wasn't sure if he\n was breathing and called EMS. He was found to have respiratory\n depression and was given Narcan at that time, and per report became\n more responsive with spontaneous respirations, never requiring\n intubation.\n .\n According to his friend, he has had a long term alcohol problem and has\n been in detox on multiple occasions, the most recent sometime late\n , early . He has been seen at for alcohol intoxication in\n the past. He most recently has been very depressed (though she denies\n his mention of suicidal ideation), after his father was diagnosed with\n rhabdomyosarcoma of the ?lung. Also recently divorced 2/.\n .\n On arrival to the ED, his vitals were AF, 73 126/65 19 97% on RA. He\n did not require intubation, but had end-tidal CO2 monitoring which was\n normal. CT Head and C-spine were performed and showed no acute injury,\n bleed or fracture. EtOH level was found to be 522. Per ED report he was\n awake and alert x 3 at the time of transfer.\n .\n Upon arrival to the ICU, the patient is alert and oriented x 3. He\n denies symptoms of withdrawal, states that he feels well. Denies\n suicidal ideation. States that he drank approx 1 pint of vodka today.\n Otherwise he has intermittent binges, but usually only has 1 glass of\n wine with dinner. He denies any prior hospitalizations for alcohol\n intoxication. He denies ever having sx of withdrawal, including\n seizures.\n .\n ROS: The patient denies any fevers, chills, nausea, vomiting, abdominal\n pain, diarrhea, constipation, chest pain, shortness of breath, cough,\n urinary frequency, lightheadedness, gait unsteadiness, focal weakness,\n vision changes, headache, rash or skin changes.\n History obtained from Patient, Family / Friend\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Home meds: none\n Past medical history:\n Family history:\n Social History:\n Alcohol abuse\n Alcoholic hepatitis\n Father - Rhabdomyosarcoma of ?lung. No heart disease or other cancers\n Occupation: researcher in substance abuse\n Drugs: denies\n Tobacco: 1 ppd\n Alcohol: 1 glass wine/d + occas binge - up to 1 pint vodka\n Other: As above. Heavy drinker for many years, in and out of detox.\n Heavy tobacco use. Works as a researcher at . Lives with close\n friend who is also his collegue. Recent divorce .\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever, No(t) Weight loss\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema,\n No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Psychiatric / Sleep: No(t) Suicidal, No(t) Delirious\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:52 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n HR: 75 (75 - 93) bpm\n BP: 105/67(75) {105/67(75) - 160/102(113)} mmHg\n RR: 16 (14 - 16) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 550 mL\n PO:\n TF:\n IVF:\n 301 mL\n Blood products:\n Total out:\n 0 mL\n 220 mL\n Urine:\n 220 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 330 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 98%\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Anxious,\n No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube\n Lymphatic: Cervical WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Crackles : , No(t) Wheezes : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right: Absent, Left: Absent, No(t) Cyanosis, No(t)\n Clubbing\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Normal, Alert, oriented to person, place, and time\n though speaks slowly. CN II\n XII grossly intact. Moves all 4\n extremities. Strength 5/5 in upper and lower extremities. Nl\n finger-to-nose.\n Labs / Radiology\n 189\n 16.2\n 97\n 0.8\n 6\n 29\n 100\n 3.7\n 143\n 44.5\n 7.7\n [image002.jpg]\n Other labs: Lactic Acid:2.5, PO4:E\n Fluid analysis / Other labs: EtOH - 522\n .\n U/A clear\n .\n Serum tox, urine tox - negative\n Imaging: CXR: PRELIM - No acute cardiopulmonary abnormalities\n .\n CT Head: PRELIM - No hemorrhage, midline shift, or large territorial\n infarct. L periventricular hypodensity (7mm) unchanged from one yr ago,\n nonspecific finding, no fracture\n .\n CT C-spine: PRELIM - no acute fracture or malalignment\n ECG: Sinus rhythm at 79 bpm, nl axis, nl PR, QRS, and QT intervals,\n nl-wave progress, no ST or T-wave changes.\n Assessment and Plan\n Assesment: This is a 38 yo M with hx of alcohol abuse presenting with\n respiratory depression secondary to alcohol intoxication with EtOH\n level of 522, now with normalization of respiratory status without need\n for intubation/mechanical ventilation.\n Plan:\n # Alcohol abuse/intoxication: Pt denies prior hospitalizations,\n however, per friend he has been hospitalized in the past and\n participated in rehab. No reported hx of alcohol withdrawal or\n seizures, denies daily alchol ingestion. Denies SI.\n - Monitor on telemetry and CIWA scale q4hr (Ativan given reported hx of\n alcoholic hepatitis - unknown status)\n - thiamine, folate, MVI\n - pt declining SW c/s at this time, will readdress in am.\n - Cont. IVFs overnight\n - Recheck EtOH level in am\n .\n # Respiratory depression: Appears to have completely resolved.\n End-tidal CO2 monitoring normal (39) in the emergency department. Tox\n screen negative, so presumably from EtOH overdose which is most likely\n given level >500. Nl respiratory rate and exam. Pt is awake and alert.\n Will cont. to monitor and limit medications that cause respiratory\n depression\n .\n # Depression: Severe per patient's friend. Offered social work\n consultation. Denies SI. Expresses sadness over his father's recent\n diagnosis and reports drinking excessively in response to this.\n - avoid Prozac given reported allergy (unknown)\n - readdress in am and offer resources\n .\n # Alcoholic hepatitis: Per friend's report. Denies knowledge of viral\n hepatitis.\n - add on LFTs\n - limit medications that are hepatically cleared\n .\n # FEN: IVFs - NS overnight, regular diet, replete lytes as needed\n .\n # Access: PIV\n .\n # PPx: Heparin sc, bowel regimen\n .\n # Code: Full, confirmed with patient and ICU consent signed\n .\n # Dispo: ICU care\n .\n # Comm: Dr. , cell \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:05 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 420976, "text": "Chief Complaint: unresponsive\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 38 yr old man who was found by his roomate last evening passed out on\n floor of home, EMS called- cyanotic - resp depression, given narcan,\n questionable response.\n Of note, history of alcohol abuse, recent depression., In ED\n hemodynamically stable. Kept on end tidal CO2 monitoring. ETOH level of\n 522.\n Pt states he does not drink regularly but endorses bingr drinking-\n father recently diagnosed with termminal cancer.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:43 AM\n Other medications:\n Thiamine, MVI, folate,\n Past medical history:\n Family history:\n Social History:\n Alcohol abuse - has been in rehab, no hx of DTs\n Alcohoic hepatitis\n father rhabdomyosarcoma\n Occupation: substance abuse researcher\n Drugs:\n Tobacco: heavy\n Alcohol:\n Other: lives with roomate, divorced\n Review of systems:\n Constitutional: Fatigue\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Flowsheet Data as of 08:34 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.2\nC (97.1\n HR: 89 (75 - 93) bpm\n BP: 103/65(73) {95/54(64) - 160/102(113)} mmHg\n RR: 18 (12 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 1,500 mL\n PO:\n TF:\n IVF:\n 1,002 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,150 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: no edema\n Skin: warm\n Neruo: a and o x 3 , ambulating in , no tremor or asterixis\n Labs / Radiology\n 192 K/uL\n 43.6 %\n 16.1 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 5 mg/dL\n 28 mEq/L\n 106 mEq/L\n 5.1 mEq/L\n 146 mEq/L\n 5.1 K/uL\n [image002.jpg]\n 03:02 AM\n WBC\n 5.1\n Hct\n 43.6\n Plt\n 192\n Cr\n 0.8\n Glucose\n 95\n Other labs: Ca++:9.2 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ALCOHOL ABUSE\n - Monitored on telemetry and CIWA scale q4hr (Ativan given reported hx\n of alcoholic hepatitis - unknown status)\n has not required any Ativan\n since 0.5 mg last night for sleep not + CIWA\n - cont thiamine, folate, MVI\n - pt declining SW c/s at this time.\n be able to d/c to home if safe home situation can be deterined and\n PCP follow up arranged.\n ICU Care\n Nutrition: reg diet\n Glycemic Control: prn\n Lines / Intubation:\n 16 Gauge - 01:05 AM\n Communication: with pt and friend\n status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 420942, "text": "Chief Complaint: unresponsive\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 38 yr old man who was found by his roomate last evening passed out on\n floor of home, EMS called- cyanotic - resp depression, given narcan,\n questionable response.\n Of note, history of alcohol abuse, recent depression., In ED\n hemodynamically stable. Kept on end tidal CO2 monitoring. ETOH level of\n 522.\n Pt states he does not drink regularly but endorses bingging- father\n recently diagnosed with termminal cancer.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:43 AM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Alcohol abuse - has been in rehab, no hx of DTs\n Alcohoic hepatitis\n father rhabdomyosarcoma\n Occupation: substance abuse researcher\n Drugs:\n Tobacco: heavy\n Alcohol:\n Other: lives with roomate, divorced\n Review of systems:\n Constitutional: Fatigue\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Flowsheet Data as of 08:34 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.2\nC (97.1\n HR: 89 (75 - 93) bpm\n BP: 103/65(73) {95/54(64) - 160/102(113)} mmHg\n RR: 18 (12 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 1,500 mL\n PO:\n TF:\n IVF:\n 1,002 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,150 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 192 K/uL\n 43.6 %\n 16.1 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 5 mg/dL\n 28 mEq/L\n 106 mEq/L\n 5.1 mEq/L\n 146 mEq/L\n 5.1 K/uL\n [image002.jpg]\n 03:02 AM\n WBC\n 5.1\n Hct\n 43.6\n Plt\n 192\n Cr\n 0.8\n Glucose\n 95\n Other labs: Ca++:9.2 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ALCOHOL ABUSE\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n 16 Gauge - 01:05 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 420945, "text": "Chief Complaint: unresponsive\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 38 yr old man who was found by his roomate last evening passed out on\n floor of home, EMS called- cyanotic - resp depression, given narcan,\n questionable response.\n Of note, history of alcohol abuse, recent depression., In ED\n hemodynamically stable. Kept on end tidal CO2 monitoring. ETOH level of\n 522.\n Pt states he does not drink regularly but endorses bingr drinking-\n father recently diagnosed with termminal cancer.\n Patient admitted from: ER\n History obtained from Patient\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 02:43 AM\n Other medications:\n Thiamine, MVI, folate,\n Past medical history:\n Family history:\n Social History:\n Alcohol abuse - has been in rehab, no hx of DTs\n Alcohoic hepatitis\n father rhabdomyosarcoma\n Occupation: substance abuse researcher\n Drugs:\n Tobacco: heavy\n Alcohol:\n Other: lives with roomate, divorced\n Review of systems:\n Constitutional: Fatigue\n Eyes: No(t) Blurry vision\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Tachycardia\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, Nausea, No(t) Emesis, No(t)\n Diarrhea, No(t) Constipation\n Flowsheet Data as of 08:34 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.2\nC (97.1\n HR: 89 (75 - 93) bpm\n BP: 103/65(73) {95/54(64) - 160/102(113)} mmHg\n RR: 18 (12 - 18) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 1,500 mL\n PO:\n TF:\n IVF:\n 1,002 mL\n Blood products:\n Total out:\n 0 mL\n 350 mL\n Urine:\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,150 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///28/\n Physical Examination\n General Appearance: Well nourished\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender\n Extremities: no edema\n Skin: warm\n Labs / Radiology\n 192 K/uL\n 43.6 %\n 16.1 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 5 mg/dL\n 28 mEq/L\n 106 mEq/L\n 5.1 mEq/L\n 146 mEq/L\n 5.1 K/uL\n [image002.jpg]\n 03:02 AM\n WBC\n 5.1\n Hct\n 43.6\n Plt\n 192\n Cr\n 0.8\n Glucose\n 95\n Other labs: Ca++:9.2 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n Assessment and Plan\n ALCOHOL ABUSE\n - Monitored on telemetry and CIWA scale q4hr (Ativan given reported hx\n of alcoholic hepatitis - unknown status)\n - cont thiamine, folate, MVI\n - pt declining SW c/s at this time.\n - Cont. additional 500cc IVFs and encourage po intake\n ICU Care\n Nutrition: reg diet\n Glycemic Control: prn\n Lines / Intubation:\n 16 Gauge - 01:05 AM\n Comments:\n Prophylaxis:\n DVT:\n Stress ulcer:\n Communication: with pt and friend\n status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 420958, "text": "Chief Complaint: Alcohol intoxication\n 24 Hour Events:\n -no significant events overnight\n - denied SI & HI\n -pt does not want SW, states he is planning on seeing a psychiatrist\n through his work ()\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.2\nC (97.1\n HR: 80 (75 - 93) bpm\n BP: 95/54(64) {95/54(64) - 160/102(113)} mmHg\n RR: 16 (12 - 18) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 1,248 mL\n PO:\n TF:\n IVF:\n 999 mL\n Blood products:\n Total out:\n 0 mL\n 320 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 928 mL\n Respiratory support\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), RRR\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 16.1 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 5.1 mEq/L\n 5 mg/dL\n 106 mEq/L\n 146 mEq/L\n 43.6 %\n 5.1 K/uL\n [image002.jpg]\n 03:02 AM\n WBC\n 5.1\n Hct\n 43.6\n Plt\n 192\n Cr\n 0.8\n Glucose\n 95\n Other labs: Ca++:9.2 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n ALT: 167 AST:199 AP:59 LDH: 233 Tbili:0.7 Alb:4.9\n CK:183 MB:3 Trop<0.01\n EtOH:376\n Urine & Serum Tox Negative\n Assessment and Plan\n ALCOHOL ABUSE\n Assesment: This is a 38 yo M with hx of alcohol abuse presenting with\n respiratory depression secondary to alcohol intoxication with EtOH\n level of 522, now with normalization of respiratory status without need\n for intubation/mechanical ventilation.\n Plan:\n # Alcohol abuse/intoxication: Pt denies prior hospitalizations,\n however, per friend he has been hospitalized in the past and\n participated in rehab. No reported hx of alcohol withdrawal or\n seizures, denies daily alcohol ingestion. Pt had 1 pint of vodka PTA.\n Denies SI. EtOH level 376. Pt has been stable overnight. Pt oriented\n and mentating at baseline. No signs of acute intoxication.\n - Monitor on telemetry and CIWA scale q4hr (Ativan given reported hx of\n alcoholic hepatitis - unknown status)\n - cont thiamine, folate, MVI\n - pt declining SW c/s at this time will seek resources from .\n - Cont. additional 500cc IVFs and encourage po intake\n .\n # Respiratory depression: Pt back to baseline respiratory status.\n End-tidal CO2 monitoring normal (39) in the emergency department. Tox\n screen negative, so presumably from EtOH overdose which is most likely\n given level >500. Pt is awake and alert. Pt off NC and back to\n baseline. Will cont. to monitor and limit medications that cause\n respiratory depression\n .\n # Depression: Severe per patient's friend. Offered social work\n consultation. Denies SI & HI. Expresses sadness over his father's\n recent diagnosis and reports drinking excessively in response to this.\n - avoid Prozac given reported allergy (unknown)\n - pt declined psych, SW consults, states will see psych at .\n .\n # Transaminitis: alcoholic hepatitis per friend's report. Denies viral\n hepatitis and vaccinated for Hep B. Mildly elevated LFT. ALT 167 AST\n 199. Likely alchoholic hepatitis.\n - limit medications that are hepatically cleared\n - cont to trend LFT\n .\n # FEN: IVFs - NS as above, regular diet, replete lytes as needed\n .\n # Access: PIV\n .\n # PPx: Heparin sc, bowel regimen\n .\n # Code: Full, confirmed with patient and ICU consent signed\n .\n # Dispo: If patient is able to ambulate, tolerate po, shows no active\n signs of intoxication or withdrawl can be discharged. Will arrange\n transport for the patient home. Pt was offered resources, but\n declined.\n .\n # Comm: Dr. , cell \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:05 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2190-10-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 420933, "text": "Chief Complaint: Alcohol intoxication\n 24 Hour Events:\n -no significant events overnight\n - denied SI & HI\n -pt does not want SW, states he is planning on seeing a psychiatrist\n through his work ()\n Allergies:\n Prozac (Oral) (Fluoxetine Hcl)\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t)\n Tachycardia, No(t) Orthopnea\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.2\nC (97.1\n HR: 80 (75 - 93) bpm\n BP: 95/54(64) {95/54(64) - 160/102(113)} mmHg\n RR: 16 (12 - 18) insp/min\n SpO2: 98% RA\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 71.3 kg (admission): 71.3 kg\n Height: 71 Inch\n Total In:\n 1,248 mL\n PO:\n TF:\n IVF:\n 999 mL\n Blood products:\n Total out:\n 0 mL\n 320 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 928 mL\n Respiratory support\n SpO2: 98%\n ABG: ///28/\n Physical Examination\n General Appearance: No(t) Well nourished, No(t) No acute distress\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic), RRR\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): x3, Movement: Purposeful, Tone: Not assessed\n Labs / Radiology\n 192 K/uL\n 16.1 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 28 mEq/L\n 5.1 mEq/L\n 5 mg/dL\n 106 mEq/L\n 146 mEq/L\n 43.6 %\n 5.1 K/uL\n [image002.jpg]\n 03:02 AM\n WBC\n 5.1\n Hct\n 43.6\n Plt\n 192\n Cr\n 0.8\n Glucose\n 95\n Other labs: Ca++:9.2 mg/dL, Mg++:1.9 mg/dL, PO4:5.3 mg/dL\n ALT: 167 AST:199 AP:59 LDH: 233 Tbili:0.7 Alb:4.9\n CK:183 MB:3 Trop<0.01\n EtOH:376\n Urine & Serum Tox Negative\n Assessment and Plan\n ALCOHOL ABUSE\n Assesment: This is a 38 yo M with hx of alcohol abuse presenting with\n respiratory depression secondary to alcohol intoxication with EtOH\n level of 522, now with normalization of respiratory status without need\n for intubation/mechanical ventilation.\n Plan:\n # Alcohol abuse/intoxication: Pt denies prior hospitalizations,\n however, per friend he has been hospitalized in the past and\n participated in rehab. No reported hx of alcohol withdrawal or\n seizures, denies daily alchol ingestion. Pt had 1 pint of vodka PTA.\n Denies SI. EtOH level 376. Pt has been stable overnight.\n - Monitor on telemetry and CIWA scale q4hr (Ativan given reported hx of\n alcoholic hepatitis - unknown status)\n - cont thiamine, folate, MVI\n - pt declining SW c/s at this time.\n - Cont. additional 500cc IVFs and encourage po intake\n .\n # Respiratory depression: Pt back to baseline respiratory status.\n End-tidal CO2 monitoring normal (39) in the emergency department. Tox\n screen negative, so presumably from EtOH overdose which is most likely\n given level >500. Pt is awake and alert. Pt off NC and back to\n baseline. Will cont. to monitor and limit medications that cause\n respiratory depression\n .\n # Depression: Severe per patient's friend. Offered social work\n consultation. Denies SI & HI. Expresses sadness over his father's\n recent diagnosis and reports drinking excessively in response to this.\n - avoid Prozac given reported allergy (unknown)\n - pt declined psych, SW consults, states will see psych at .\n .\n # Transaminitis: alcoholic hepatitis per friend's report. Denies viral\n hepatitis and vaccinated for Hep B. Mildly elevated LFT. ALT 167 AST\n 199. Likely alchoholic hepatitis.\n - check hepatitis serologies\n - limit medications that are hepatically cleared\n - cont to trend LFT\n .\n # FEN: IVFs - NS as above, regular diet, replete lytes as needed\n .\n # Access: PIV\n .\n # PPx: Heparin sc, bowel regimen\n .\n # Code: Full, confirmed with patient and ICU consent signed\n .\n # Dispo: ICU care\n .\n # Comm: Dr. , cell \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 16 Gauge - 01:05 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:Transfer to floor\n" }, { "category": "Radiology", "chartdate": "2190-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1041660, "text": " 9:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: pna? asp?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with fouhd down in resp arrest.\n REASON FOR THIS EXAMINATION:\n pna? asp?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 38-year-old male found down in respiratory arrest. Evaluate for\n pneumonia or aspiration.\n\n COMPARISON: None.\n\n FINDINGS: An AP portable upright view of the chest was obtained. The lungs\n are clear. Cardiac size, hila and pulmonary vasculature are within normal\n limits. No fracture is identified.\n\n IMPRESSION: No acute intrathoracic process.\n\n" }, { "category": "Radiology", "chartdate": "2190-09-30 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1041661, "text": " 9:24 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: FOUND DOWN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with found down signs of trauma on anterior chest.\n REASON FOR THIS EXAMINATION:\n fx?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:11 PM\n No fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old male, found down with signs of trauma on anterior chest.\n Rule out fracture.\n\n No prior studies available for comparison.\n\n TECHNIQUE: Contiguous axial images of the cervical spine were obtained\n without IV contrast. Coronal and sagittal reformations were obtained.\n\n FINDINGS: There is no prevertebral soft tissue abnormality. Cervical\n lordosis is preserved. No acute fracture or malalignment is identified. The\n spinal canal appears widely patent without evidence of epidural hematoma.\n Visualized lung apices reveal no evidence of a pneumothorax. Small amount of\n secretions are seen within the airway.\n\n IMPRESSION: No acute fracture or malalignment.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-09-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1041662, "text": " 9:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FOUND DOWN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 38 year old man with found unresponsive in resp arrest, responded to narcan.\n history of brain mass?\n REASON FOR THIS EXAMINATION:\n bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 10:50 PM\n - no intracranial hemorrhage or mass effect.\n - stable 7mm hypodensity of left cerebral white matter, unchanged since\n .\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 38-year-old male found unresponsive, in respiratory arrest,\n responded to Narcan. History of brain mass. Question of bleed.\n\n COMPARISON: Non-contrast head CT .\n\n TECHNIQUE: Non-contrast head CT was obtained.\n\n FINDINGS: There is no intracranial hemorrhage, mass effect, or shift of\n normally midline structures. Ventricles, basal cisterns, and sulci are normal\n in size and configuration. -white matter differentiation is normally\n preserved.\n\n The left periventricular 7 mm hypodensity is unchanged in comparison to CT\n from one year prior. There is no surrounding edema. This is a nonspecific\n finding.\n\n Paranasal sinuses and mastoid air cells are well aerated. No fracture is\n identified.\n\n IMPRESSION:\n 1. No acute intracranial abnormality.\n 2. Hypodense focus of periventricular left cerebral white matter, unchanged\n in comparison to CT from one year prior.\n\n" }, { "category": "ECG", "chartdate": "2190-09-30 00:00:00.000", "description": "Report", "row_id": 220470, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nthe ventricular rate is slower.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2131-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765426, "text": " 7:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Any change in lungs - For am Cxr ~ 5 am\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n Any change in lungs - For am Cxr ~ 5 am\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 69 with status post AAA repair and change in the lungs from this\n morning's chest radiograph.\n\n AP portable chest radiograph is compared to an earlier study dated .\n\n Tubes and lines are unchanged. There is increase in the cardiac silhouette and\n problems of the perihilar region suggesting congestive failure. There is also\n a new right-sided hazy opacity suggesting effusions. There is also a left\n basilar opacity which obscures the hemidiaphragm which may represent a focal\n area of consolidation or atelectasis. No pneumothorax is identified.\n\n IMPRESSION:\n Increase in cardiac silhouette with perihilar opacity suggesting congestive\n failure. There is new right-sided pleural effusion.\n\n There is left basilar opacity which obscures the hemidiaphragm which may\n represent atelectasis or consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765334, "text": " 5:52 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute desaturation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n acute desaturation\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: S/P AAA repair with acute desaturation.\n\n Comparison: .\n\n PORTABLE AP CHEST: Again seen, is right IJ central line with SG catheter with\n tip in the right main pulmonary artery. The ET tube is in good position. The\n left IJ dialysis catheter remains unchanged. NG tube is seen with its tip\n projecting in the direction of the stomach. Heart size is within normal\n limits. Again seen, is unexplained enlargement of the upper mediastinum. CT\n evaluation of this when patient is stabilized is recommended. The lungs are\n unchanged. No evidence of CHF. No definite pleural effusions. No\n pneumothorax. The visualized soft tissues and osseous structures are\n otherwise unremarkable.\n\n IMPRESSION:\n 1) Satisfactory placement of tubes and lines.\n\n 2) Unexplained widening of the mediastinum. Please further evaluate, as\n clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-09-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765503, "text": " 10:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Asses for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n Asses for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Repair of abdominal aortic aneurysm. Assess for pneumothorax.\n\n PORTABLE CHEST: Single Ap view of the chest is available. The endotracheal\n tube is 5 cm above the carina. There is evidence of pulmonary edema with\n bilateral pleural effusions. A central venous line is noted from the right\n with its tip in the superior vena cava. Another central line from the left\n central jugular is with its tip in the left innominate vein. In comparison\n with the prior exam from there is no significant change.\n\n IMPRESSION: The tubes and lines are in correct place and position. There is\n evidence of pulmonary edema with pleural effusions on both sides that are\n unchanged from the prior film.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765617, "text": " 1:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p 02 drop, loss of L lung ascultation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n s/p 02 drop, loss of L lung ascultation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Loss of ascultation in the left lung.\n\n The ETT, NGT, and right Swan-Ganz catheter are appropriately positioned. There\n is a left IJ line with tip in the junction of the subclavian and internal\n jugular. There are bilateral layering pleural effusions with atelectases left\n base and possible consolidation in left upper lobe but tis could be\n better evaluated on an upright film.There is no pneumothorax.\n\n IMPRESSION:\n\n ?Left upper lobe consolidation.\n Bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765749, "text": " 2:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: TO SEE THE TIP OF pa CATHETER.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n TO SEE THE TIP OF pa CATHETER.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE AP FILM:\n\n HISTORY: AAA repair. Placement of pulmonary artery catheter.\n\n The Swan-Ganz catheter is in the right main pulmonary artery. Endotracheal\n tube is 4 cm above carina. Left jugular CV line is in region of the junction\n of jugular and subclavian veins. There are bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765609, "text": " 5:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of ET tube after re-intubation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n placement of ET tube after re-intubation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post reintubation.\n\n FINDINGS: Endotracheal tube is now slightly lower than on the prior film and\n is 5 cm above the carina. There is continued hazy opacity over both lungs,\n suggesting layering effusion. There continues to be dense lower lobe volume\n loss. Left lateral lung is off the film.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765795, "text": " 6:04 AM\n CHEST (PORTABLE AP) Clip # \n Reason: on pressure control vent; now with desaturation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n on pressure control vent; now with desaturation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION:\n\n Portable AP radiograph of the chest is reviewed and compared to a study of\n yesterday. The study is limited due to patient's body habitus. The lower\n half of the left lung is not included in this radiograph.\n\n The tip of the endotracheal tube is identified at thoracic inlet. The right\n jugular Swan-Ganz catheter and left jugular IV catheter remain in place. No\n pneumothorax is seen.\n\n There is continued moderate pulmonary edema with bilateral effusion and\n atelectasis in both lower lobes. The heart is normal in size.\n\n IMPRESSION: Limited study. Continued moderate pulmonary edema with bilateal\n pleural effusion and atelectasis in both lower lobes. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765303, "text": " 6:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK LINE PLACEMENT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man with\n REASON FOR THIS EXAMINATION:\n CHECK LINE PLACEMENT\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate line placement.\n\n Portable AP chest radiograph dated is submitted for\n evaluation. No prior images for comparison.\n\n FINDINGS: An endotracheal tube is seen terminating approximately 4 cm above\n the level of the carina. There is a nasogastric tube coursing below the level\n of the hemidiaphragm. The left IJ sheath is seen within the distal jugular\n vein. A pulmonary artery catheter is seen terminating within the proximal\n right pulmonary artery. There is no evidence of pneumothorax.\n\n Note is made of rightward deviation of the trachea at the level of the\n thoracic inlet. The precise etiology of this is not certain, but it could\n represent enlargement of the thyroid or a mediastinal mass. A CT of the chest\n is recommended to better evaluate this finding. The cardiac contours are\n within normal limits. There is pulmonary vascular engorgement and upper zone\n redistribution consistent with congestive heart failure. There is a small\n pleural effusion. There is elevation of the right hemidiaphragm. The\n visualized osseous structures and soft tissues are unremarkable.\n\n IMPRESSION:\n 1. Satisfactory placement of a Swan Ganz catheter within the proximal right\n pulmonary artery.\n 2. Left catheter introducer sheath within the distal jugular vein.\n 3. Rightward deviation of the trachea at the level of the thoracic inlet,\n concerning for an enlarged thyroid or mediastinal abnormality. A CT is\n recommended to better evaluate this finding.\n 4. Pulmonary vascular engorgement and upper zone redistribution consistent\n with congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765310, "text": " 7:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK POSITION OF LEFT IJ DIALYSIS CATHETER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n CHECK POSITION OF LEFT IJ DIALYSIS CATHETER\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Evaluate position of left IJ dialysis catheter.\n\n Portable AP chest radiograph dated is compared to the prior\n study performed two hours earlier.\n\n FINDINGS: There has been interval placement of a left IJ dialysis catheter\n with its tip terminating within the distal jugular vein. The Swan Ganz\n catheter, endotracheal tube, and nasogastric tube are in stable position. Note\n is again made of rightward deviation of the trachea at the level of the\n thoracic inlet. The cardiac contours appear stable. There is pulmonary\n vascular engorgement and upper zone redistribution, consistent with congestive\n heart failure. There is no pleural effusion on the right side. The left\n costophrenic angle is omitted from this study.\n\n IMPRESSION:\n 1. Satisfactory placement of dialysis catheter.\n 2. Pulmonary vascular engorgement and upper zone redistribution consistent\n with congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 766028, "text": " 10:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pt is currently intubated, r/o any intra pulmary causes of h\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n pt is currently intubated, r/o any intra pulmary causes of hemodynamic decresae\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to previous study of .\n\n INDICATION: Respiratory failure. Intubation.\n\n An ETT, Swan-Ganz catheter, NG tube and left internal jugular vascular\n catheter are in satisfactory position. Cardiac and mediastinal contours are\n within normal limits for portable supine technique. There are moderate sized\n layering bilateral pleural effusions. It is difficult to exclude underlying\n pulmonary parenchymal process in the lung bases. Diffuse haziness of the upper\n abdomen likely reflects ascites, and there is probably anasarca present as\n well.\n\n IMPRESSION: Moderate sized bilateral pleural effusions. Probable ascites and\n anasarca.\n\n" }, { "category": "Radiology", "chartdate": "2131-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765599, "text": " 1:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: R/O INFILTRATE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n R/O INFILTRATE\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY; S/P aneurysm repair.\n\n Reference exam: .\n\n ET tube is still too high, with tip at the level of T1. There is a right IJ\n SG catheter with tip in the right main pulmonary artery. There is a left IJ\n line with tip probably in the subclavian vein. There is increased hazy\n opacity overlying both lungs, likely representing layering effusions. There\n is dense consolidation in bilateral lower lobes and the left upper lobe. It is\n unclear how much of this is interstitial infiltrate and how much is volume\n loss.\n\n IMPRESSION:\n 1) High position of ET tube.\n\n 2) Worsening appearance of the chest with large layering effusions and\n multifocal areas of consolidation/volume loss.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-09-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 765854, "text": " 2:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: wire change of lt. subclavian quinton cath. TO SEE THE TIP O\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 69 year old man S/P AAA REPAIR\n\n REASON FOR THIS EXAMINATION:\n wire change of lt. subclavian quinton cath. TO SEE THE TIP OF CATHETER. TO R/O\n PTHX.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post AAA repair with placement of Quinton catheter.\n\n A single view of the chest is compared to a previous study dated .\n\n The study is limited due to body habitus. The ET tube, NG tube and Swan-Ganz\n catheter are in appropriate position. The Quinton catheter is within the\n right atrium. The cardiac contours are difficult to assess but not\n significantly changed in comparison to the previous study. There is hazy\n opacity involving both lung fields probably representing effusion and\n atelectasis. There is diffuse stable moderate-to-severe pulmonary edema.\n There is no large pneumothorax.\n\n IMPRESSION:\n\n Moderate-to-severe pulmonary edema.\n\n Bilateral pleural effusions and atelectasis.\n\n Quinton catheter which is within the right atrium.\n\n\n\n" }, { "category": "Echo", "chartdate": "2131-09-06 00:00:00.000", "description": "Report", "row_id": 72927, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nS/P AAA rupture/repair.\nHeight: (in) 71\nBP (mm Hg): 114/68\nStatus: Inpatient\nDate/Time: at 16:10\nTest: Portable TEE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was intubated, sedated, paralyzed and supported with dobutamine\nand norepinephrine per SICU protocol. FiO2 was increased to 100% during the\nprocedure.\n\nA catheter is present in the right ventricle.\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The interatrial septum is aneurysmal.\n\nLEFT VENTRICLE: There is symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis moderately depressed.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal. Right ventricular\nsystolic function appears depressed.\n\nAORTA: There are focal calcifications in the aortic root.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is mild\nmitral annular calcification.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation.\n\nGENERAL COMMENTS: A transesophageal echocardiogram was performed in the\nlocation listed above. I certify I was present in compliance with HCFA\nregulations. The patient was monitored by a nurse throughout the\nprocedure. There were no TEE related complications. The patient is tachycardic\n(HR>100bpm). The results were personally reviewed with the physician caring\nfor the patient.\n\nConclusions:\nThe interatrial septum is aneurysmal (no shunting is visualized). There is\nsymmetric left ventricular hypertrophy. The left ventricular cavity size is\nnormal. Overall left ventricular systolic function is moderately and globally\ndepressed (? LVEF 30%) Right ventricular chamber size is normal. Right\nventricular systolic function appears depressed. The aortic leaflets (3) are\nmildly thickened. Mild (1+) aortic regurgitation is seen. The mitral leaflets\nare mildly thickened. No significant mitral regurgitation is detected. No\nsignificant pericardial effusion is present. The descending thoracic aorta is\ndiffusely atheromatous (non-mobile).\n\n\n" }, { "category": "Echo", "chartdate": "2131-09-06 00:00:00.000", "description": "Report", "row_id": 72928, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nTachycardic and hypotensive S/P AAA rupture\nHeight: (in) 71\nWeight (lb): 176\nBSA (m2): 2.00 m2\nBP (mm Hg): 112/74\nStatus: Inpatient\nDate/Time: at 10:48\nTest: Portable TTE(Focused views)\nDoppler: Focused pulse and color flow\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nA catheter is noted in the right ventricle.\nLEFT VENTRICLE: The left ventricle is not well seen. The left ventricular\ncavity size is normal. LV systolic function appears depressed.\n\nRIGHT VENTRICLE: The right ventricle is not well seen.\n\nAORTA: The aortic root is mildly dilated.\n\nAORTIC VALVE: The number of aortic valve leaflets cannot be determined. The\naortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are structurally normal. There is mild\nmitral annular calcification.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. The pulmonary artery\nsystolic pressure could not be determined.\n\nGENERAL COMMENTS: Suboptimal image quality. The patient was on a ventilator.\nThe patient is tachycardic (HR>100bpm).\n\nConclusions:\nThe left ventricle is not well seen. The left ventricle may be hypertrophied.\nThe left ventricular cavity size is normal. LV systolic function appears\ndepressed. The LVEF cannot be estimated. The right ventricle is not well seen.\nThe aortic root is mildly dilated. The aortic leaflets (? number) are mildly\nthickened. The mitral leaflets are structurally normal. No significant mitral\nregurgitation is detected on limited mitral Doppler.The pulmonary artery\nsystolic pressure could not be determined. There is a small to moderate\necho-dense space seen anteriorly and posteriorly c/w pericardial effusion\nand/or fat.\n\nA TEE would better assess the cardiac structures (did this patient have an\nintra-operative TEE at the time of his surgical procedure?).\n\n\n" }, { "category": "ECG", "chartdate": "2131-09-14 00:00:00.000", "description": "Report", "row_id": 176486, "text": "Sinus tachycardia\nNonspecific ST changes\nGeneralized low QRS voltages\nSince previous tracing, lower QRS voltage\n\n" }, { "category": "ECG", "chartdate": "2131-09-05 00:00:00.000", "description": "Report", "row_id": 176487, "text": "Sinus tachycardia. Q waves in leads III and aVF of uncertain significance.\nBorderline low limb lead voltage. RSR' pattern in lead V1. Early R wave\nprogression. ST-T wave abnormalities. Clinical correlation is suggested. No\nprevious tracing available for comparison.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-09-06 00:00:00.000", "description": "Report", "row_id": 1494525, "text": "CONDITION UPDATE\nD.WITH ONGOING HYPOXIA,PT WAS SEDATED AND PARALYZED,ULTIMATELY PLACED ON PRESSURE CONTROL VENTILATION.PT WAS MOVING ALL EXTREMITIES PRIOR TO BEING STARTED ON PARALYTICS.\n AFEBRILE,ST 100'2 ON 25 MCQ ESMOLOL. ESMOLOL TURNED OFF X2 WITH IMMEDIATE INCREASE OF HR TO 120'S. DR, AWARE AND THUS REMAINS ON.BP FOLLOWED BY A-LINE PER DR. . LEVOPHED TITRATED UP TO .5MCQ TO MAINTAIN SBP 100 IF POSSIBLE. INTERMITTENTLY PT HAS SUDDEN SBP DROPS RESPONDING TO FLUID BOLI .DOPAMINE TURNED OF ONCE DOBUTAMINE STARTED AND CI REMAINS >2.O.CARDIAC ECHO INCONCLUSIVE THUS ETT TO BE DONE. TODAY'S CK,MB AND TRIPONIN LEVELS ALL ELEVATED. BY THIS PM PCWP UP TO 17.MIVF AT 125ML/HR.CVHD WITH NO FLUID REMOVAL..FUNCTIONING WELL AT THIS TIME.\n HCT STABLE,INSULIN DRIP FOR BS,CONTINUOUS CALCIUM DRIP TITRATED AS ORDERED.\n PT'S DAUGHTER IN . DR. SPOKE TO HER IN LENGTH. WIFE ON ROUTE. DAUGHTER AWARE OF GRAVITY OF PT'S CONDITION.\n A.MAINTAIN SBP >90-100 IF POSSIBLE. PRN FLUID BOLI IF NECCESSARY'\nR. CONDITION VERY CRITICAL.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-09-07 00:00:00.000", "description": "Report", "row_id": 1494526, "text": "STATUS\nD: REMAINS ON INSULIN/DOBUT/LEVO/ESMOLOL/FENT/CA+/CISTA GTT'S..LABILE BP.. LAB'S Q2H.. A: LEVO UP .6 & 3 N/S BOLUSES GIVEN FOR BP & CVP..REMAINS ON CVVH WITHOUT PROB..NO FLUID REMOVED..K+ REPLETED X2..MAGSO4 REPLETED X1.. CA+ GTT REMAINS @ 70CC/H..INSULIN @ 10U..CISTA DOWN TO 1 CONTINUES WITH NO TWITCHES..RECTAL TUBE DRAINING FOUL SMELLING MAROON +.. ESSENTIALLY NO HUO..ABD INCISION C&D NO BOWEL SOUNDS..VERY EDEMATOUS UNABLE TO PALPATE OR DOPPLER LF PEDAL HO AWARE FOOT COOL WITH SL DUSKY BIG TOE..PALP FEM PULSE\nR: CONDITION GUARDED\nP: ATTEMPT TO WEAN LEVO AS TOL..CONTINUE WITH Q2 LABS\n" }, { "category": "Nursing/other", "chartdate": "2131-09-07 00:00:00.000", "description": "Report", "row_id": 1494527, "text": "Resp Care: Pt remains intubated via #8 ETT secured 24cm at lip. BS bilat rales. Not req. freq. sx'ing. Req. recruit. manuv. 2to decreasing PaO2's, w/o gd effect. Cxray shows bilat pl. effus. FiO2^'d to .65. PCV Vt=620-680. no other vent changes made this shift. Please see carevue for further vent inqueries.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-07 00:00:00.000", "description": "Report", "row_id": 1494528, "text": "nsg progress note\nneuro- sedated with fentanyl, paralyzed with citatcranium, 0/0 with tof. pearl 2mm/2mm.\n\nresp- pressure control vent with poor abg's. see flow sheet. requiring increase in peep to 22 for decrease sats. ips 20. spont tid vol 400's. sxn minimal secretions. placed on rotating bed this pm.\n\nhemodynamics- pa line. levo gtt weaning-neo gtt started. cont esmolol to keep hr less than 110. dobutaminme weaned to off. see flow shheet for pa, co #'s and gtt amounts.\n\nheme- plattlet count to 60. md aware.\n\ncardiac. troponin r/i mi. to cont to cycle.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-11 00:00:00.000", "description": "Report", "row_id": 1494537, "text": "STATUS\nD: CVVHD CLOTTED OFF..LABILE BP..ICA UP TO 1.2..OXI SWAN NOT WORKING PROPERLY\nA: CVVHD OFF X2H RESTARTED NOW REMOVING 150CC FLUID QH CONTINUES TO HAVE SOME ACCESS HIGH PRESSURES WHEN TURNING ON LF SIDE..SWAN CHANGED (NOT CORDIS) IN GOOD POSITION PER X- IMPROVED CO/CI..CA GTT DOWN TO 50CC/H..LEVO GTT UP & DOWN..BP CUFF REMOVED FROM LF ARM DUE TO BLISTERS..CONTINUES TO OOZE BLOODY FROM MOUTH..OOZING LGE AMT SEROUS FROM ABD & SCROTUM..BUTTOCKS EXCORIATED GEL & DUDODERM APPLIED..RT ARM CONTINUES TO OOZE MOD AMT SEROUS KALDOSAT DSD APPLIED..VENT CHANGES ABG'S (SEE FLOW SHEET)\nR: SL IMPROVED PULMON STATUS\nP: CONTINUE TO WEAN AS TOL FROM GTT'S & VENT..ATTEMPT TO REMOVE FLUID\n" }, { "category": "Nursing/other", "chartdate": "2131-09-12 00:00:00.000", "description": "Report", "row_id": 1494538, "text": "NURSING UPDATE\n PT STABLE THROUGHOUT , NO CHANGES REQUIRED TO GTTS. THEN AT 0530 BEGAN TO DESATURATE, SPO2 IN 80'S, SVO2 IN 50'S, VENT ALARM LOW EXPIRED TIDAL VOLUMES. AMBU/LAVAGE/SXN BY NURSING AND RT OBTAINING SCANT THICK PLUGS ONLY, BREATH SOUNDS DIMINISHED, STATUS REFLECTED IN 0600 ABG'S, FURTHER PULMONARY TOILET CLEARED SMALL AMT THICK TAN ONLY. BREATH SOUNDS IMPROVED, AND STATUS RESOLVED SLOWLY AS REFLECTED IN 0645 ABG. SBP DROPPED INTO 80'S DURING PULMONARY CARE REQUIRING INCREASE IN LEVO GTTS, WEANING BACK DOWN AT TIME OF REPORT.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-12 00:00:00.000", "description": "Report", "row_id": 1494539, "text": "FOCUS: CONDITION UPDATE\nD: CVVH FILTER CLOTTED THIS MORNING AFTER MUCH DIFFICULTY WITH ACCESS PRESSURE. DR. MADE AWARE, TREATMENT STOPPED, CVVH TUBING DC/D. PATIENT VERY STABLE THIS MORNING, WITH IMPROVING ABGS AND LOWERING DOSES OF LEVO, KEEPING MAP>65 AND CI>2.0. CALCIUM INFUSION TURNED OFF AFTER CVVH STOPPED AND IONIZED CA >1.2. QUINTON CHANGED OVER WIRE BY DRS. AND , TIP SENT FOR CULTURE. CXRAY DONE. ATIVAN INCREASED TO 2 MG/HR, FENTANYL INCREASED TO 300 MCG. PATIENT TURNED POST LINE CHANGED, THEN PROCEEDED TO DROP PRESSURE AND O2 SATS (SEE FLOW SHEET FOR SPECIFIC NUMBERS). LEVO INCREASED, CURRENTLY ON 0.2MCG/KG/MIN AND 1L NORMAL SALINE GIVEN. MULTIPLE VENT CHANGES MADE BY RESPIRATORY, CURRENTLY ON .9%, WILL CHECK GAS. LYTES SENT, BLOOD CULTURES SENT FROM PA LINE (WBC UP TO 17). RENAL BY SEVERAL TIMES DURING THIS PERIOD TO START CVVH, AWAITING CONNECTION OF MACHINE AND WILL TRY TO REMOVE FLUID AND GO UP ON PRESSORES IF NEEDED.\nA: WORSENING SEPSIS, REQUIRING MORE PRESSOR SUPPORT AND FLUID.\n WILL CHECK LABS, SHOOT NUMBERS AT 1800, CALL HO WITH INFORMATION, HOPEFULLY RESTART CVVH. MINIMAL MOVEMENT REST OF SHIFT, NO TURNING ON BED.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-05 00:00:00.000", "description": "Report", "row_id": 1494523, "text": "ADMISSION NOTE\nD. PT ADMITTED AT 1705 COLD,BARE HUGGER APPLIED. HR STEADILY INCREASED TO 110-140 BY 1800,SBP INITIALLYY AS HIGH AS 190 REQUIRING NTG DRIP WHICH PT WAS ADMITTED WITH TO 5MCQ DECREASING SBP TO 140.UNABLE TO WEDGE LINE BUT CVP=10 AND PAD=18 FOR WHICH PT RECEIVED BOLUS AND IVF AT 125ML/HR.PT ALSO WAS GIVEN TOTAL OF MSO4 10MG AND AWAITING MSO4 DRIP.\n PT REMAINS UNRESPONSIVE POST ANESTHESIA WITH PUPILS PINPOINT.\n PT CONTINUES WITH MINIMAL UO.. RENAL CONSULT IN.\n SHORTLY UPON ARRIVAL PT OF MASSIVE LIQ. GROSSLY QUIAC POS. LIGHT BROWN STOOL WITH BLOOD FLEX. ODOR ? ISCHEMIC BOWEL SMELL.\nA. PT EXTREMELY UNSTABLE. FAMILY NEEDS TO BE FOUND AND NOTIFIED.MESSAGES LEFT BY OR TEAM.\nR. EXTREMELY UNSTABLE.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-06 00:00:00.000", "description": "Report", "row_id": 1494524, "text": "STATUS UPDATE\nHEMODYNAMICS\n PT RECEIVED ON NTG AND SNP GTTS, CVL IN LIJ CHANGED TKO QUINTON CATH OVER A WIRE. CVVH STARTED @ 2130 BY DR , FLUID REMOVAL RATE OF 150CC/H. HR ESCALATING TO RATE OF 140'S. ESMOLOL BOLUS GIVEN PER BREVIBLOC SCALE AND GTTS STARTED @ 50MCG/KG/MIN. HR RESPONDED WELL BUT BP DROPPED. NTG AND SNP WEANED TO OFF, BP FAILED TO RESPOND, LR 500CC FLUID BOLUS GIVEN FOR TOTAL OF 3000CC, BP RESPONDED WELL TO FLUID DURING INFUSION BUT DROPPED TO 70'S ONCE BOLUS COMPLETED. ESMOLOL WEANED OFF AND DOPAMINE AND LEVOPHED GTTS COMMENCED FOR BP SUPPORT, BUT RESULTED IN TACHY BACK IN 140'S, ESMOLOL RESTARTED WITH GOOD EFFECT, LEVO TITRATED TO MAINTAIN BP WITHIN SET PARAMETERS. ALINE DAMPENED NAD UNABLE TO RECOVER SINCE 0400, DR AWARE, REMAINS PATENT FOR BLOOD DRAWING SO CUFF BP MONITORED AND PLANS TO REPLACE ALINE THIS AM. 12 LEAD EKG UNREMARKABLE. MAGNESIUM REPLETED X2. TOES SLIGHTLY MOTTLED THIS AM, THOUGH PEDAL PULSES REMAIN WEAKLY PALPABLE. POURING BLOOD TINGED LIQUID AND LOOSE STOOL, SOAKING BED EARLY , RECTAL TUBE INSERTED WITH GOOD EFFECT. FECAL FLUID RESEMBLING HEMATURIA IN APPEARANCE @ TIMES.\n\nRESPIRATORY\n INITIAL CXR INDICATED ETT OUT TOO FAR, ADVANCED FROM 21CM TO 24CM BY RRT PER REQUEST OF HO. BREATH SOUNDS CLEAR EXCEPT SLIGHTLY DIMINISHED @ LLL, SATS 97-100% ON 60%FIO2 THROUGH SHIFT UNTIL 0400, PT DESATURATED TO 80'S, AMBU AND LAVAGED FOR SMALL THICK TAN PLUG ONLY. HYPOXIA/ACIDOSIS REFLECTED IN , RRT AND AWARE OF LABS, ONLY VENT CHANGE ORDERED FOR PEEP INCREASE FROM 10-12.5, WITH ONLY MINIMAL IMPROVEMENET IN ABG'S. S/B DR THIS AM, PLAN TO SEDATE AND PARALIZE TO OPTIMALLY VENTILATE TODAY. CXR REPEATED THIS AM, AWAITING REPORT.\n\nNEURO\n PT NOT RESPONSIVE UNTIL WAKING UP @ 2200, IMMEDIATELY FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES, NODS AND SHAKES HEAD SLIGHTLY AND APPROPRIATELY IN RESPONSE TO QUESTIONS, REMAINS CALM, THOUGH EXPRESSING PAIN S/P SURGERY, MSO4 GTTS INCREASED UNTIL PAIN AND PT REMAINED CONSCIOUS, HO DECLINED IV SEDATION OTHER THAN ATIVAN 1MG Q6, PROPOFOL ORDER REQUESTED ONLY TO BE USED IF PT (WHICH HE WAS NOT AT ANY TIME).\n\nHISTORY/SOCIAL\n WIFE AND IN PHONE CONTACT THROUGH , DAUGHTER WILL ARRIVE FROM CAPE THIS AM, AND WIFE WILL BE FLYING UP FROM LONG-ISLAND. WIFE STATED THAT PT HAD HX OF TUMOR IN\"TAIL-BONE AREA\" FOR WHICH HE RECEIVED XRT AND HAS HAD BOWEL PROBLEMS SINCE. SHE DENIES THAT PT DRINKS ANYTHING OTHER SOCIALLY, BUT PT HE DRINKS WHISKEY EVERY DAY.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-10 00:00:00.000", "description": "Report", "row_id": 1494533, "text": "NURSING UPDATE\n INFUSION OF HYPERAL STOPPED @ CHANGE OF SHIFT (1900) DUE TO HEPARIN CONTENT OF FORMULA AND PT NOT YET RULED OUT FOR H.I.T. MAINTENANCE INFUSION OF D5NS RESUMED PER ORDER. FRESH SPEC SENT FOR HEPARIN ANTIBODY THIS AM,- TO ENSURE ACCURACY (ORIGINAL SPEC SENT @ TIME OF ORDER). PLATELET LEVEL DROPPED TO 32, SMALL AMOUNT OF BLOOD OOZING FROM MOUTH AND NARES, WHEN PT TURNED FOR HYGIENE. 5-PACK PLATELETS TRANSFUSED, PLTS UP TO 61 THIS AM.\n BLOOD PRESSURE LABILE DURING EVENING, RESPONDING TO NOISE AND TOUCH WITH HYPERTENSIVE EPISODES SBP 200. ATIVAN GTTS ADDED FOR ADEQUATE SEDATION AND FENTANYL CONTINUES @ 200MCG/H ALSO. PARALYZED ON CISATRACURIUM GTTS.\n SVO2 DIMINISHED TO 60 @ 0100, AND DIMINISHED TO LOW OF 54 AFTER 5MINS. BREATH SOUNDS DIMINISHED TO ABSENT ON LEFT. ABG 7.31/47/46/25/80%, PLACED ON FIO2 100%, AMBU AND LAVAGED BY RT OBTAINING VERY LARGE GREYISH MUCOUS PLUG - SENT FOR CX. RESOLVED, ABG'S 7.39/36/92/21/- @ 0445.\n CONTINUOUS CVVH, HOURLY FLUID REMOVAL GOAL 100CC, TOLERATING WELL HEMODYNAMICALLY. CONTINUES ON LEVOPHED GTTS. 5CC BLOODY URINE OUTPUT ONLY.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-10 00:00:00.000", "description": "Report", "row_id": 1494534, "text": "STATUS\nD: LABILE BP..REMAINS ON LEVO/CISTA/FENT/ATIVAN/CA GTT'S..CONTINUES ON CVVHD WITH CITRATE\nA: LEVO UP 0.166 FOR DROP IN BP 80/'S..CONTINUES TO OOZE FROM NOSE & MOUTH(APPEARS TO HAVE BITTEN TONGUE)..ABD INCISION OOZING LGE AMT SEROUS..SM BROWN STOOL BUTTOCKS EXCORIATED WITH DK AREAS..OOZING LGE AMT FROM RT BRACIAL..SUCTIONED FOR SM AMT THICK TAN WITH PLUGS.. PRESSURE SUPPORT DOWN TO 18 WITH ADQUATE ABG'S..BLADDER PRESSURE 40 .. MIN BLOODY URINE\nR: GUARDED\nP: CONTINUE TO WEAN AS TOL..INCREASE FLUID REMOVAL WITH CVVHD AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2131-09-11 00:00:00.000", "description": "Report", "row_id": 1494535, "text": "CONDITION UPDATE\nS/O: VSS, SBP LABILE, CONT TO REQUIRE LEVO, REMAINS ON ALL PREVIOUS DRIPS. ADEQUATELY PARALYZED ON CISAT. NO FACIAL TWITCHES W/ TOF, NO CLINICAL INDICATORS FOR NEED TO INCREASE PARALYTIC. CONT TO OOZE BLOODY DRAINAGE FROM NOSE AND MOUTH. LUNGS COARSE, AGGRESSIVE SUCTIONING THROUGH THE NIGHT FOR THICK, TAN SPUTUM. W/ SUCTIONING LUNGS CTA BILAT, DIMINISHED AT BASES. ABG'S ACCEPTABLE ON CURRENT VENT SETTINGS. ABD DISTENDED, ABSENT BSOUNDS. INCISION, APPROXIMATED, PINK, COPIOUS AMTS OF SEROUS DRAINAGE. DRESSING CHANGED PRN. MIN URINE OUTPUT. CONT ON CVVH. DIFFICULTY W/ MACHINE, KEPT ALARMING FOR HIGH ACCESS PRESSURE - FELLOW NOTIFIED. NO NEW ORDERS, TOLD TO REPOSITION PATIENT ( MD ). NO STOOL THIS SHIFT. WHEN TURNED PT . QUESTION MALFUNTION W/ SWAN SECONDARY TO ABNORMAL READINGS, MD AWARE.\nA/P: CONT AGGRESSIVE PULM TOILET, PAIN MANAGEMENT, MONITOR FOR S/S OF BLEEDING, S/S INFECTION. STRICT HEMODYNAMIC MONITOR. CONT FAMILY TEACHING. MAINTAIN SKIN INTEGRITY. CONT ICU CARE AND ASSESSMENTS.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-11 00:00:00.000", "description": "Report", "row_id": 1494536, "text": "Resp. Note\nPt remains intubated paralyzed and sedated on TCPCV 18/18, Rate 20, IT 1.2 sec, 50%. ABGs 7.36,42,117. Able to wean vent settings steadily over pass three days. BBs diminished. Will cont weaning as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-16 00:00:00.000", "description": "Report", "row_id": 1494545, "text": "Progress Note\nStill paralyzed and sedated. Continues on ativan, fentanyl and cisatracurium ggt.\nCV: pt continues on levophed to keep MAP>60, bp maintained within parameters, PAP,CI,CO,SVR,PCWP unchanged (see flowsheet). CVVHD continues. ultrafilt 170cc/hr, bp tolerating.\nRESP: sxn'd Q2-4hr for amt of brownish secretions, lungs coarse but diminshsed at the bases. O2 sat 97%, SVo2-58-62%\nGI: ngt in situ to lcwsx for bilious secretions. Abd firm and distended, no bowel sounds. abd drsg , drianage.\nGU: no u/o.\nSKIN: generalized edema, skin still oozing drainage. scrotum excoriated and red, very edematous and oozing large amts of drainage.\nPLAN: pt to continue on CVVHD and monitor closely for significant changes.\n\n" }, { "category": "Nursing/other", "chartdate": "2131-09-16 00:00:00.000", "description": "Report", "row_id": 1494546, "text": "Resp Care: Pt continues sedated intubated and on ventilatory support with pcv: driving press down to 18x20/fio2 .5/I time 1.2 sec with I/E 1:1.5/fio2 .5/ +14 peep with acceptable abg; BS coarse, sxn thick tan/white secretions, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-16 00:00:00.000", "description": "Report", "row_id": 1494547, "text": "STATUS\nD: REMAINS ON LEVO/FENT/ATIVAN/CISTA GTT'S..WBC'S 26\nA: VENT TO A/C WITH ADQUATE ABG'S..CVVHD FLUID REMOVAL INCREASED TO 200CC/H & HEPARIN DOWN TO 600U WITH PTT>60..CONTINUES OOZING FROM RT ARM,ABD WD & SCROTUM..BUTTOCKS DECUB IMPROVED..OOZING SM AMT BLOODY FROM RECTUM..SM AMT AMBER URINE\nR: ABLE TO WEAN LEVO SM AMT\nP: CONTINUE TO WEAN AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2131-09-16 00:00:00.000", "description": "Report", "row_id": 1494548, "text": "CALLED ICU SURGICAL RESIDENT TO EVALUATE NEW ONSET OF HEMATURIA, DECREASED CO/SVO2, AND SBP TO 70'S.\nLEVOPHED ^ .35MCG, LABS DRAWN, FOLEY IRRIGATED AND BLADDER PRESSURE RECORDED (25) AND SENIOR NOTIFIED\nNO SIGNIFICANT CHANGES W/LABS, RECALIBRATED OXISWAN WILL MONITOR CLOSELY\n\n" }, { "category": "Nursing/other", "chartdate": "2131-09-17 00:00:00.000", "description": "Report", "row_id": 1494549, "text": "Resp Care: Pt continues sedated intubated and on ventilatory support with A/C 700x20/fio2 .5/+14 peep with pip 35/plat 33, acceptable abg; BS coarse, sxn thick white/tan secretions, see carevue for details.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-17 00:00:00.000", "description": "Report", "row_id": 1494550, "text": "FOCUS: CONDITION UPDATE\nD: PATIENT STABLE ALL DAY ON LEVO/FENT/ATIVAN/CIST UNTIL TURNED AT 1700. DROPPED PRESSURE AFTER TURN TO AS LOW AS 50/. DRS. (HO AND ATTENDING), LEVO INCREASED/FLUID GIVEN, WITH GOOD RESPONSE. BLOOD PRESSURE BACK TO BASELINE AND DRIPS BACK TO BASELINE AFTER 10 . ? CAUSE OF DROP. CONTINUES ON CVVHD, REMOVING AROUND 200 CCHR. BLADDER IRRIGATION STARTED BECAUSE OF CLOTTING IN FOLEY. FAMILY IN MOST OF THE DAY. WIFE STATING HER FRUSTRATIONS, FEELS HUSBAND IS NOT GETTING ANY BETTER, AND SHE KNOWS HE WOULD NOW WANT TO BE KEPT ALIVE THIS WAY. FAMILY MEETING PLANNED FOR TOMORROW AT 1630--WIFE WANTS TO WITHDRAW CARE AND PROVIDE PATIENT WITH CMO. HO AND TEAM AWARE.\nA: NO FURTHER TURNING. FREQUENT LAB CHECKS. CALL HO WITH ANY CHANGE/DROP IN BLOOD PRESSURE.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-08 00:00:00.000", "description": "Report", "row_id": 1494529, "text": "STATUS UPDATE\n CONTINUES ON PRISMA CVVH THERAPY, HEMOFILTRATION ONLY, NO FLUID REMOVAL. ALL PRESSURES WNL. LEVOPHED GTTS SLOWLY WEANED TO OFF, ATTEMPTED WEANING NEO GTTS BUT BP DROPPED TO 83/37 AFTER 45MINS, RESUMED @ 5MCG/KG/MIN. PARALYZED ON CISATRACURIUM GTTS, TITRATED DOWN DUE TO NO TOF RESPONSE, BUT PT BEGAN MOVING BILATERAL FEET AND HANDS, CISAT GTTS RESUMED @ .07MG/KG/HR (8CC/H). PLATELETS DOWN TO 55 @ 2300, ?HIT, HEPARIN DC'D AND HIT PANEL SENT TO LAB. PLACED ON ROTOREST BED W/AIR MATTRESS, PERCUSSION UTIILIZED FOR CHEST PT. BREATH SOUNDS CLEAR THOUGH DIMINISHED @ BASES,CXR DONE- UNREMARKABLE. DIFFICULTY OBTAINING PULSE OXIMETRY, SEVERAL SITES ATTEMPTED, SA02 95-98% ON ABG.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-08 00:00:00.000", "description": "Report", "row_id": 1494530, "text": "FOCUS: CONDITION UPDATE\nD: PATIENT CONTINUES ON CVVH, RUNNING WELL. LYTES CHECKED FEQUENTLY, WITH K/NA DECREASING DURING THE DAY. CALCIUMS CHECKED FEQUENTLY, AND IV FLUIDS ADJUSTED PER SLIDING SCALE AND PRN CALCIUM GLUC. GIVEN AS ORDERED. DR. MADE AWARE, RENAL FELLOW UP TO EVALUTATE, NOTHING CHANGED EXCEPT ALL DRIPS AND IV FLUIDS WILL NOW BE IN NORMAL SALINE. BEGUN TO REMOVE 50CC HR. TODAY, TOLERATING WELL. SLOWLY WEANING NEO, CURRENTLY ON 0.5 MCG/KG/MIN, MAINTAING MAP>65. NO URINE OUTPUT. VSS (SEE FLOW SHEET FOR NUMBERS). WIFE AT BEDSIDE MOST OF THE DAY. PULSES PRESENT WITH DOPPLER AS BEFORE, INCISION INTACT, OOZING SMALL AMOUNT OF SEROUS FLUID AT BOTTOM OF INCISION. BLACK AREA AROUND LEFT HEAL, WAFFLE BOOOTS ON ALL SHIFT.\nA: STABLE. SLOWLY WENAING PRESSORS. REMAINS MASSIVELY FLUID OVERLOADED.\nHO AWARE OF ALL OF ABOVE.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-09 00:00:00.000", "description": "Report", "row_id": 1494531, "text": "FOCUS: CONDITION UPDATE\nD:TRAUMA CORDIS AND SWAN CHANGED OVER WIRE TO OXIMETRIC SWAN, WITH ONE PORT CHANGED FOR TPN. MORE AWAKE POST LINE CHANGE, AIR LEAK THROUGH ETT, ?BIT THROUGH TUBE. DR. UP , CHANGED ETT TO 8.5 UNEVENFULLY, NO DROP IN SATS OR CHANGE IN BLOOD PRESSURE. REMAINS ON CVVH AND REMOVING 50CC HOUR, YET NEEDED TO GIVE HIM SOME SMALL FLUID BOLUSES DURING THE DAY.\nA: LINE CHANGED/ETT CHANGED/ BACK ON LEVO/NEO. MORE STABLE NOW. WILL CHECK LABS, REPLACE AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-10 00:00:00.000", "description": "Report", "row_id": 1494532, "text": "RESP CARE\nPT. REMAINS INTUBATED,SEDATED,PARALYZED ON PCV. ABLE TO DECREASE RESPIRATORY RATE DOWN TO 20BPM WITH ACCEPTABLE ABG'S.BS: DECREASED T/O, AT ONE POINT NONEXISTANT ON L. SIDE, WITH DESATS TO 80'S. AMBUED LAVAGED AND SXN'D LARGE TENACIOUS RUSTY PLUG. BREATH SOUNDS AUDIBLE ON L> S/P SXN. PT. STILL HAVING OXYGENATION ISSUES, FIO2 TITRATED ACCORDINGLY.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-13 00:00:00.000", "description": "Report", "row_id": 1494540, "text": "nsg progress note\nNeuro- Sedated with fentanyl and ativan gtts, paralyzed with cisatracurim. 0/0 thumb twitches with tof.\n\nHemodynamics- oxy pa line still in place. see flow sheet for pa #'s. svo2 62-65. levo gtt to keep map 60-70 .16 to .18 hr. ivf tko, pcwp 20-23 and cvp 20. nsr no ectopy.\n\nRenal- cvvh changed to cvvhd with -200/hr. heparin started with cvvhd pr renal md at 1600u/hr. ptt 123 heparin off x1 hr to restart at 1200.\n\nSkin- buttuck cont excoriated- a+d, with znox applied with mycistatin powder. blisters weeping right arm- ostomy bag over to collect drg. abd incs. staples intact, serrous drg distal end.\n\nResp- cont pressure cont vent. peep decrease to 16 from 18. not tolerating insp press to 18 from 20 as po2 decrease to 60. po2 with i.p. 20 113. lungs clear bases, suction thick tan secretions\n" }, { "category": "Nursing/other", "chartdate": "2131-09-14 00:00:00.000", "description": "Report", "row_id": 1494541, "text": "nsg progress note\nNeuro- sedated with ativan and fentanyl gtts. paralyzed with cistacrnium. tof 0/0 thumb twitches.\n\nHemodynamics- oxy swan, svo2 55-65. levophed gtt .38- .42mcg/kg/min. received albumin 12.5 gm/50 cc x1. ivf tko. -150 hr via cvvhd. 0-5cc uo. see flow sheet for co, pcwp cvp #'s.\n\nRenal: Cont cvvhd. replacement fluid changed to .45ns with 50 meq nahco3 at 500/hr, fluid off decreased to 150 from 200 2nd to hypotension. cont heparinptt 1600 pm 123. heparin off x1hr then return to 900u/hr. next ptt due 8 pm.\n\nResp- lungs clear bilat bases, suction thick tan secretions. sputum cx sent. cont pressure cont vent with peep 16 and ip 20. no9 vent changes today. gm + rods sputum cx sent 48 hrs ago.\n\nI.D.- gm + rods sputum cx, gm neg rods blood cx, vanco and ceftaz started, levofloxin changed from q48 to q24.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-15 00:00:00.000", "description": "Report", "row_id": 1494542, "text": "system update\nd: hemodynamics: afebrile. HR 90-108 NSR-ST WITHOUT ECTOPY. SBP REMAINS LABILE- SEE CAREVUE FOR SPECIFICS. LEVO WEANED TO 0.308 MAINTAINING MAP>60. PA NUMBERS UNCHANGED-SEE CAREVUE\nRESP: REMAINS ON PCV WITH INSPIRATORY PRESSURE OF 20, ABG STABLE. BS DIMINISHED IN BASES. SX FOR SCANT AMTS TAN BLOOD TINGED SECRETIONS. SATS 95-97%\nGI: NPO. ABD FIRM AND DISTENDED. NGT PATENT AND DRAINING MOD AMTS BILIOUS. NO STOOL\nGU: CONTINUES ON CVVHD. HEPARIN GTT ADJUSTED PER PROTOCOL. MINIMAL UO.- SEE CAREVUE FOR SPECIFICS OF REPLACEMENT ETC\nNEURO: SEDATED ON ATIVAN/FENT/ AND CISTACURIUM\nA: HEMODYNAMICS AND RENAL PARAMETERS MONITORED, LEVO TITRATED AS ORDERED\nR: BP REMAINS LABILE- CONTINUE TO WEAN LEVO AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2131-09-15 00:00:00.000", "description": "Report", "row_id": 1494543, "text": "pt.remains on pres.control ventilation. pres.20-rr.20-50%-16 peep, it.1.20-ie 1-1.50, breathe sounds diminished, bp unstable, sedated as not to assist on vent.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-15 00:00:00.000", "description": "Report", "row_id": 1494544, "text": "STATUS\nD: REMAINS ON LEVO/CISTA/ATIVAN/FENT GTT'S..LABILE BP\nA: INSULIN GTT RESTARTED FOR BS 130'S..CVVHD FLUID REMOVAL INCREASED TO 170CC/H..HEPARIN REMAIN @ 800U..CONTINUES OOZING FROM LOWER ABD INCISION/SCROTUM/RT ARM DUODERM REMOVED FROM BUTTOCKS OOZING BLOODY SKIN ABRASION IMPROVED.. PEEP DECREASED TO 14 WITH ADQUATE ABG'S\nR: IMPROVING PULMONARY STATUS\nP: CONTINUE TO WEAN AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2131-09-18 00:00:00.000", "description": "Report", "row_id": 1494551, "text": "Progress note\nPt continues on levophed, fentanyl, cisatucarium, and ativan ggt. pt started on amiodarone drip @ 2200 for episode of SVTs, Hr-160-170s. Dr. and Dr. present. Mg and Ca repleted to maintain opitmal lyte levels. Bp Goal Map>65. afebrile. (See flowsheet).\nPt continues o CVVHD, tolerating ultrafiltrate rate of 200cc/hr.\nResp: no changes with vent settings during the night, O2 sat maintained @ 97%, lungs coarse bilat.\nGI: abd slightly firm and distended, no bowel sounds, no further attempts to start tubefeeds due to high residuals.\nGU: Gu irrigant with sterile h2o @ 40cc/hr, gu Gu tract appears patent no clots noted.\nSKIn: Scrotum still oozing large amts of drainage, DSD applied and changed Q2-4hr. Unable to turn patient for back care due hemdynamic instability when mobilized.\nFamily: Dr. spoke with pt's wife( ), pt's status changed to DNR, remains a full treat. Family meeting today with pt's daughter and wife to discuss prognosis an d further treatment measures.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-18 00:00:00.000", "description": "Report", "row_id": 1494552, "text": "nsg progress note am\nfamily at bedside- spoke with Dr about wishes to withdraw care- family meeting scheduled for 1630 pm with icu team and Dr . Wife requesting to not increase \"bp rx\" (levophed) pre meeting if bp decreases. pt was made dnr by wife yesterday . Dr notified of wife's request. Levophed not to be increased if b.p. decreases pre family meeting.\n" }, { "category": "Nursing/other", "chartdate": "2131-09-18 00:00:00.000", "description": "Report", "row_id": 1494553, "text": "nsg progress note am\n1630 pm- family meeting. pt changed from dnr to cmo. family consenting to autopsy pf abd/thoracic region. consent obtained by Dr .\n" }, { "category": "Nursing/other", "chartdate": "2131-09-18 00:00:00.000", "description": "Report", "row_id": 1494554, "text": "nsg note\nfamily meeting at 430 pm- pt made cmo as noted previous nsg note. levophed and amiodarone off. fent, mso4, and ativan gtts. asystolye 615 pm md .\n" } ]

[ { "category": "Radiology", "chartdate": "2143-11-10 00:00:00.000", "description": "CHG NEPHROTOMY/PYLOSTOMY TUBE", "row_id": 1217351, "text": " 5:33 PM\n URIN CATH REPLC Clip # \n Reason: please change tubes given excrutiating pain and hydronephros\n Admitting Diagnosis: BILATERAL FLANK PAIN\n Contrast: OPTIRAY Amt: 25\n ********************************* CPT Codes ********************************\n * CHG NEPHROTOMY/PYLOSTOMY TUBE CHG NEPHROTOMY/PYLOSTOMY TUBE *\n * -59 DISTINCT PROCEDURAL SERVICE CHANGE PERC TUBE OR CATH W/CON *\n * CHANGE PERC TUBE OR CATH W/CON -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with chronic bilat nephrostomy radiation fibrosis p/w\n severe bilat flank pain and hydronephrosis\n REASON FOR THIS EXAMINATION:\n please change tubes given excrutiating pain and hydronephrosis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 49-year-old woman with chronic bilateral nephrostomy tubes\n secondary to radiation fibrosis and bilateral ureteral obstruction with\n occlusion of the tubes, hydronephrosis, and flank pain with fever, concerning\n for sepsis.\n\n PHYSICIAN: . , attending radiologist, was present and performed\n the procedure. Dr. , fellow.\n\n PROCEDURE:\n 1. Bilateral existing tube nephrostograms.\n 2. Successful exchange of 12 French nephrostomy tubes bilaterally.\n\n MEDICATIONS: The procedure performed, general anesthesia, the patient in the\n past has a low pain threshold and is unable to tolerate these procedures with\n moderate sedation. Additionally, the patient received IV antibiotics.\n\n CONTRAST: 15 mL Optiray.\n\n PROCEDURE: Prior to initiation of the procedure, written informed consent was\n obtained. The patient was brought down to the IR suite, and a preprocedure\n timeout was performed. Anesthesiology service induced anesthesia, and the\n patient was placed prone on our angiographic table and both tubes were prepped\n and draped in sterile manner.\n\n Initially, the left tube was addressed. Contrast injection demonstrated some\n patency of a few side holes within the pigtail catheter. A guidewire and\n Kumpe catheter could not be advanced through the existing tube due to this\n obstruction. A stiff guidewire was advanced with the Kumpe catheter alongside\n the tube and positioned within the renal pelvis, and the tube was then\n removed. A new 12 French nephrostomy tube was placed over the wire with the\n pigtail formed within the left renal pelvis, and contrast confirmed location.\n The catheter was secured to the skin with a silk suture and a Flexi-Trak.\n\n Attention was paid to the right tube. Contrast injection could not be\n performed as the tube was completely obstructed. A stiff guidewire and Kumpe\n (Over)\n\n 5:33 PM\n URIN CATH REPLC Clip # \n Reason: please change tubes given excrutiating pain and hydronephros\n Admitting Diagnosis: BILATERAL FLANK PAIN\n Contrast: OPTIRAY Amt: 25\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n catheter were advanced alongside the tube and positioned within the renal\n pelvis, and the catheter was then removed. A new 12 French nephrostomy tube\n was advanced over the wire with the pigtail positioned and formed within the\n right renal pelvis. A sample of frank pus/urine was removed and sent for\n culture. The catheter was secured to the skin and contrast injection\n confirmed location.\n\n FINDINGS:\n 1. Complete obstruction of the right nephrostomy tube and partial resection\n of the left nephrostomy tube.\n 2. Successful exchange of both for new 12 French nephrostomy tubes.\n\n IMPRESSION: Obstructed bilateral nephrostomy tubes, successfully exchanged,\n as described above.\n\n" }, { "category": "ECG", "chartdate": "2143-11-14 00:00:00.000", "description": "Report", "row_id": 208855, "text": "Normal sinus rhythm. Low voltage in the limb leads. Poor R wave progression.\nRSR' pattern in lead V2. Compared to the previous tracing of no\ndiagnostic interval change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2182-03-20 00:00:00.000", "description": "Report", "row_id": 80666, "text": "PATIENT/TEST INFORMATION:\nIndication: Chronic lung disease. Right ventricular function. Shortness of breath.\nHeight: (in) 65\nWeight (lb): 268\nBSA (m2): 2.24 m2\nBP (mm Hg): 109/77\nHR (bpm): 91\nStatus: Inpatient\nDate/Time: at 08:47\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Suboptimal technical\nquality, a focal LV wall motion abnormality cannot be fully excluded. Overall\nnormal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Markedly dilated RV cavity. Abnormal septal motion/position\nconsistent with RV pressure/volume overload. Prominent moderator\nband/trabeculations are noted in the RV apex.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Mildly dilated ascending aorta. Mildly dilated aortic arch. No 2D\nor Doppler evidence of distal arch coarctation.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS. Significant PR. The end-diastolic PR\nvelocity is increased c/w PA diastolic hypertension.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - body habitus.\n\nConclusions:\nThe left atrium is moderately dilated. The right atrium is moderately dilated.\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity is unusually small. Due to suboptimal technical quality, a focal wall\nmotion abnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is normal (LVEF>55%). The right ventricular cavity is markedly\ndilated There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload. The ascending aorta is mildly dilated.\nThe aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly\nthickened but aortic stenosis is not present. No aortic regurgitation is seen.\nThe mitral valve leaflets are mildly thickened. There is no mitral valve\nprolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension. Significant pulmonic regurgitation is seen. The\nend-diastolic pulmonic regurgitation velocity is increased suggesting\npulmonary artery diastolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Markedly dilated right ventricle with global hypokinesis and\npressure-volume overload of the left ventricle. Due to the size of the right\nventricle, the left ventricle appears small and compressed within the\npericardial sac. Overall LV systolic function is probably normal, a focal wall\nmotion abnormality cannot be excluded. At least moderate pulmonary artery\nsystolic hypertension.\n\nCompared with the prior study (images reviewed) of , the estimated\npulmonary artery systolic pressures are slightly lower (may be underestimated\non the current study). The other findings are similar.\n\n\n" }, { "category": "Radiology", "chartdate": "2182-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1185843, "text": " 4:53 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for inilftrate/pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with chest pain\n REASON FOR THIS EXAMINATION:\n eval for inilftrate/pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest, two frontal portable views.\n\n CLINICAL INFORMATION: 75-year-old male with history of chest pain.\n\n COMPARISON: .\n\n FINDINGS: Two AP upright portable views of the chest were obtained. There is\n patchy right base opacity which may in part relate to overlying structures,\n though is more prominent than on the prior study, underlying consolidation\n from infection or aspiration is of concern. No pleural effusion or\n pneumothorax is seen. The cardiac silhouette remains top normal. The aorta\n is calcified and tortuous. Minimal central pulmonary vascular engorgement is\n suggested.\n\n\n" }, { "category": "ECG", "chartdate": "2182-03-16 00:00:00.000", "description": "Report", "row_id": 203970, "text": "Sinus tachycardia. Left atrial abnormality. Incomplete right bundle-branch\nblock. Inferior lead QRS configuration with left axis deviation may be due to\nprior inferior myocardial infarction and possible left anterior fascicular\nblock. Consider anterior wall myocardial infarction of indeterminate age.\nCannot exclude myocardial ischemia. Clinical correlation is suggested. No\nprevious tracing available for comparison.\n\n" }, { "category": "ECG", "chartdate": "2182-03-16 00:00:00.000", "description": "Report", "row_id": 203971, "text": "Sinus tachycardia. Incomplete right bundle-branch block. Indeterminate axis.\nConsider inferior myocardial infarction of indeterminate age but baseline\nartifact in the limb leads makes assessment difficult. Consider anterior wall\nmyocardial infarction of indeterminate age but cannot exclude myocardial\nischemia. Clinical correlation is suggested. No previous tracing available for\ncomparison.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2140-04-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 864418, "text": " 5:29 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET tube placement? cardiopulm process\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74M with arrythmia, intubated urgently.\n REASON FOR THIS EXAMINATION:\n ET tube placement? cardiopulm process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory distress requiring intubation. COMPARISON: None.\n\n SINGLE SUPINE PORTABLE AP VIEW OF THE CHEST: There is cardiomegaly. A small\n left effusion is seen. There is left lower lobe atelectasis/consolidation.\n The right lung is clear. An endotracheal tube, nasogastric tube, and left-\n sided ICD with leads in the right atrium and ventricle are seen in good\n position. Surrounding osseous and soft tissue structures are unremarkable.\n\n IMPRESSION: Left lower lobe atelectasis/consolidation.\n\n" }, { "category": "Radiology", "chartdate": "2140-04-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 864689, "text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evidence of PNA or other acute process?\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74M with CAD, CHF, arrythmia, recently extubated, now w/temp 103.\n REASON FOR THIS EXAMINATION:\n evidence of PNA or other acute process?\n ______________________________________________________________________________\n FINAL REPORT\n 2 VIEWS CHEST:\n\n COMPARISON: .\n\n INDICATION: Fever.\n\n An ICD remains in satisfactory position. There has been removal of an\n endotracheal tube and nasogastric tube. There is stable cardiac enlargement.\n Pulmonary vascularity is within normal limits for technique. Note is made of\n a residual small left pleural effusion, improved in the interval, with\n improving adjacent atelectasis as well.\n\n IMPRESSION: Improving left pleural effusion and adjacent left basilar\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 864560, "text": " 12:46 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: r/o acute stroke.\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man s/p VT ablation, now with unequal pupils.\n REASON FOR THIS EXAMINATION:\n r/o acute stroke.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 74-year-old man status post VT ablation, now with unequal pupils.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no evidence of intracranial hemorrhage, mass effect,\n hydrocephalus, shift of normally midline structures, or major vascular\n territorial infarct. Decreased attenuation in the periventricular white\n matter is consistent with chronic microvascular angiopathy. Focus of\n decreased attenuation in the left posterior frontal/parietal white matter may\n represent a lacune. Rounded area of slightly decreased attenuation in the\n right frontal white matter may be related to chronic changes. However, a\n subacute microvascular infarction cannot be excluded. The density values of\n the brain parenchyma are within normal limits. Mucosal thickening is noted in\n the right maxillary sinus. The surrounding osseous and soft tissue structures\n are otherwise unremarkable.\n\n IMPRESSION: No evidence of intracranial hemorrhage or major vascular\n territorial infarction. Small area of slightly decreased attenuation in the\n right frontal white matter may represent a chronic or subacute small vessel\n infarct. Please note that MRI with diffusion-weighted imaging is more\n sensitive in the detection of acute ischemia.\n\n\n" }, { "category": "Radiology", "chartdate": "2140-04-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 864794, "text": " 6:20 PM\n PORTABLE ABDOMEN Clip # \n Reason: R/O intraabdominal pathology\n Admitting Diagnosis: SUPRAVENTRICULAR TACHYCARDIA\\CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 74 year old man with acute diarrhea and fever\n REASON FOR THIS EXAMINATION:\n R/O intraabdominal pathology\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 74-year-old man with acute diarrhea and fever, rule out intra-\n abdominal pathology.\n\n TWO VIEWS, AP, SUPINE ABDOMEN: No priors for comparison. A rectal tube is in\n place. There is air seen throughout the cecum, ascending colon, transverse\n colon and distally within the rectum. There is no evidence of obstruction.\n The cecum is slightly prominent, measuring 8.2 cm, but does not demonstrate\n the effacement of the haustral pattern. There is no free air identified;\n however, the diaphragms are not included on this film. There are no unusual\n soft tissue calcifications or masses within the abdomen. The osseous\n structures are unremarkable. There are clips overlying the right inguinal\n area likely due to previous hernia repair. Neck artery calcification.\n\n IMPRESSION: Unremarkable abdominal plain film, without evidence of obstruction\n or other acute intra-abdominal pathology.\n\n\n" }, { "category": "ECG", "chartdate": "2140-04-07 00:00:00.000", "description": "Report", "row_id": 157527, "text": "A-V paced rhythm\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-04-07 00:00:00.000", "description": "Report", "row_id": 157528, "text": "A-V paced rhythm\nDemand pacing\nVentricular premature complex, fusion beat\nSince previous tracing, fusion beat noted\n\n" }, { "category": "ECG", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 157529, "text": "Dual chamber pacemaker.\nPacemaker rhythm - no further analysis\nVentricular premature complex or atrial premature complex with aberrant\nconduction\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 157530, "text": "A-V paced rhythm\nFusion beat\nVentricular premature complex or atrial premature complex with aberrant\nconduction\nSince previous tracing, ventricular premature complex noted\n\n" }, { "category": "ECG", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 157531, "text": "A-V sequential pacing. Compared to the previous tracing of no major\nchange.\n\n" }, { "category": "ECG", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 157532, "text": "A-V sequential pacing. Compared to the previous tracing of no definite\nchange.\n\n" }, { "category": "ECG", "chartdate": "2140-04-15 00:00:00.000", "description": "Report", "row_id": 157519, "text": "Baseline artifact. There is atrial and ventricular sequential pacing. Compared\nto the previous tracing no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-04-14 00:00:00.000", "description": "Report", "row_id": 157520, "text": "Baseline artifact. Ventricular pacing. The atrial rhythm cannot be determined.\nCompared to the previous tracing of there is probably no diagnostic\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-04-13 00:00:00.000", "description": "Report", "row_id": 157521, "text": "A-V paced rhythm\nVentricular premature complexes\nProbable atrial premature complex\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-04-11 00:00:00.000", "description": "Report", "row_id": 157522, "text": "A-V paced rhythm with ventricular premature complexes\nProbable atrial premature complex\nSince previous tracing of , ventricular response less irregular\n\n" }, { "category": "ECG", "chartdate": "2140-04-10 00:00:00.000", "description": "Report", "row_id": 157523, "text": "Dual chamber pacemaker with an irregular rhythm which may be due to sensing\nproblems with the atrial lead. Compared to the previous tracing of the\n problem may be new.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2140-04-09 00:00:00.000", "description": "Report", "row_id": 157524, "text": "Dual chamber pacemaker with occasional premature beats. Pacemaker rhythm. No\nfurther analysis. Compared to the previous tracing of no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 157525, "text": "Dual chamber pacemaker. Pacemaker rhythm. No further analysis. Compared to the\nprevious tracing no significant change.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 157526, "text": "Dual chamber pacemaker\nPacemaker rhythm - no further analysis\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 157758, "text": "Atrio-ventricular sequential pacing. Compared to the previous tracing\nof no major change.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 157759, "text": "Atrial ventricular sequential pacing. Compared to the previous tracing\nof no major change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 157760, "text": "Dual chamber electronic pacemaker in atrio-ventricular sequential pacing mode.\nCompared to the previous tracing of no major change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 157761, "text": "Dual chamber pacemaker in atrio-ventricular sequential pacing mode. Compared to\nthe previous tracing of no diagnostic change.\nTRACING #1\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-07 00:00:00.000", "description": "Report", "row_id": 1403574, "text": "Pt is a 74y.o. male with PMH CAD, MI/CEA in ' with vfib arrest-ICD placed, ischemic CMP, PVD, COPD, GERD, VT, Right BKA initially admitted to for cath-> cypher stent x2 to RCA (agitation/confusion inc ath lab->lido toxicity which was dc'd and pt transferred to CCU. Pt developed runs of symptomatic VT overnight req'g restart of lido gtt. , pt hemodynamically stable, no further runs VT, lido dc'd and BP increased, MS cleared. Pacer rate increased to 75 with NSVT noted, however hemodynamically stable. Was transferred to 6 awaiting VT ablation on thursday.\nToday, apporx 15 mins after rec'g dofetilide, pt had 18 bt run VT with stable BP. Rec'd IVP Magnesium 2mg and 100mg IVP lido. Runs VT continued until ICD fired. Pt rec'd 100mg additional lido, 4mg mso4, 4mg ativan and 5 mg lopressor and continued with freq runs VT/vfib and ICD firing. Decision made to intubate for further management and comfort. Awaiting VT ablation Friday morning. Transferred to CCU.\n\nALLERGIES: amiodarone\n\nNEURO: Intubated and sedated with propofol gtt. Wrists restrained for safety of tubes and lines.\n\nRESP: Intubated on CMV 14 x600 5 peep 100%. LS clear.\n\nCARDIAC: EP at bedside making multiple changes to pacer-> presently AV paced at 60. HR 60's AV paced with frequent runs VT causing ICD to fire frequently. BP 90/50's. Lidocaine gtt infusing at 2mg/min.\n\nGI: abd soft NT. +BS\n\nGU: urinated large amt in bed. COndom cath now in place.\n\nACCESS: Right radial aline placed 3 peripheral #20 angios in place and working well.\n\nA: 74 y.o. male with R/I MI s/p RCA stent now with prolonged VT causing ICD to fire frequently on Lido gtt and paced at 60. Intubated for comfort and airway management. Awaiting VT ablation in am.\n\nP: Follow hemodynamics closely. Lido gtt. VT ablation.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 1403575, "text": "Resp Care Note:\n\nPt cont intub with OETT, sedated and on mech vent as per Carevue. Lung sounds ess clear after suct sm th pale yellow sput. ABGs stable; vent adjusted to optimize gas exchange. Cont mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 1403576, "text": "CCU NPN: 7p-7a\n\nS: Intubated and sedated - unable to verbalize\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 90s-60s, AV-paced. Ectopy: occ. PVCs throughout shift w/ 3-6 beat runs NSVT during initial loading of Procainamide and w/ discontinuation of Procainamide (in preparation for VT ablation ). Procainamide infusion initiated after completion of loading dose at at 2mg/min. Discontinued as ordered by Dr. at 0300 w/ administration of 250mcg Dofetilide per NGT (confirmed w/ Drs. , and ). Lytes monitored frequently - PM lytes (1800): K+ 3.1 (repleted w/ 40meq KCl per NGT x2) and Mg+ 2.5. Repeat lytes (2350): K+ 4.8 and Mg+ 2.3. AM labs pending. BP stable w/ exception of decreased perfusion w/ periods of NSVT - SBP 80s-120s w/ MAPs 55-70. One episode of hypotension in setting of high urine output (after foley catheter insertion) during which SBP dropped to 60s-70s and returned to 100s w/ 500cc NS fluid bolus. Decreased SBP also associated w/ increased doses of Propofol. Denies pain, discomfort. Slightly hypothermic w/ temps 95.5 PO and 94.8 AX - bair-hugger applied w/ positive results - Tmax 99.0 PO at 0400.\n\nRESP: Remains intubated w/ mechanical ventilation - current vent settings: AC/0.30/500/10/5 w/ AM ABG: 7.39/44/115/28/97%. Vent adjustments made throughout night - tolerated FiO2 decrease 0.40-0.30 and vT decrease 600-500 w/o difficulty. Suctioned occasionally for thin, yellow-white sputum.\n\nGI/GU/ENDO: Abd. soft, non-tender, non-distended. OGT placement confirmed by auscultation. BS active x4 quadrants. NPO for VT ablation. Maintenance NS IVF initiated after completion of IVF bolus per Dr. . Initially voiding via condom cath - w/ gestures pt. indicated discomfort peri-cath site - external cath replaced w/ foley and pt. w/ immediate 620cc output w/ resultant hypotension - Drs. and aware. UOP 85-620cc/hr. +245cc and -250cc thus far. H/o borderline DM: FS at HS: 84.\n\nNEURO: Sedated on Propofol. Arousable to name when addressed and follows commands. Responds to questions appropriately w/ nodding head yes and no - appears to understand situation and plan of care. MAE. Pupils equal and reactive to light. Occasionally w/ slight hand tremors. Re-oriented frequently and emotional support/teaching given.\n\nA: Presented to w/ and sustained VT - S/P cardiac cath w/ stent x2 to RCA (prox and mid) . Poss. Lidocaine toxicity as evidenced by severe agitation and confusion. Multiple ICD and PCM interrogations - awaiting VT ablation until experienced extensive runs of NSVT accompanied by multiple ICD firings. Lidocaine and Procainamide administered to control ectopy. Intubated for airway protection. Episodes of NSVT decreased w/ Procainamide and electrolyte repletion - awaiting VT ablation (1st case) .\n\nP: Continue to monitor hemodynamics, rhythm. Follow respiratory status. Propofol for sedation. AM labs\n" }, { "category": "Nursing/other", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 1403577, "text": "(Continued)\npending - replete lytes as needed. NPO for VT ablation . Emotional support, teaching and comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 1403578, "text": "Resp Care\nPt remains intubated and vented on full ventilatory support with no changes made this shift. BS clear to slightly course at times sxing for scant to small amts of thick tan secretions. Transported to and from EP lab for ablation without any incident. WIll cont with vent support.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-12 00:00:00.000", "description": "Report", "row_id": 1403587, "text": "CCU NPN 7p-7a\nS: \"I feel that I was able to get some sleep last night.\"\nO: see carevue for complete assessment data.\nNERUO: A&Ox3, MAE, assists w/ turning. PERRL 2mm, brisk. C/o HA early in shift, relieved w/ 650mg tylenol. Later c/o trouble sleeping, able to sleep for a few hours after 5mg ambien.\n\nCV: HD stable, MAP 55-70s, HR 60s-80s AV paced w/ frequent PVC's. 2gm Mg and 2pkt neutra phos. AM labs pending. No VT/NSVT or c/o CP/palpitations. L PT/DPs palp. 0200 metoprolol held d/t SBP 88, tolerated MAP 55 while asleep ^65 when awake, did not re-initiate IVF hydration after discussion w/ Dr. . Pt. asymptomatic w/ hypotension.\n\nRESP: LSCTA bilat, breathing comfortably on 2L NC, RR @ times 24-26 w/ no subjective c/o SOB. Sputum sample obtained.\n\nGI/GU: abdomen firm, mildly distended, nontender. +BS, mushroom catheter draining green liquid stool, OB pos. >800cc out for shift. Voiding small amts cloudy amber urine, 325cc for shift.-850cc yesterday, -350cc since MN. Tolerating POs and meds; minimal appetite. KUB yesterday wnl.\n\nID: persistent low grade temp, tmax 99.4, 650mg tylenol for HA. BC sent earlier growing GNR 1 of 4 bottles, C&S pending; to start gentamicin.\n\nSKIN: sacrum/coccyx reddened, pt. repositioning self in bed, no breakdown noted. Multiple areas of ecchymosis, arms and R flank.\n\nA: 74yo w/ VT/VF s/p stent x2 to RCA c/b lido toxicity and recurrent VT requiring frequent ATP/defib of AICD. Currently HD stable w/ no further VT/NSVT. Now w/ persistent loose stool () and tspike w/ + blood cultures.\nP: follow up am labs. Cont to monitor HDs, follow fever curve, pan cultured->results pending. Starting gent, needs trough immediately before 2nd dose. Monitor fluid balance and renal fxn w/ start of aminoglycoside abx. ? CT abdomen today to eval source of diarrhea.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 1403570, "text": "CCU NPN 1900-0700\nO: 35 yo female with DM, HTN, ESRD on PD, non compliance. was just d/c'd to home for hypergylemia/HTN and now returned back to EW with c/o headache and reporting seizure at home.\n\nIn EW BP 220/100, BG >1000, anion gap 16. neg. ketones in urine. pt. with c/o headache- rx with 2morphine, hydralazine, insulin gtt and IVF. K+ 6.7- no treatment.\nBP down to 160/100, gluc. 900. pt. lethargic- moaning....head CT done. CXR done.\n\ntransferred to CCU ~ 0100. pt. arrived laying on side, moaning , calling out for \"mommy\". opening eyes to name. moving back and forth in bed...posey belt placed for safety given right fem. TLC.\n\nCV: HR 70's SR. no VEA. no peaked TW's. BP on admit 190/100, down to 150/95 by 0300. NPO at this time. pt. is too lethargic to safetly take meds.\nendo: arrived on insulin gtt at 8u/hr. gluc. 900 ~ MN. insulin gtt titrated up to max 10u/hr: gluc. coming down to 530 by 0200.\nIVF .45NS at 200/hr x2L ordered.\nCXR neg. ketones neg. BCx2 sent from TLC. also peritoneal fluid sent.\nrenal: PD catheter accessed per protocol and drained 1200cc cloudy yellow fluid. spec. sent for culture. Did not dwell at this time.\n\nGU: foley draining small amt. yellow urine\nGI:\n" }, { "category": "Nursing/other", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 1403571, "text": "CCU NPN 1900-0700\nThis note written on wrong patient. please disregard\n" }, { "category": "Nursing/other", "chartdate": "2140-04-06 00:00:00.000", "description": "Report", "row_id": 1403572, "text": "CCU NPN 1900-0700\nO:\nafeb. HR 60's AV paced. no VEA. BP 120's/60's. RR 14-22. sats 98% on 2lnc. LS clear.\n\ntolerated lopressor 75mg, ACE. to start aldactone in AM. also to start lasix po in AM.\n\nno c/o. pt. slept.\nusing condom cath until AM. ~ 800cc x12hr.\n\nA/P: stable night off lido gtt. no VEA. MA clearing. no confusion.\npt. has slight expressive aphasia which he says is his baseline. A/O x3.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-07 00:00:00.000", "description": "Report", "row_id": 1403573, "text": "Resp. Care Note\nPt intubated on 6 with 7.5ETT secured at 21cm lip.Pt intubated for recurrent VT and freq. firing of ICD. Pt to CCU and placed on vent with settings AC 600x 14x 100% peep 5.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-11 00:00:00.000", "description": "Report", "row_id": 1403585, "text": "CCU NPN 1900-0700\nS: \" This is awful- I have to go again \"\nO: pt. having freq. episodes of diarhea/liquid stool in eve. unable to control- incontinent. no cramps/abd pain. sent for c.diff in eve and cultures sent in AM. mushroom catheter placed ~ MN- draining >1.3L by 0400. stool now more green in color/mostly liquid with some semiformed. guaic positive. given immodium x3 doses. HO notified of change and amt. of stool. started IVF at 50cc/hr at 0500.\nquinidine on hold for now.\n\nCV: HR 62-70 AV paced. freq. to occas. PVC's. bt runs- more in eve. lopressor 50mg at 0100- tol. well.also started moexipril(Ace). BP 122-105/50's.\nno CP/SOB. K+ 3.7 in AM - repleted with total 60meq KCL. MG+ 2.4.\ncoumadin Qhs- INR 1.6\n\nResp: LS clear. no wheezes. 97-100% on 2lnc. pt. with Hx COPD.\nGU: foley d/c'd in afternoon . voided small amts in bedpan in eve. condom cath placed at MN- has not voided yet despite reminders. need to reinsert foley later today.\n\nneuro: A/O x3. no deficit noted. MAE.\nID: TM 100.4-97.7 by 0500. #2 BC sent in eve. also stool for C.diff x2 and cultures (see order).\n\nA: new fever/diahrea ? d/t quinidine. quinine on hold. taking immodium for stool. mushroom catheter for comfort. IVF started d/t large amt. out.\nBC x2 /stool sent. may need to place foley today. contin. lopressor/Ace. follow lytes and replete per team.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-11 00:00:00.000", "description": "Report", "row_id": 1403586, "text": "CCU Progress Note:\n\nS- \"I feel like I have the flu\".\n\nO- see flowsheet for all objective data.\n\ncv- Tele: AV paced rhythm with occ PVC's- HR 62-74- B/P 98-122/40-71- lopressor held this am due to low B/P- K 3.7 this am- KCL 60meq po given- labs repeated @ 1600- K 4.4- Mg 2.2\n\nresp- In O2 2L via NC- lung sounds clear bilaterally- resp even, non-labored- SpO2 95-100%.\n\nneuro- A&O X3- moving all extremities- pleasant & cooperative- follows command- Pt is OOB to chair this am with 2 assist.\n\ngi- abd soft (+) bowel sounds- mushroom cath con't to drain liquid green colored stool (700cc this shift)- stool culture pending- stool for C diff (-).\n\ngu- condom cath on- voided amber colored urine (430cc this shift)- hydrating IV con't @ 50cc/hr (due to large amt loss from diarrhea stool)- BUN 20 Crea .9\n\nid- T max 100.1 Po- blood cultures & stool culture pending- unable to obtain sputum culture.\n\nA- S/P VT ablation - started on quinidine on c/b fever & diarrhea- quinidine on hold- awaiting culture results\n\nP- monitor vs, lung sounds, I&O and labs- con't mushroom cath for comfort- IVF @ 50cc/hr until output decreases- follow lytes & replete PRN- offer emotional support- keep Pt updated on plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1403567, "text": "CCU Admit Note 7p-7a\n\nTransferred to from Hospital where pt. was admitted w/ NSTEMI and VT requiring Lidocaine infusion. To cath lab w/ stent placement x2 to prox and mid RCA. Severe agitation in cath lab attributed to Lidocaine toxicity - arrived to CCU w/ Lidocaine on hold. Restarted d/t runs of VT during which pt. symptomatic - overdrive pacing and ICD fired once.\n\nS: \"I'm in my house - what are you doing here?\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 60, AV-paced/V-paced w/ occ. PVCs. Experienced two runs of VT - both w/ overdrive pacing and ICD fired x1. Symptomatic w/ VT - reported to have \"fluttery feeling in chest\", cyanotic and unresponsive. Dofetilide adm. (w/ EKG obtained pre and post administration) and EP fellow notified (Dr. after first run and Lidocaine infusion restarted at 1mg/min. After second VT run (approx. 20 minutes later) - bolused w/ Lidocaine and infusion increased to 1.5 mg/min. Occasional PVCs as a result - no further runs noted. R arterial sheath (post-cath) removed at 2035 per cardiology fellow (Dr. . Pt. required frequent reminders to adhere to post-cath activity restrictions - per Dr. recommendations, 1:1 sitter at bedside. Right groin site D/I - pressure dressing intact secondary to slight ooze post-sheath pull despite manual pressure applied x 10minutes. Doppler distal pulses. Integrilin continues at 2mcg/kg/min - PLT post-procedure: 215, 190. H/H stable: 43.2/14.8. PM lytes: K 4.1, Mg 1.8 (repleted w/ 2g Magnesium sulfate IVPB).\n\nNEURO: Pt. alert and oriented to self and year upon initial assessment. Unable to state location and name of current president. (Lidocaine off at that point.) MAE, required frequent reminders to keep right leg straight and keep head on pillow. After runs of VT and reinitiation of Lidocaine, pt. developed increased confusion - oriented to self only. Multiple attempts to climb OOB and required continuous observation to maintain pt. safety.\n\nRESP: Lungs clear in bilateral apices, slightly diminished in bases. RR 14-20s. Denies SOB, DOE. O2 sat > 95% on 2L NC.\n\nGI/GU/ENDO: Abd. soft, slightly distended w/ mild tenderness w/ palpation. BS active x4 quadrants. Received snack at HS - refused meal post-sheath removal. NPO for possible VT ablation. Adequate UOP via condom cath. +574cc and -116cc thus far. Pt. reported to be \"borderline diabetic\" - FS at hs: 99 - no coverage adm.\n\nID: Afebrile. AM WBC: 8.8. Received 1g Vanco IVPB in cath lab secondary to poss. contamination as pt. attempted to self-dc sheath twice.\n\nA: Pt. w/ h/o VT/VF arrest in for which pacemaker/ICD placed. VT sustained despite medical management (Dofetilide, Mexiletine) - found to have sustained VT upon visit to PCPs office - admitted to OSH w/ chest pressure and R/I NSTEMI w/ VT requiring synchronized DCCV and Lidocaine infusion. Transferred to for cath w/ stent x2 to RCA. Lidocai\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1403568, "text": "(Continued)\nne as anti-arrhythmic despite agitation and confusion. Possible VT ablation or - ICD interrogation per EP team. Dofetilide as ordered - QTc within parameters. 1:1 sitter to maintain pt. safety while confused. Lytes repleted as necessary. Right groin w/ pressure dressing intact.\n\nP: Continue to monitor mental status and arrhythmias. Lidocaine at 1.5mg/min - poss. ICD interrogation and/or VT ablation. NPO for poss. VT ablation. Dofetilide as ordered - EKG required 2h post-dose? Maintain safety w/ frequent re-orientation. Monitor right groin - assess need for further pressure dressing. Monitor for sx's of infection secondary to possible contamination during cath. Integrilin x 18h - discontinue at 1100. Awaiting further plans from team.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1403569, "text": "CCU NPN 7a-7p\nS: \"We're in ....This is , I was at for my heart.\"\n\nO: 74 y/o male with hx of VT s/p ICD placement, pt to PCP in VT,chest pressure, transferred to OSH->, pt got synchronized DCCV and ICD interogation, lidocaine gtt started. Pt to cath lab-> cypher stent x 2 to pt with agitation and confusion in cath lab->lidocaine toxicity. Lido gtt dc'd, pt to CCU for further monitoring. Pt with runs of syptomatic VT overnoc, lidocaine gtt restarted, pt overdrive paced and ICD firing. Please see careview for VS and additional data.\n\nCV: Pt HR 60 AV paced, no runs of VT or ectopy noted this shift. NBP 111-135/59-86. Received pt on lidocaine gtt at 1.5 mg/min and integrillin gtt at 2 mcg/kg/min. Integrillin dc'd at 1100 as ordered, lidocaine dc'd at 1000-no VT noted. Pt metoprolol dose increased to 75 mg TID (was 50 mg TID), pt tol. EP up to eval pt/interogate pacer at approx 0845, see EP note in chart. R groin site CDI, area soft. Pt pulses dopplerable only.\n\nNeuro: Received pt this am-pt alert and oriented x1-2, pt knew self and year but unable to state location, pt stated he was in . Pt with sitter at bedside. Pt MS clearing throughout shift, sitter dc'd, pt now alert and oriented x 3. Pt knows self, date and location, forgetful at times, but pt at baseline with some forgetfulness per brother. Pt pleasant and cooperative, asking appropriate questions regarding care, pt having some difficulty at times verbalizing questions, but communicating effectively. Pt MAE.\n\nResp: Pt LS clear at apices to diminished at bases, RR 14-22, O2 sats 96-99 on 2 L n.c. Pt denies SOB. Pt does not tol head of bed flat, pt face pink-blue with head down and turning, pt maintains O2 sats, pt color returns once HOB is at least 30 degrees. Pt with hx COPD and home O2.\n\nGI/GU: Pt abd soft and distended, +BS x 4. Pt initially NPO this am for ? VT ablation-ablation postponed, pt eating meals-good appetite, no stool this shift. Pt voiding via condomn cath, u/o avg approx 125 cc clr yellow urine/hr.\n\nEndo: FS 118-130, no ss insulin coverage given.\n\nSocial: Pt two brothers in to visit pt, family spoke with RN and MD and were updated on pt .\n\nA/P: 74 y/o male remains hemodynamically stable, no runs VT noted. Pt tol increased dose of beta-blocker and dc of lidocaine gtt. Pt MS clearing. As discussed per interdisciplinary rounds, continue to monitor pt hemodynamics, EKG and rhythm. Anticipate VT ablation in EP lab on Thurs or Fri this week. Continue to monitor resp status and u/o. Continue to follow lytes, FS. Continue to asses pt MS pt as needed. Continue to provide emotional support to pt and family.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-09 00:00:00.000", "description": "Report", "row_id": 1403582, "text": "PT C RECURRENT FIRING OF AICD FOR VT SP SUCCESSFUL ABLATION .\n\nEXTUBATED 8AM,SAT 98 ON 2L NP,C/R THICK TAN .\nAVPACED C FREQUENT PVCS,COUPLETS,SEEN BY EPS NO ANTIARRHYTHMICS AT THIS TIME,ON DIG,CAPTOPRIL ,LOPRESSER.ALINE DC.R GROIN ECCYMOTIC NO HEMATOMA .PT PULSE L LEG BY DOP,PALP FEM PULSE R BKA . MG REPLETED\n\n\n\nE/D WELL CL LIQS,HAD ABD PAIN BUT IMPROVED C FOOD,NO STOOL 3DAYS,ONE DULCOLAX GIVEN.\n\nHUO 20 TO 20 HR,DIURETICS HELD\n\nALERT,ORIENTED ,COOPERATIVE ,PUPILS EQUAL REACTIVE,HAD BEEN UNEQUAL EARLIER,CVA RO BY CT SCAN .OOB X 1 .\n\nCOCCYX SORE AND RED .PT KEPT OFF BACK.HAS ECCYMOTIC AREA L FLANK\n\nREPORT INCREASING ECTOPY\nCORRECT LYTES\nKEEP PT OFF BACK AS MUCH AS POSSIBLE\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-10 00:00:00.000", "description": "Report", "row_id": 1403583, "text": "NURSING PROGRESS NOTE 7P-7A\nS: \"CAN I USE THE COMMODE?\"\n\nO: NEURO: PT. ALERT AND ORIENTED X3. MAE. PUPILS EQUAL AND REACTIVE TO LIGHT. TRANSFERS TO COMMODE WITH 1 ASSIST, WEIGHT BEARING ON LEFT LEG. PLEASANT AND COOPERATIVE.\n\nCV: HR 73-78 AV PACED WITH FREQUENT PVC'S, 5-8 BEAT RUN OF VT, NO FIRING OF AICD. ASYMPTOMATIC, BP STABLE. DENIES C/O CHEST PAIN. RIGHT GROIN C&D, WEAK PALP PULSES.\n\nRESP: CONT ON 2L NC, DIMINISHED BREATH SOUNDS AT BASES. COUGHING AND RAISING THICK TAN SPUTUM. SPUTUM CULTURE FROM SHOWING GRAM POS COCCI IN PAIRS AND CLUSTERS.\n\nGI: APPETITE FAIR, ABD SOFT + BOWEL SOUNDS. PASSING LARGE AMT OF LIQUID BROWN STOOL. CULTURE SENT FOR C-DIFF.\n\nGU: FOLEY DRAINING AMBER COLORED URINE IN SMALL AMTS. URINE HAS SMALL AMT OF SEDIMENT.\n\nSKIN: COCCYX LESS RED. ENCOURAGE PT. TO REMAIN ON SIDE AS MUCH AS POSSIBLE WHILE IN BED.\n\nA: S/P ABLATION FOR VT.\n\nP: FOLLOW LYTES, I/O. ?INCREASE LOPRESSOR AND CAPTOPRIL DOSE. UPDATE PT. AND FAMILY ON PLAN OF CARE.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-10 00:00:00.000", "description": "Report", "row_id": 1403584, "text": "PT C AICD,SP STEMI,2 STENTS TO RCA AND ABLATION FOR RECURRENT VT .\n\nAV PACED C FREQ PVCS COUPLETS AND SOME SHORT RUNS ,HAD 13 BEAT RUNS ON NIGHTS, STARTED ON QUINIDINE . BP TOL INCREASE IN ACE,BB. PLATELETS LOW,SC HEPARIN DC,CHECKING FOR HIT . PT HAS BRUISE L FLANK,R GROIN,STABLE HCT .PT PULSE L FOOT BY DOP,R BKA. STAYING IN UNIT WHILE MEDS ADJUSTED .MG REPLETED .\n\nCO SOB C ACTIVITY,SAT 96 2LNP, LASIX RESTARTED .\n\nFAIR APPETITE ,NEG LIQUID STOOL POST DULCLAX .OOB TO COMMODE X1.FOLEY DC, INC LG AMT URINE .\n\nT MAX 99.8 .\n\nCOCCYX RED,UNBROKEN SORE .PT KEEPING OFF BACK\n\nMONITOR FOR INCREASED ECT\nCORRECT LYTES\nCORRECT LYTES\n" }, { "category": "Nursing/other", "chartdate": "2140-04-08 00:00:00.000", "description": "Report", "row_id": 1403579, "text": "CCU Progress Note:\n\nS- intubated & sedated.\n\nO- see flowsheet for all objective data.\n\ncv- To EP lab @ 0815- returned @ 1600- VT ablation done- no inducable transferred to CCU on dopamine gtt @ 10mcq/kg/min & propofol gtt @ 20mcq/kg/min- R fem arterial sheath attached to transducer- 2 venous sheaths intact- small amt oozing noted- L radial A line- SBP >100- dopamine gtt weaned off- SBP 108-126 @ present- Hct 45- K 3.9 KCL 40meq via OGT given- Mg 1.9- oozing increasing R fem @ 1730- ACT 172- sheaths pulled by fellow- Tele: AV paced rhythm- no VT noted- HR 60-75.\n\nneuro- L pupil smaller than R- reported to HO- examined to CCU team- neuro consulted & in to see Pt- propofol gtt decreased to 10mcq/kg/min- Pt able to follow commands @ present- moving all extremities.\n\nresp- con't on vent CMV 500/10/30%/5- ABG done upon return from EP lab\n7.36-48-71-93%- rate increased to 12 & FiO2 increased to 50%- lung sounds clear bilaterally- suctioned small amt thick lt tan colored mucous- SpO2 97-100%.\n\ngi- abd soft (+) hypoactive bowel sounds- OGT clamped- no BM today.\n\ngu- foley draining amber colored urine qs- BUN 15 Crea .9\n\nA- S/P VT ablation with asymetrecal pupil size noted & oozing from sheaths sites & L radial A line site.\n\nP- Monitor neuro status closely- ? CT scan repeat labs- Plan is to keep Pt intubated overnight, so increase propofol gtt for comfort- monitor vs, I&0, and labs.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-09 00:00:00.000", "description": "Report", "row_id": 1403580, "text": "Resp Care Note:\n\nPt cont intub with OETT and on mech vent as per Carevue. Lung sounds sl coarse suct sm th off white sput. ABGs stable able to wean FIO2 overnoc. Pt transported to and from CT scan without incident. Cont mech vent wean to extub today.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-09 00:00:00.000", "description": "Report", "row_id": 1403581, "text": "NURISNG PROGRESS NOTE 7P-7A\nS: INTUBATED.\n\nO: NEURO: PT. MAE, FOLLOWS ALL COMMANDS. PUPILS R 2MM, L 1MM. BOTH SLUGGISH TO LIGHT. PROPOFOL CONT THROUGHOUT NIGHT FOR MILD SEDATION. GRASPS EQUAL, WEAK. HEAD CT DONE; NEG. PROPOFOL OFF THIS AM IN PREP FOR POSSIBLE EXTUBATION.\n\nCV: HR 60-68 AV PACED, OCC PVC NOTED THIS AM. REPEAT K LAST NOC 4.4 (RECEIVED 40 KCL FOR K 3.9). BP 78-94 SYS. GIVEN FLUID BOLUS X3 ( 250,250,500). BP NOW 100-104 SYS. RIGHT GROIN C&D, NO BLEEDING OVERNIGHT. PRESSURE DRESSING INTACT. DOP PULSES ON RIGHT. LOPRESSOR HELD FOR LOW BP.\n\nRESP: COARSE BREATH SOUNDS. O2 SAT 98%. SUCTIONING FOR THICK TAN SPUTUM. SPEC SENT FOR CULTURE. NOTED TO HAVE INCREASE ORAL SECRETIONS. RSBI 34 NOW ON CPAP/5.\n\nGU: URINE POOR 15-30 CC/HR. HO AWARE. FAIR RESPONSE TO FLUID BOLUS. URINE AMBER, CLEAR.\n\nGI: ABD SOFT, + BOWEL SOUNDS. OGT INTACT, DRAINING COFFEE GROUND MATERIAL. GUIAC POS, PH 2. STARTED ON PPI.\n\nSKIN: COCCYX RED, SEVERAL ECCHYMOTIC AREAS NOTED ON BACK (BELOW SHOULDER BLADE) AND HIP. REPOSITIONED FREQ FOR PRESSURE RELIEF.\n\nA: VT, S/P ABLATION.\n\nP: EXTUBATE TODAY, FOLLOW LYTES, REPLETE AS NEEDED. UPDATE FAMILY AND PT. ON PLAN OF CARE.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2157-11-08 00:00:00.000", "description": "Report", "row_id": 1531857, "text": "Neuro: pt weaned off propofol, alert oriented answering questions appropriately. anxious at times.\nResp: Once awake vent weaned to cpap with good abg's. pt extubated without difficulty. placed on 50% open face tent with sats around 96%. attempted to wean to 4 l np but sats dropped to 90-91% pt sleeping in naps and breathing through mouth at time.\nC/V:pt heart rate once extubated creeping up into low 100's sinus with PVC's. Lytes treated with improvement in ectopy. Pacing wires sense and Capture both A and V's. pt remains on epi at 0.02 mcg with no changes and neo up to 1.5mcg to maintain a MAP greater than 60. IABP on 1:1 with good augmentation. Pedal pulses present by doppler feet cool to touch but good sensation and movement noted.\nGI: pt tolerating small sips this am.\nEndo: blood sugars elevated on nsulin gtt until early am when bs dropped to 60's drip off presently monitoing.\ngU: excellent urine outputs greater than 100cc/hr clear yellow. weight up 6 kg.\nSkin: Dsg D&I no drainage.\nPain: Once awake pt requiring 2mg every 1 hour for pain control. moaing continuously in bed. 10 mins after pain med given pt would say he was better but than 45 mins later would increase groaning. Dose increased to 4mg sc with good relief per pt but pain back in 2hours. Presently medicating pt with percocoet will evaluate in 1 hour for releif.\nPlan: wean Epi and IaBP possible transfer to floor late today.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-08 00:00:00.000", "description": "Report", "row_id": 1531858, "text": "Neuro: A&Ox3, calm & cooperative, MAE's, follows command\n\nCV: Afeb; NSR 80's with freq PVC's; IABP DC'd in afternoon, palapble pulses on LE bilat, no hematoma noted around site; on neo gtt, MAP >65; 2A 2V wires to pacer box, sensing & capturing\n\nResp: Lung sound clear, dim @ bases; try to change to NC, desat to 88%, mouth breather, put back on face tent @ 35% FiO2, sat high 90's; non-productive cough; IS to 600; chest tubes draining minimal serrousang drainage; sleep apnea, own CPAP machine @ bedside\n\nGI: Tolerating ice chips, swallow pills with water; abd soft, hypoactive bowel sound; c/o nausea after PO percocet, 10 mg IV reglan given with good effect\n\nGU: Foley draining marginal amount clear yellow urine, diuresis after lasix 20 mg IV\n\nInteg: Intact; scant amount of serrousang drainage noted on sternal drsg; ACE wrap on L leg\n\nPain: C/O incisional pain, , IV morphine 2 mg q2H with good effect\n\nFamily: Family visited most of PM\n\nA/P: pulm toilet; inc activity; ?DC chest tube tomorrow; inc PO intake as tolerated; switch to PO pain meds when eating\n" }, { "category": "Echo", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 100087, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Intra-op TEE for emergent CABG\nHeight: (in) 69\nWeight (lb): 192\nBSA (m2): 2.03 m2\nStatus: Inpatient\nDate/Time: at 16:51\nTest: TEE (Congenital)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. PFO is present.\nLeft-to-right shunt across the interatrial septum at rest.\n\nLEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV cavity. Moderate\nregional LV systolic dysfunction. Moderately depressed LVEF. [Intrinsic LV\nsystolic function likely depressed given the severity of valvular\nregurgitation.]\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall.\n\nAORTA: Normal aortic root diameter. Focal calcifications in aortic root.\nMildly dilated ascending aorta. There are complex (>4mm) atheroma in the\naortic arch. There are complex (>4mm) atheroma in the descending thoracic\naorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MS. Mild to moderate (+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications. The patient was under general anesthesia throughout the\nprocedure. The patient appears to be in sinus rhythm. Results were personally\nreviewed with the MD caring for the patient. See Conclusions for post-bypass\ndata\n\nConclusions:\nPRE-BYPASS:\n1. A patent foramen ovale is present.\n2. Left ventricular wall thicknesses are normal. The left ventricular cavity\nis mildly dilated. There is moderate to severe regional left ventricular\nsystolic dysfunction with inferior, lateral and inferolateral hypokinesis.\nOverall left ventricular systolic function is moderately depressed. [Intrinsic\nleft ventricular systolic function is likely more depressed given the severity\nof valvular regurgitation.]\n3. Right ventricular chamber size is normal. There is modertate focal\nhypokinesis of the apical free wall of the right ventricle.\n4. The ascending aorta is mildly dilated. There are complex (>4mm) atheroma in\nthe aortic arch and in the descending thoracic aorta.\n5. There are three aortic valve leaflets. There is no aortic valve stenosis.\nTrace aortic regurgitation is seen.\n6. The mitral valve leaflets are structurally normal. There is central\nregurgitant jet by color doppler c/w mild to moderate (2+) mitral\nregurgitation is seen.\n7. There is no pericardial effusion.\n\nPOST-BYPASS:\n\nPt is being Apaced and is on an infusion of phenylephrine and epinephrine\n1. Slight improvement of RV and LV systolic function\n2. Aorta is intact\n3. MR \n\n\n" }, { "category": "ECG", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 276227, "text": "Normal sinus rhythm, rate 86. Compared to the previous tracing there is now\nclear evidence for acute inferior current of injury with associated anterior\nST segment depression consistent with ischemia. There are occasional atrial\npremature beats. The overall sequence of five tracings suggests acute inferior\nmyocardial infarction with associated anterolateral ischemia. True posterior\ninjury current cannot be excluded.\nTRACING #5\n\n" }, { "category": "ECG", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 276228, "text": "Sinus rhythm. Compared to the previous tracing there is more ST segment\ndepression in the mid and lateral precordial leads. T wave inversion in\nlead V6 persists.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 276229, "text": "Compared to tracing #1 ventricular ectopy has resolved. ST segment depressions\nare less marked in the mid-anterior leads and there is new T wave inversion in\nthe lateral precordial leads. The findings are consistent with possible old\ninferior wall myocardial infarction and evolving anterolateral ischemia.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 276230, "text": "Right precordial leads are submitted. Compared to the previous tracing right\nprecordial leads are new. There is no evidence for right ventricular\ninfarction. There is borderline low voltage in the standard leads.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 276231, "text": "Normal sinus rhythm, rate 090, with first degree A-V block. Non-diagnostic\nQ waves in leads III and aVF. Mid-precordial ST segment depression consistent\nwith ischemia. Frequent ventricular premature beats in a trigeminal pattern.\nCompared to the previous tracing of mid-precordial ST segment\ndepressions and ventricular premature beats are new.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2157-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930034, "text": " 6:14 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ptx, effusion\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with chest pain s/p Emergent CABG on IABP\n\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 59-year-old man with chest pain status post emergent CABG on\n intra-aortic balloon pump. Evaluate.\n\n COMPARISON: AP upright portable chest x-ray dated .\n\n AP UPRIGHT PORTABLE CHEST X-RAY: The patient is status post median\n sternotomy, with sternal wires and clips. An endotracheal tube terminates 7\n cm above the carina. A nasogastric tube descends below the diaphragm with the\n tip not visualized. Two left-sided chest tubes terminate in the left base and\n mid lung zones. A mediastinal drain is in place. A right internal jugular\n central venous catheter terminates within the upper/mid SVC. No intraaortic\n balloon pump is visualized.\n\n The mediastinum is widened consistent with recent surgery. There is left\n lower lobe collapse/consolidation. Perihilar fullness is likely related to\n atelectasis. There is no pneumothorax.\n\n IMPRESSION: No pneumothorax. No intraaortic balloon pump is seen.\n Remaining lines and tubes as indicated above.\n\n" }, { "category": "Radiology", "chartdate": "2157-11-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 929996, "text": " 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: infiltrate, edema, free air\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with chest pain, s/p endoscopy\n REASON FOR THIS EXAMINATION:\n infiltrate, edema, free air\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Chest pain.\n\n Single AP view of the chest is obtained at 11:55 hours and is\n compared with the prior radiograph of . No significant adverse\n interval change has occurred. The heart is not enlarged. There is moderate\n tortuosity of the aorta. The lung fields show no evidence of acute\n infiltrate, pleural effusion, or pneumothorax. There is no evidence of\n pneumoperitoneum.\n\n IMPRESSION:\n\n No convincing radiographic evidence of acute cardiopulmonary disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-11-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930268, "text": " 10:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ptx s/p CT d/c\n Admitting Diagnosis: CORONARY ARTERY DISEASE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 59 year old man with chest pain s/p Emergent CABG on IABP\n\n REASON FOR THIS EXAMINATION:\n eval ptx s/p CT d/c\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 59-year-old male with chest pain.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: Status post median sternotomy. The left chest tube and NG tube\n have been removed. Right IJ central line tip is in the mid SVC. Mild\n cardiomegaly. There is interval improvement of left lower lobe opacity which\n could represent atelectasis or consolidation. Persistent right infrahilar\n opacity stable since the prior study. No pneumothorax. Small left pleural\n effusion.\n\n IMPRESSION:\n 1. Interval improvement in left retrocardiac, right infrahilar\n consolidations.\n\n 2. Small left pleural effusion is unchanged\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2157-11-07 00:00:00.000", "description": "Report", "row_id": 1531855, "text": "Resp Care\nPt s/p CABG remains intubated with 7.5 ETT 21@lip. Pt currently on SIMV+PS 600x14 100%. plan at this time is to continue vent support and wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-08 00:00:00.000", "description": "Report", "row_id": 1531856, "text": "Respiratory Care\nPt extubated to 60% cool aerosol face tent. ABG post extubation WNL.\nPlan: wean Fio2 as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-09 00:00:00.000", "description": "Report", "row_id": 1531859, "text": "Resp Care\nPt's home CPAP set up for use. Pt says he wears unit every night, however when attempted to wear last night, pt did not tolerate- Spo2 dropped to 89%, RR ^ 30's. CPAP off for the night, pt on 6 L NC. SpO2=96%\nPlan: maintain O2 support, try CPAP again tonight.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-09 00:00:00.000", "description": "Report", "row_id": 1531860, "text": "Neuro: Pt A&O X3. MAE. Obeys commands. 2 mg Morphine IV q2h for incisional pain. Cap refill <3 sec. Extremities warm to touch. Change to PO pain med once pt is eating (pt afraid of becoming nauseous). Reglan X1 for nausea. Pt requested his Trazodone restarted to help him sleep. Pt on Wellbutrin for depression.\n\nID: Pt receiving Vanco.\n\nCV: Pt's HR in high 90's entire shift. NSR with frequent PVC's each hour. Neo weaned, now off. K, Ca, and Mag repleted. Palpable pedal pulses, confirmed by Doppler. Pt afebrile.\n\nResp: Pt on 4L NC. Lungs clear at apexes, dim at bases. CT with minimal serosanguinous drainage. Pt has own CPAP machine for use-machine at bedside.\n\nEndo: RISS per CSRU protocol.\n\nGI/GU: Pt tolerating PO meds. +BS, no BM. Voiding clear yellow urine of SQ via Foley.\n\nInteg: No skin issues at this time.\n\nA/P: Pulmonary toilet. Treat pain. Advance diet and activity. Replete lytes as necessary.\n" }, { "category": "Nursing/other", "chartdate": "2157-11-09 00:00:00.000", "description": "Report", "row_id": 1531861, "text": "Respiratory Care:\nPt has his own BiPap unit and said he will try to use it tonoc.\n" } ]

[ { "category": "ECG", "chartdate": "2208-04-29 00:00:00.000", "description": "Report", "row_id": 262173, "text": "Probable sinus tachycardia. Intraventricular conduction delay of right\nbundle-branch block type. ST-T wave abnormalities. Since the previous tracing\nof , the rate is faster. Otherwise, unchanged.\n\n" }, { "category": "ECG", "chartdate": "2208-04-29 00:00:00.000", "description": "Report", "row_id": 262174, "text": "Same as tracing #1 with no interval change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2208-04-29 00:00:00.000", "description": "Report", "row_id": 262175, "text": "Sinus tachycardia. Right bundle-branch block. Non-specific inferior and\nprecordial T wave changes may be due to the right bundle-branch block.\nCompared to the previous tracing of the rate has increased.\nTRACING #1\n\n" } ]

[ { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711075, "text": "Pt with sig PMH including emphysema, home O2 (2-4L), cardiomyopathy\n (EF 15%)sepsis, pna PE, HTN presents with SOB, sats 85%, T 103.6R, BP\n 81/30, HR 70's, WBC 12.6, BUN 34, creat 2.5. BC, UC obtained.\n Lethargic, OX3. Placed on BiPap. Given 2L IVF, meropenum, tylenol.\n Able to transition to 5L NP with sats 100%.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n" }, { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711179, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--2 liter IVF given in Levophed and Meropenem\n started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n Continues on Levophed at .2 mcg/kg/min. MAP\ns 60-70\n. Oliguric\n throughout shift. No response to NS 500 cc X3. On meropenem, vanco,\n tamiflu . Afeb. No cough\n Action:\n No change in Levophed dose. Currently receiving NS 1000 cc bolus for\n CVP 10. On droplet precautions for R/O flu. R/O flu. Nasal swab to r/o\n flu obtained\n Response:\n Assess after 1L NS bolus\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics, tamiflu.\n Altered mental status (not Delirium)\n Assessment:\n MS waxing & from awake & oriented (briefly) to having to shout\n at pt to open eyes. Primarily lethargic most of the shift. ABG\n 154/47/7.30/24/-3. BS 143. PM labs pnd . Follow up on PM labs\n Action:\n Head Ct scan done. Three rails up. Bed locked & low position. Ongoing\n assessment\n Response:\n Remains very lethargic.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n HX AF. HR 70\ns-80\ns V paced with frequent PVC\ns, bigemity\n Action:\n Ongoing assessment. EKG done to confirm rhythm. Cardiology in to\n interrogate pacer\n Response:\n BP stable on levophed\n Plan:\n Ongoing assessment. Wean levophrd as tol. Maintain MAP > 65\n Admitted with Stage II 1 CM X 0.3 CMressure ulcer on R gluetal\n butocks. Area surrrounding ulcer 3CM X 6 CM,red, blanchable.\n" }, { "category": "Nursing", "chartdate": "2170-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711610, "text": "Shock, septic\n Assessment:\n Remains afebrile, this shift. Tmax 97. Pan cultured yesterday. WBC\n O2 3LNC , spo2 maintaining above 95%. Occasional moist productive\n cough, bringing out thick white secretions. LS rhoncherous. Continues\n on levophed , was on 0.15mcg/kg/min at start of shift. BP stable with\n MAP above 65. UOP above 30cc/hr.\n No fluid boluses this shift.\n Received 1unit blood for a crit of 23.4\n Action:\n . Continues on Vancomycin , meropenem. ID team in to visit.\n Doxycycline 100mg IV q12hrs started. Levophed dose titrated for a\n goal of MAP above 65.\n Response:\n Levo dose titrated , Bp remains stable. Afebrile this shift. Post\n transfusion crit.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate and wean\n Levophed as tolerated to MAP >65. Cont antibiotics. Pan cultured\n yesterday. Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X1, sleeping for most part of the shift, irritable and angry\n upon awakening.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Frequently redirected.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65.\n Action:\n Contnues on digoxin. Magnesium sulfate 2gms repleted.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Heeling stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Mepiplex on. . R buttocks with\n echymotic areas, ? Deep tissue injury. Pt endorses he fell at home &\n hit that particular r area. L & R great toes with small open areas on\n tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE\n Response:\n No change\n Plan:\n Ongoing assessment. ? vascular to see pt for eval of L&R great toes.\n" }, { "category": "Physician ", "chartdate": "2170-12-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 711686, "text": "Chief Complaint: hyotension\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 75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n 24 Hour Events:\n BLOOD CULTURED - At 12:28 PM\n BLOOD CULTURED - At 12:28 PM\n SPUTUM CULTURE - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n FEVER - 101.5\nF - 12:00 PM\n Given 1U PRBC yesterday.\n Weaned off levophed (off all pressors) this morning.\n Doxycycline added to cover stenotrophomonas.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Meropenem - 05:36 AM\n Doxycycline - 08:23 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n hydrocortisone 50 q 24h.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: Moderate\n Pain location: back pain, discomfort\n Flowsheet Data as of 11:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 35.6\nC (96\n HR: 74 (70 - 107) bpm\n BP: 115/46(62) {97/46(60) - 124/51(66)} mmHg\n RR: 24 (17 - 32) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 230 (7 - 233)mmHg\n Total In:\n 2,950 mL\n 792 mL\n PO:\n 720 mL\n 400 mL\n TF:\n IVF:\n 1,855 mL\n 392 mL\n Blood products:\n 375 mL\n Total out:\n 2,090 mL\n 690 mL\n Urine:\n 2,090 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 860 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: irreg irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Rhonchorous: loud\n rhonchi), coughing up yellow thin secretions, improved\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no peripheral edema\n Skin: Warm, thin, easily torn skin, purpuric lesions\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 284 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 134 mEq/L\n 25.2 %\n 11.7 K/uL\n [image002.jpg]\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n Plt\n 381\n 414\n 322\n 284\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n TropT\n 0.02\n TCO2\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n Other labs: PT / PTT / INR:34.8/65.0/3.6, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n Imaging: multifocal patchy opacities, not significantly changed since\n yesterday given technique\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CARDIOMYOPATHY, OTHER\n HYPERTENSION, BENIGN\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n SHOCK, SEPTIC\n IMPAIRED SKIN INTEGRITY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Family meeting held , ICU consent signed Comments:\n Discussed with pt and daughter at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2170-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711774, "text": "Impaired Skin Integrity\n Assessment:\n Very fragile areas on both arms\n Action:\n Pt. bleeding interm. On right arm.\n Mepiplex replaced on coccyx this pm.\n Both toe areas remain the same. Pt. does c/o slight discomfort when\n Toes covered. turned\n Response:\n Plan:\n Use paper tape only.\n Shock, septic\n Assessment:\n Cont. not to require Levophed.\n Action:\n Resp: pt. with strong cough. Able to cough and raise.\n Sputum thick yellow-brown.\n Pt. cont. to be rhoncherous. Sats 100% on 4L.\n Gi: improved appetite. Stool x2 guaiac +.\n Renal: u/o\ns 30-50cc/hr. output dropped this pm, but foley noted to be\n kinked.\n Neuro: attitude much improved. Daughter into visit. Attorney to see pt.\n tomorrow.\n Cv: hemodynamically stable today. Far less ect noted. Remains in paced\n rythym.\n Art bp was 112/48 mean of 71 and cuff was 120/54 mean of 64.\n Id: afebrile. Today. Cont. on antibiotics.\n Access: a-line d/c\n Coags: coumadin held this pm.\n Endoc: k= repleted.\n Activity: up in chair for 1hr.\n Social: daughter explained that her father has a difficult time talking\n about end of life.\n He may open up to someone like our social worker.\n Response:\n Cont. to improve\n Plan:\n Hold coumadin if inr >3,0. needs palliative care consult. Needs social\n service consult to handle end of life issues.\n" }, { "category": "Physician ", "chartdate": "2170-11-30 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 711276, "text": "Chief Complaint: SHOCK-Septic or Hypovolemic\n Hypoxia\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 MULTI LUMEN - START 09:30 AM\n ARTERIAL LINE - START 12:00 PM\n -Pacer function--A-fib, not Vt episodes or events to be consistent with\n source of acute event\n -CVP-start at 2 and with IVF bolus at 4 liters had improved urine\n output and with CVP increase to 8 and with ScVO2 at 78 cardiac\n compsomise less likely\n -Patient with improved alertness overnight\n -Vasopressors weaned\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 10:00 PM\n Infusions:\n Norepinephrine - 0.25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Respiratory: Cough, Tachypnea, rare\n Gastrointestinal: No(t) Abdominal pain\n Flowsheet Data as of 10:17 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: 94 (71 - 114) bpm\n BP: 106/44(57) {101/38(51) - 106/44(57)} mmHg\n RR: 23 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 11 (2 - 11)mmHg\n Mixed Venous O2% Sat: 78 - 78\n Total In:\n 4,524 mL\n 899 mL\n PO:\n 100 mL\n 430 mL\n TF:\n IVF:\n 4,424 mL\n 469 mL\n Blood products:\n Total out:\n 665 mL\n 555 mL\n Urine:\n 515 mL\n 555 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,859 mL\n 344 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.29/39/125/19/-6\n Physical Examination\n General Appearance: Well nourished\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: Systolic), \n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: , Rhonchorous: bilateral and diffusely)\n Abdominal: Soft, Non-tender\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 8.2 g/dL\n 414 K/uL\n 123 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 29 mg/dL\n 103 mEq/L\n 132 mEq/L\n 25.0 %\n 11.7 K/uL\n [image002.jpg]\n 11:15 AM\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n WBC\n 10.9\n 11.7\n Hct\n 32\n 143\n 25.1\n 25.0\n Plt\n 381\n 414\n Cr\n 2.0\n 1.7\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 24\n 23\n 20\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:25.8/55.0/2.5, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n Fluid analysis / Other labs: AG-10\n Imaging: CXR-Small increase in bilateral pulmonary infiltrates\n CT HEad--no acute process\n Microbiology: Influenza-Negative\n Assessment and Plan\n 75 yo male with admission with quite significant hypoxemia with rapid\n resolution and a real minimum of radiographic findings on CXR\n concerning for extrapulmonary shunting. He did have admission\n additionally significant for hypotension in the setting of cardiac\n dysfunction and hypovolemia with only a single fever arguing strongly\n for infectious or septic source of shock. With intervention he has\n shown substantial improvement in the past 24 hours. However, patient\n does retain significant hypotension with wean of pressors and we will\n need to further optimize cardiac output to maintain adequate MAP.\n 1)SHOCK-Septic or Hypovoelmic--at admission. We do have concern for\n signfiant contribution from cardiogenic source of hypotension at this\n time but with preserved central venous O2 sat this would seem to be\n less likely. With his hypotension we will have to continue to titrate\n down pressors and maintain an effective cardiac output.\n -Sputum sent for culture\n -Continue ABX\n -IVF bolus as needed for fall in CVP or decrease in urine output\n -Will continue with pacer at current settings and will have to tolerate\n the bigeminy seen although it dose lead to a realtively high frequency\n of ineffective SV with PVC\ns. I would argue that we need stabilization\n of SVR to allow full and effective wean of pressors to allow cardiac\n output to allow stability.\n -Return to po intake but will have to maintain fluid balance as even in\n the setting of diarrhea\n -Continue with stress dose steroids\n 2)Acute Renal Failure--Improved urine flow and improved creatinine\n -Continue to support BP and effective fluid replacement\n 3)ATRIAL FIBRILLATION (AFIB)-\n -Continue with digoxin at this time\n 4)ALTERED MENTAL STATUS (NOT DELIRIUM)-\n -Resolved\n 5)CARDIOMYOPATHY, OTHER\n -Digoxin to resume\n 6)Pulmonary Embolus-\n -Return to Coumadin\n ICU Care\n Nutrition: PO diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: SQ heparin\n Stress ulcer: PO diet\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition :ICU\n Total time spent: 45\n" }, { "category": "Physician ", "chartdate": "2170-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711283, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:30 AM\n ARTERIAL LINE - START 12:00 PM\n -cards interrogated pacer; in a fib, no episodes of VT since ,\n having ectopy now (pacing with pvcs in bigeminal pattern)\n -rec'd fluid boluses, low UOP, received total of 4 L IV fluid; CVP came\n up from 2 to 8 and mixed venous sat 78%.\n -loose stool x 2, guaiac neg, sent for c diff\n -pt woke up at midnight, completely lucid (minimally arousable earlier\n in the day)\n -social work consult ordered\n -bubble study ordered because ABGs suggestive of shunt, possibly\n cardiac\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 93 (70 - 114) bpm\n BP: 106/44(57) {101/38(51) - 135/58(71)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 8 (2 - 10)mmHg\n Mixed Venous O2% Sat: 78 - 78\n Total In:\n 4,523 mL\n 379 mL\n PO:\n 100 mL\n 150 mL\n TF:\n IVF:\n 4,423 mL\n 229 mL\n Blood products:\n Total out:\n 665 mL\n 225 mL\n Urine:\n 515 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,858 mL\n 154 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.29/39/125/19/-6\n Physical Examination\n Gen: A&O x3, NAD, pleasant and talkative\n HEENT: Bitemporal wasting, dry MM, OP clear\n CV: Paced, irregular rhythm, soft systolic murmur LUSB\n Pulm: Diffusely rhonchorous b/l\n Abd: soft, NT, ND, +BS\n Extrem: no c/c/e, several healing big toe ulcers, diminished peripheral\n pulses b/l\n Labs / Radiology\n 414 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 29 mg/dL\n 103 mEq/L\n 132 mEq/L\n 25.0 %\n 11.7 K/uL\n [image002.jpg]\n 11:15 AM\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n WBC\n 10.9\n 11.7\n Hct\n 32\n 143\n 25.1\n 25.0\n Plt\n 381\n 414\n Cr\n 2.0\n 1.7\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 24\n 23\n 20\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:25.8/55.0/2.5, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n B Cx pend\n U Cx pend\n Resp viral screen pend\n C diff and stool Cx pend\n NCHCT prelim: no hemorrhage. no acute intracranial process.\n CXR today: slightly increased pulmonary vascular congestion (my read)\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presents to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n .\n # Hypotension: Given patient's acute kidney injury (with FeUrea of\n 26%), complaint of thirst, low urine output, and physical exam\n consistent with dehydration, his hypotension could be solely attributed\n to hypovolemia. In setting of fever to 103 in ED, leukocystosis to\n 12.6, and recent admissions for sepsis, this seems the most likely\n cause of his hypotension. We are currently targeting therapy to prior\n ESBL organism with vanc and meropenem. C diff is another possible\n source, as patient with recent antibiotic course for PNA and several\n episodes loose stools. There is also the concern for a cardiogenic\n component of hypotension, but with preserved central venous O2 sat this\n would seem to be less likely. With his hypotension we will have to\n continue to titrate down pressors and maintain an effective cardiac\n output.\n - Norepinephrine to keep MAPs > 65\n - Gently hydrate with 500 mL boluses given EF of 15% and history of\n volume overload, as well as DNR/DNI status\n - continue empiric vancomycin and meropenem pending culture results\n - Follow-up blood, urine cultures, stool and sputum Cx\n - f/u c diff\n - restart home dose digoxin with the hope of improving cardiac output\n .\n # Hypoxemic respiratory failure:\n Patient was not initially complaining of dyspnea while at home. Upon\n transit to the ED was noted to have a low oxygen sat in the 70s and was\n placed on NRB and subsequently was placed on BiPAP in the ED. While in\n the emergency department, oxygen sats recovered and supplemental oxygen\n was titrated down. On the floor was maintaining oxygen sat of 100% on\n RA; however, initial ABG showed a pO2 of 56. 100% facemask was applied\n and sat increased appropriately to 441. A-a gradient difficult to\n calculate given unknown exact oxygen percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n - TTE with bubble study to rule-out intracardiac shunt as cause of his\n odd ABG findings of low pO2 despite observed normal sat\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n .\n # Altered Mental Status: Improved overnight with MAP > 65 following\n several fluid boluses and increased pressors. Most likely related to\n decreased perfusion of the brain, although ICU delirium is also a\n possibility given that pt has been in and out of ICU for past several\n months. Will continue to monitor. NCHCT negative.\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n .\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA neg and tamiflu stopped\n .\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.7 today.\n - Continue to trend BUN/Cr\n - Renally dose meds\n - Hold furosemide unless patient becomes acutely dyspneic\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . 132 this AM. Will\n monitor with rehydration.\n - Trend sodium\n # COPD:\n recent PFTs or overall disease status. Reported to be on home\n supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - Trend with rehydration\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increase to 50 mg hydrocortisone given stress of acute illness (day 2\n today)\n # h/o PE, on coumadin: Remote chance that a transient PE could explain\n current presentation of hypoxia and hypotension.\n -continue coumadin with goal INR \n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time. Digoxin 0.5 on\n admission labs.\n - Restart digoxin today as above\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Nutrition: Regular diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: coumadin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: Daugher is HCP\n status: DNR/DNI\n Disposition: for now\n" }, { "category": "Physician ", "chartdate": "2170-12-02 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 711689, "text": "Chief Complaint: hyotension\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 75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n 24 Hour Events:\n BLOOD CULTURED - At 12:28 PM\n BLOOD CULTURED - At 12:28 PM\n SPUTUM CULTURE - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n FEVER - 101.5\nF - 12:00 PM\n Given 1U PRBC yesterday.\n Weaned off levophed (off all pressors) this morning.\n Doxycycline added to cover stenotrophomonas.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Meropenem - 05:36 AM\n Doxycycline - 08:23 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n hydrocortisone 50 q 24h.\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue\n Eyes: No(t) Blurry vision\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: Cough\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea\n Genitourinary: No(t) Dysuria\n Musculoskeletal: No(t) Joint pain\n Neurologic: No(t) Numbness / tingling, No(t) Headache\n Pain: Moderate\n Pain location: back pain, discomfort\n Flowsheet Data as of 11:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 35.6\nC (96\n HR: 74 (70 - 107) bpm\n BP: 115/46(62) {97/46(60) - 124/51(66)} mmHg\n RR: 24 (17 - 32) insp/min\n SpO2: 96%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 230 (7 - 233)mmHg\n Total In:\n 2,950 mL\n 792 mL\n PO:\n 720 mL\n 400 mL\n TF:\n IVF:\n 1,855 mL\n 392 mL\n Blood products:\n 375 mL\n Total out:\n 2,090 mL\n 690 mL\n Urine:\n 2,090 mL\n 690 mL\n NG:\n Stool:\n Drains:\n Balance:\n 860 mL\n 103 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 96%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Lymphatic: Cervical WNL\n Cardiovascular: irreg irreg\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : , Rhonchorous: loud\n rhonchi), coughing up yellow thin secretions, improved\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no peripheral edema\n Skin: Warm, thin, easily torn skin, purpuric lesions\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Purposeful, No(t) Sedated, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 284 K/uL\n 103 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 134 mEq/L\n 25.2 %\n 11.7 K/uL\n [image002.jpg]\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n Plt\n 381\n 414\n 322\n 284\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n TropT\n 0.02\n TCO2\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n Other labs: PT / PTT / INR:34.8/65.0/3.6, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n Imaging: multifocal patchy opacities, not significantly changed since\n yesterday given technique\n Assessment and Plan\n 75yo M with adrenal insufficiency, severe cardiomyopathy, recent\n Klebsiella pneumonia sepsis.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Shock, multifactorial\n Off pressors\n Adrenal insufficiency: on outpt dose of hydrocortisone.\n Infection\n Vanc/meropenem/doxycycline empirically for septic shock for ESBL\n klebsiella and stenotrophomonas bacteremia. (Discuss antibiotic choice\n with ID.)\n Hypoxemia, resp failure. Likely has undiagnosed COPD or bronchiolitis\n as well as possible cardiac shunt. Supplemental oxygen is close to home\n dose.\n Afib, Vpaced.\n On digoxin, coumadin. Need to address rationale for continuing coumadin\n in setting of end stage CM, goals of care.\n Renal failure and hyponatremia, improved.\n Communication\n Need better understanding of pt\ns goals for his own care and end of\n life plan. Need to specifically discuss whether he wants to undergo\n this type of management, ICU course again, and whether he would want\n a-line, central line, continue coumadin.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines: Plan to remove a-line, central line.\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Communication: Family meeting held , ICU consent signed Comments:\n Discussed with pt and daughter at bedside\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2170-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711691, "text": "TITLE: Resident Progress Note\n Chief Complaint: Hypoxia, Respiratory Distress\n 24 Hour Events:\n - Spoke with daughter about allergies, she doesn't have any information\n about his possible allergies but says he hasn't had a reaction to\n antibiotics in the last few years that she knows of\n - Fever of 101.5, cultures sent\n - Clarified allergies with PCP: Fever/chills, Augmentin -\n nausea/vomiting, Cephalexin - uncertain (patient and PCP denied /o\n reaction), Bactrim - hives\n - Added doxycycline for possible stenotrophomonas coverage\n - Gram stain showed mixed flora, but didn't want to do induced sputum\n - Gave 1 unit PRBCs for anemia and for volume repletion\n - Weaned levophed completely\n BLOOD CULTURED - At 12:28 PM\n BLOOD CULTURED - At 12:28 PM\n SPUTUM CULTURE - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n FEVER - 101.5\nF - 12:00 PM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Doxycycline - 08:00 PM\n Meropenem - 05:36 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:36 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 36\nC (96.8\n HR: 104 (70 - 107) bpm\n BP: 106/44(57) mmHg\n RR: 21 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 9 (5 - 233)mmHg\n Total In:\n 2,950 mL\n 356 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n 1,855 mL\n 256 mL\n Blood products:\n 375 mL\n Total out:\n 2,090 mL\n 530 mL\n Urine:\n 2,090 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 860 mL\n -174 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Gen: NAD, alert and conversant, daughter at bedside\n CV: no murmurs\n Pulm: Subtantial rhonchi and expiratory wheezes/squeaks throughout lung\n fields bilaterally, also with productive wet cough\n Abd: +BS soft, NT, ND\n Ext: no edema, chronic hyperpigmentation and venous stasis changes, no\n tenderness, small ulcers tops of b/l 1^st toes, has right A-line\n Labs / Radiology\n 284 K/uL\n 8.1 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 134 mEq/L\n 25.2 %\n 11.7 K/uL\n [image002.jpg]\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n Plt\n 381\n 414\n 322\n 284\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n TropT\n 0.02\n TCO2\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n Other labs: PT / PTT / INR:34.8/65.0/3.6, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n 12:33 pm SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n and Blood cultures pending\n Urine culture pending\n C Diff negative\nCXR today in OMR\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presented to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n # Hypotension: Felt to most likely have combination septic and\n cardiogenic shock with low SvO2 two days ago. Sepsis most likely a\n pulmonary source with h/o ESBL PNA. Has been hemodynamically stable\n since admission and weaned off pressors. Has been C Diff negative.\n Got 1 unit PRBC\ns yesterday with good effect and appropriate hct bump.\n - Maintain MAP>60-65, will attempt without pressors today\n - Continue empiric vancomycin and meropenem pending culture results for\n likely pulmonary source, have added doxycycline to try to cover\n Stenotrophomonas\n - Follow-up blood, urine cultures, and sputum culture\n - restarted home digoxin on \n # Hypoxemic respiratory failure: Likely related to recurrent\n pneumonias.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n # Altered Mental Status: Has improved with IV fluid resuscitation and\n blood pressure improvement.\n - Continue to monitor\n # Acute renal failure: Creatinine has decreased to 1.2 from 2.0 on\n admission. Most liekly improving with better cardiovascular status.\n - Renally dose meds\n # Hyponatremia: Improved to 134 at this time, will monitor\n # COPD: recent PFTs or overall disease status. Reported to be on\n home supplemental oxygen, though unknown when this was started.\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, currently close to baseline although\n given 1 unit PRBC\ns yesterday with appropriate bump.\n - Maintain active type and screen\n - Guaiac positive stools, will investigate if he has had GI w/u in the\n past. Consider iron studies.\n # Adrenal insufficiency: Patient on 10 mg hydrocortisone at home and\n was getting 50mg IV hydrocort x 3 days here for stress of acute\n illness.\n - Start back on home dose\n # H/o PE, on coumadin: INR elevated today so will hold Coumadin dose\n today. Unclear risk vs benefit of Coumadin for this patient\n - Will confirm goals of care and readdress Coumadin necessity\n # Atrial fibrillation: Stable v-paced rhythm on telemetry at this time.\n - On home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension: Holding home antihypertensives\n # Hyperlipidemia: Holding atorvastatin\n # Goals of care: Will discuss with family\n ICU Care\n Diet: Regular, cardiac-heart healthy\n Glycemic Control: None\n Lines: Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n will d/c A-line today\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: With patient and daughter\n status: DNR/DNI\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711828, "text": "Shock, septic\n Assessment:\n Afebrile this shift. Continues on O2 4LNC , spo2 maintaining above\n 95%. Occasional moist productive cough, bringing out thick white\n secretions. LS rhoncherous.\n WBC trending down 9.5 this a.m.\n Off levophed since 6a.m. yesterday. BP stable with MAP above goal of\n 65.\n Received 1unit blood for a crit of 23.4 during the weekened. HCT stable\n since then. 24.5 this a.m. Pt had x1 loose brown guaic + stool this\n a.m.\n UOP adequate above30 cc/hr.\n Action:\n Continues on Vancomycin , meropenem and Doxycycline ( Started as\n per ID rec )\n Response:\n Remains off levophed with stable BP with MAP at goal of 65.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status. Continue antibiotics. Pan\n cultured on for elevated temp . Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3, sleeping for most part of the shift, pleasant and\n compliant with care.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65. Off levophed since yesterday .\n Action:\n Contnues on digoxin.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n Abdomen soft. +BS. Passing flatus. Had x1 loose brown BM, guaic +\n Pt\ns Attorney will be in to visit today.\n Social work consult given.\n 2peripheral lines inserted this a.m in L arm. ? Central line to be\n removed after discussion with ICU team.\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711439, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue , fell on the floor of the\n bathroom . 911 called. En route--patient with SaO2-70% and with BIPAP\n pressure decreased and CVL placed--2 liter IVF given in Levophed and\n Meropenem started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711442, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue , fell on the floor of the\n bathroom . 911 called. En route--patient with SaO2-70% and with BIPAP\n pressure decreased and CVL placed--2 liter IVF given in Levophed and\n Meropenem started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n Afebrile, although WBC trending up 13.9 this a.m ( 10.9 upon\n admission), Tmax 97. Continues to have congested cough expectorating\n white thick sputum. Has been ruled out for flu.\n On NC 2L, spo2 maintaining above 93%. LS rhoncherous. On Levophed\n 0.15 mcg/kg/min,. CVP 8- 10. UO 35-50 cc hr. Had received fluid\n boluses on day of admission. None over 24hrs.\n Action:\n . Continues on Vancomycin and meropenem. Continues on levophed 0.15 for\n a MAP of goal above 65..\n Response:\n UOP improved, maintaining above 35cc/hr. CVP up to 10\n MAP above 65 with current dose of 0.15mcg levophed.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3 , waxes and wanes on and off. Sometimes very appropriate,\n other times trying to pick at EKG cable. WBC trending up 13.9 this a.m\n Action:\n Ongoing assessment\n Response:\n Mental status back to baseline with periods of confusion on and off. .\n Side rails up. Bed locked in low position.\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\n Action:\n Digoxin restarted yesterday.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Heeling stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with echymotic areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small open\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE\n Response:\n No change\n Plan:\n Ongoing assessment. ? vascular to see pt for eval of L&R great toes.\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711437, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue , fell on the floor of the\n bathroom . 911 called. En route--patient with SaO2-70% and with BIPAP\n pressure decreased and CVL placed--2 liter IVF given in Levophed and\n Meropenem started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n" }, { "category": "Nursing", "chartdate": "2170-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711765, "text": "Impaired Skin Integrity\n Assessment:\n Very fragile areas on both arms\n Action:\n Pt. bleeding interm. On right arm.\n Mepiplex replaced on coccyx this pm.\n Both toe areas remain the same. Pt. does c/o slight discomfort when\n Toes covered.\n Response:\n Plan:\n Use paper tape only.\n Shock, septic\n Assessment:\n Cont. not to require Levophed.\n Action:\n Resp: pt. with strong cough. Able to cough and raise.\n Sputum thick yellow-brown.\n Pt. cont. to be rhoncherous. Sats 100% on 4L.\n Gi: improved appetite. Stool x2 guaiac +.\n Renal: u/o\ns 30-50cc/hr. output dropped this pm, but foley noted to be\n kinked.\n Neuro: attitude much improved. Daughter into visit. Attorney to see pt.\n tomorrow.\n Cv: hemodynamically stable today. Far less ect noted. Remains in paced\n rythym.\n Art bp was 112/48 mean of 71 and cuff was 120/54 mean of 64.\n Id: afebrile. Today. Cont. on antibiotics.\n Access: a-line d/c\n Coags: coumadin held this pm.\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2170-12-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711918, "text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -Changed to home dose of Hydrocort\n -Sent sputum cx\n -Fe studies ordered\n -D/c'd A line\n -I/O +500 cc at 2100, but no lasix ordered b/c still maps 55-60.\n -coumadin held for high INR\n ARTERIAL LINE - STOP 12:02 PM\n SPUTUM CULTURE - At 05:02 PM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Doxycycline - 08:00 PM\n Meropenem - 05:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 83 (70 - 88) bpm\n BP: 130/56(71) {102/38(54) - 130/57(71)} mmHg\n RR: 25 (19 - 31) insp/min\n SpO2: 93%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 221 (221 - 230)mmHg\n Total In:\n 1,793 mL\n 250 mL\n PO:\n 870 mL\n 100 mL\n TF:\n IVF:\n 923 mL\n 150 mL\n Blood products:\n Total out:\n 1,075 mL\n 450 mL\n Urine:\n 1,075 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n -200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///22/\n Physical Examination\n Gen: NAD, alert and conversant\n CV: RRR no murmurs\n Pulm: Subtantial rhonchi and expiratory wheezes throughout lung fields\n bilaterally, also with productive wet cough, decreased breath sounds at\n bases L>R\n Abd: +BS soft, NT, ND\n Ext: no edema, chronic hyperpigmentation and venous stasis changes, no\n tenderness, small ulcers tops of b/l 1^st toes\n Labs / Radiology\n 270 K/uL\n 8.1 g/dL\n 96 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 19 mg/dL\n 104 mEq/L\n 132 mEq/L\n 24.8 %\n 9.5 K/uL\n [image002.jpg]\n Hct at baseline\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n 04:35 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n 9.5\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n 24.8\n Plt\n 381\n 414\n 322\n 284\n 270\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n 96\n Other labs: PT / PTT / INR:39.3/65.0/4.1, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.2 mg/dL, Mg++:1.7\n mg/dL, PO4:2.1 mg/dL\n Iron: 16\n calTIBC: 215\n Ferritn: 288\n TRF: 165\n 3:00 pm SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n <10 PMNs and >10 epithelial cells/100X field.\n Gram stain indicates extensive contamination with upper respiratory\n secretions. Bacterial culture results are invalid.\n PLEASE SUBMIT ANOTHER SPECIMEN.\n RESPIRATORY CULTURE (Final ):\n TEST CANCELLED, PATIENT CREDITED.\n and Blood cultures pending\n Urine culture pending\n C Diff negative\n No Chest Xray today\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presented to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n # Hypotension: Felt to most likely have combination hypovolemic, septic\n and cardiogenic shock with low SvO2 two days ago. Sepsis most likely a\n pulmonary source with h/o ESBL PNA. Has been hemodynamically stable\n since admission and weaned off pressors. Has been C Diff negative.\n Got 1 unit PRBC\ns yesterday with good effect and appropriate hct bump.\n Now feel like biggest barrier to improvement is volume overload due to\n low EF and recent aggressive fluid resuscitation.\n - Continue empiric vancomycin and meropenem pending culture results for\n likely pulmonary source, have added doxycycline to try to cover\n Stenotrophomonas (today is day 3 of doxy, day 5 of vanc/)\n - Follow-up blood, urine cultures, and sputum culture\n - Likely has some CHF at this time as is significantly volume up from\n admission, goal -1L negative daily\n - Restart lasix, will give 40mg IV Lasix now and reassess I/O\ns in the\n afternoon\n may benefit from a Lasix drip to diurese\n - restarted home digoxin on \n - will restart home CHF meds later today vs tomorrow including losartan\n and metoprolol\n - daily weights, will need close follow-up with CHF team as an\n outpatient\n - need to check digoxin level as doxy and digoxin can interact\n # Hypoxemic respiratory failure: Likely related to recurrent\n pneumonias.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n # Altered Mental Status: Has improved with IV fluid resuscitation and\n blood pressure improvement.\n - Continue to monitor\n # Acute renal failure: Creatinine has decreased to 1.3 from 2.0 on\n admission. Most liekly improving with better cardiovascular status.\n - Renally dose meds\n # Hyponatremia: Improved to 132 at this time, will monitor\n # COPD: Unknown recent PFTs or overall disease status. Reported to be\n on home supplemental oxygen, though unknown when this was started.\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, currently close to baseline although\n given 1 unit PRBC\ns two days ago with appropriate bump\n - Maintain active type and screen\n - Guaiac positive stools, iron studies likely iron def anemia\n # Adrenal insufficiency: Patient on 10 mg hydrocortisone at home and\n was getting 50mg IV hydrocort x 3 days here for stress of acute\n illness.\n - Now back on home dose\n # H/o PE, on coumadin: INR elevated today so will hold Coumadin dose\n today. Unclear risk vs benefit of Coumadin for this patient\n - Will hold for now given elevated INR\n # Atrial fibrillation: Stable v-paced rhythm on telemetry at this time.\n - On home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension: Holding home antihypertensives\n # Hyperlipidemia: Holding atorvastatin\n # Goals of care: Need to discuss with patient regarding disposition as\n does not want to go to rehab but also likely not going to be able to\n take care of his sister/himself at home after discharge.\n - PT consult today\n ICU Care\n Diet: Regular, cardiac-heart healthy\n Glycemic Control: None\n Lines: Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n will d/c A-line today\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: With patient and daughter\n status: DNR/DNI\n Disposition: can call out today, possibly to as major issue will\n likely be fluid management and may need lasix gtt\n" }, { "category": "Physician ", "chartdate": "2170-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711232, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:30 AM\n ARTERIAL LINE - START 12:00 PM\n -cards interrogated pacer; in a fib, no episodes of VT since ,\n having ectopy now (pacing with pvcs in bigeminal pattern)\n -rec'd fluid boluses, low UOP, received total of 3.5 L IV fluid; CVP\n came up from 2 to 8 and mixed venous sat 78%.\n -loose stool x 2, guaiac neg, sent for c diff\n -pt woke up at midnight, completely lucid (minimally arousable earlier\n in the day)\n -social work consult ordered\n -bubble study ordered because ABGs suggestive of shunt, possibly\n cardiac\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 93 (70 - 114) bpm\n BP: 106/44(57) {101/38(51) - 135/58(71)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 8 (2 - 10)mmHg\n Mixed Venous O2% Sat: 78 - 78\n Total In:\n 4,523 mL\n 379 mL\n PO:\n 100 mL\n 150 mL\n TF:\n IVF:\n 4,423 mL\n 229 mL\n Blood products:\n Total out:\n 665 mL\n 225 mL\n Urine:\n 515 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,858 mL\n 154 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.29/39/125/19/-6\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 414 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 29 mg/dL\n 103 mEq/L\n 132 mEq/L\n 25.0 %\n 11.7 K/uL\n [image002.jpg]\n 11:15 AM\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n WBC\n 10.9\n 11.7\n Hct\n 32\n 143\n 25.1\n 25.0\n Plt\n 381\n 414\n Cr\n 2.0\n 1.7\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 24\n 23\n 20\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:25.8/55.0/2.5, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n B Cx pend\n U Cx pend\n Resp viral screen pend\n C diff and stool Cx pend\n NCHCT prelim: no hemorrhage. no acute intracranial process.\n CXR today:\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presents to hospital with\n syncope, hypoxia, and hypotension.\n # Hypoxemic respiratory failure:\n Patient was not initially complaining of dyspnea while at home. Upon\n transit to the ED was noted to have a low oxygen sat in the 70s and was\n placed on NRB and subsequently was placed on BiPAP in the ED. While in\n the emergency department, oxygen sats recovered and supplemental oxygen\n was titrated down. On the floor was maintaining oxygen sat of 100% on\n RA; however, initial ABG showed a pO2 of 56. 100% facemask was applied\n and sat increased appropriately to 441. A-a gradient difficult to\n calculate given unknown exact oxygen percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n - TTE with bubble study to rule-out intracardiac shunt as cause of his\n odd ABG findings of low pO2 despite observed normal sat\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n .\n # Hypotension:\n Given patient's acute kidney injury (with FeUrea of 26%), complaint of\n thirst, low urine output, and physical exam consistent with\n dehydration, his hypotension could be solely attributed to hypovolemia.\n Additionally supporting hypovolemia as cause of hypotension is fact\n that his blood pressure dropped with positive pressure non-invasive\n ventilation in ED, which would have decreased his right heart filling\n pressures causing transient severe hypotension. In setting of fever to\n 103 in ED, leukocystosis to 12.6, and recent admissions for sepsis,\n must consider that patient septic as cause of his hypotension. Given\n this, it is reasonable to empirically treat with vancomycin and\n meropenem (target toward ESBL Klebsiella identified in prior\n admission). Slightly reassuring that lactate of 1.9 initially trended\n down to 0.9 with initial ABG in MICU. Will consider whether untreated\n stenotrophomonas from sputum sample should be treated. C\n diff is another possible source, as patient with recent antibiotic\n course for PNA and several episodes loose stools.\n - Norepinephrine to keep MAPs > 65\n - Gently hydrate with 500 mL boluses given EF of 15% and history of\n volume overload, as well as DNR/DNI status\n - continue empiric vancomycin and meropenem pending culture results\n - Follow-up blood and urine cultures\n - f/u c diff and stool studies\n .\n # Altered Mental Status: Improved overnight with MAP > 65 following\n several fluid boluses and increased pressors. Most likely related to\n decreased perfusion of the brain, although ICU delirium is also a\n possibility given that pt has been in and out of ICU for past several\n months. Will continue to monitor. NCHCT\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n .\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA\n - Empiric oseltamivir 75 daily for 5 days pending influenza DFA\n .\n # Syncope:\n Patient's enciting event for hospitalization was fall at home today. No\n known head trauma and unclear history of fall at home, though patient\n sank to ground and felt like he may have lost consciousness. Pacer\n interrogation did not show cardiac cause of syncope. Given AMS while\n in ICU in context of hypotension, that is the most likely cause of LOC.\n - Continuous cardiac monitoring\n - Cont to hold digoxin while in \n - Treat hypotension as above\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.7 today.\n - Continue to trend BUN/Cr\n - Renally dose meds and hold digoxin\n - Hold furosemide\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . 132 this AM. Will\n monitor with rehydration.\n - Trend sodium\n # COPD:\n recent PFTs or overall disease status. Reported to be on home\n supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - Trend with rehydration\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increase to 50 mg hydrocortisone given stress of acute illness\n # h/o PE, on coumadin:\n Remote chance that a transient PE could explain current presentation of\n hypoxia and hypotension.\n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time. Digoxin 0.5 on\n admission labs.\n - Hold digoxin while in acute kidney injury\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Nutrition: Regular diet when mentally clear\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2170-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711665, "text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - Spoke with daughter about allergies, she doesn't have any information\n about his possible allergies but says he hasn't had a reaction to\n antibiotics in the last few years that she knows of\n - Fever of 101.5, cultures sent\n - Clarified allergies with PCP: Fever/chills, Augmentin -\n nausea/vomiting, Cephalexin - uncertain (patient and PCP denied /o\n reaction), Bactrim - hives\n - Didn't add Timentin b/c pharmacy didn't have but would cover\n stenotrophomonas - so added doxycycline\n - Gram stain showed mixed flora, but didn't want to do induced sputum\n - Gave 1 unit PRBCs for anemia and for volume repletion\n - Weaned levophed completely\n - Add steroids back in the morning (dc'ed hydrocortisone 50mg IV q24h)\n BLOOD CULTURED - At 12:28 PM\n BLOOD CULTURED - At 12:28 PM\n SPUTUM CULTURE - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n FEVER - 101.5\nF - 12:00 PM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Doxycycline - 08:00 PM\n Meropenem - 05:36 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:36 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 36\nC (96.8\n HR: 104 (70 - 107) bpm\n BP: 106/44(57) {0/0(0) - 0/0(0)} mmHg\n RR: 21 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 9 (5 - 233)mmHg\n Total In:\n 2,950 mL\n 356 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n 1,855 mL\n 256 mL\n Blood products:\n 375 mL\n Total out:\n 2,090 mL\n 530 mL\n Urine:\n 2,090 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 860 mL\n -174 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Gen: NAD\n CV: rrr no murmurs\n Pulm: end expiratory wheezes/squeaks at bases b/l\n Abd: +BS soft ntnd\n Ext: no edema, chronic VSD, small ulcers tops of b/l 1^st toes\n Labs / Radiology\n 284 K/uL\n 8.1 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 134 mEq/L\n 25.2 %\n 11.7 K/uL\n [image002.jpg]\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n Plt\n 381\n 414\n 322\n 284\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n TropT\n 0.02\n TCO2\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n Other labs: PT / PTT / INR:34.8/65.0/3.6, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n 12:33 pm SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n and Blood cultures pending\n Urine culture pending\n C Diff negative\nCXR today in OMR\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presented to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n # Hypotension: Felt to most likely have combination septic and\n cardiogenic shock with low SvO2 two days ago. Sepsis most likely a\n pulmonary source with h/o ESBL PNA. Has been hemodynamically stable\n since admission and weaned off pressors. Has been C Diff negative.\n Got 1 unit PRBC\ns yesterday with good effect and appropriate hct bump.\n - Maintain MAP>60-65, will attempt without pressors\n - Continue empiric vancomycin and meropenem pending culture results,\n have added doxycycline to try to cover Stenotrophomonas\n - Follow-up blood, urine cultures, and sputum culture\n - restarted home digoxin on \n # Hypoxemic respiratory failure: Patient was not initially complaining\n of dyspnea while at home. Upon transit to the ED was noted to have a\n low oxygen sat in the 70s and was placed on NRB and subsequently was\n placed on BiPAP in the ED. While in the emergency department, oxygen\n sats recovered and supplemental oxygen was titrated down. On the floor\n was maintaining oxygen sat of 100% on RA; however, initial ABG showed a\n pO2 of 56. 100% facemask was applied and sat increased appropriately to\n 441. A-a gradient difficult to calculate given unknown exact oxygen\n percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n (is on home oxygen-unclear why, so keep on if needed)\n - continue prn albuterol nebs\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n # Altered Mental Status: Improved overnight after admission with MAP >\n 65 following several fluid boluses and increased pressors. Most likely\n related to decreased perfusion of the brain, although ICU delirium is\n also a possibility given that pt has been in and out of ICU for past\n several months.. NCHCT negative.\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA neg and tamiflu stopped\n .\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.4 today.\n - Continue to trend BUN/Cr\n - Renally dose meds\n - Hold furosemide unless patient becomes acutely dyspneic\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . 129 this am.. Will\n monitor with rehydration.\n # COPD: recent PFTs or overall disease status. Reported to be on\n home supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - blood as above\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increased to 50 mg hydrocortisone given stress of acute illness, will\n decrease to home dose tomorrow as has had 3 days at increased dose.\n # h/o PE, on coumadin: Remote chance that a transient PE could explain\n current presentation of hypoxia and hypotension.\n -continue coumadin with goal INR \n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time.\n - home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: icu for now given pressors\n" }, { "category": "Physician ", "chartdate": "2170-12-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711667, "text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n - Spoke with daughter about allergies, she doesn't have any information\n about his possible allergies but says he hasn't had a reaction to\n antibiotics in the last few years that she knows of\n - Fever of 101.5, cultures sent\n - Clarified allergies with PCP: Fever/chills, Augmentin -\n nausea/vomiting, Cephalexin - uncertain (patient and PCP denied /o\n reaction), Bactrim - hives\n - Didn't add Timentin b/c pharmacy didn't have but would cover\n stenotrophomonas - so added doxycycline\n - Gram stain showed mixed flora, but didn't want to do induced sputum\n - Gave 1 unit PRBCs for anemia and for volume repletion\n - Weaned levophed completely\n - Add steroids back in the morning (dc'ed hydrocortisone 50mg IV q24h)\n BLOOD CULTURED - At 12:28 PM\n BLOOD CULTURED - At 12:28 PM\n SPUTUM CULTURE - At 12:28 PM\n URINE CULTURE - At 12:28 PM\n FEVER - 101.5\nF - 12:00 PM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Doxycycline - 08:00 PM\n Meropenem - 05:36 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 02:36 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 07:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 36\nC (96.8\n HR: 104 (70 - 107) bpm\n BP: 106/44(57) {0/0(0) - 0/0(0)} mmHg\n RR: 21 (17 - 32) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 9 (5 - 233)mmHg\n Total In:\n 2,950 mL\n 356 mL\n PO:\n 720 mL\n 100 mL\n TF:\n IVF:\n 1,855 mL\n 256 mL\n Blood products:\n 375 mL\n Total out:\n 2,090 mL\n 530 mL\n Urine:\n 2,090 mL\n 530 mL\n NG:\n Stool:\n Drains:\n Balance:\n 860 mL\n -174 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n Gen: NAD\n CV: rrr no murmurs\n Pulm: end expiratory wheezes/squeaks at bases b/l\n Abd: +BS soft ntnd\n Ext: no edema, chronic VSD, small ulcers tops of b/l 1^st toes\n Labs / Radiology\n 284 K/uL\n 8.1 g/dL\n 103 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 104 mEq/L\n 134 mEq/L\n 25.2 %\n 11.7 K/uL\n [image002.jpg]\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n Plt\n 381\n 414\n 322\n 284\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n TropT\n 0.02\n TCO2\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n Other labs: PT / PTT / INR:34.8/65.0/3.6, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.0 mg/dL, Mg++:2.0\n mg/dL, PO4:2.4 mg/dL\n 12:33 pm SPUTUM Source: Expectorated.\n GRAM STAIN (Final ):\n >25 PMNs and <10 epithelial cells/100X field.\n 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH\n OROPHARYNGEAL FLORA.\n RESPIRATORY CULTURE (Preliminary):\n and Blood cultures pending\n Urine culture pending\n C Diff negative\nCXR today in OMR\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presented to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n # Hypotension: Felt to most likely have combination septic and\n cardiogenic shock with low SvO2 two days ago. Sepsis most likely a\n pulmonary source with h/o ESBL PNA. Has been hemodynamically stable\n since admission and weaned off pressors. Has been C Diff negative.\n Got 1 unit PRBC\ns yesterday with good effect and appropriate hct bump.\n - Maintain MAP>60-65, will attempt without pressors\n - Continue empiric vancomycin and meropenem pending culture results,\n have added doxycycline to try to cover Stenotrophomonas\n - Follow-up blood, urine cultures, and sputum culture\n - restarted home digoxin on \n # Hypoxemic respiratory failure:\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n (is on home oxygen-unclear why, so keep on if needed)\n - continue prn albuterol nebs\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n # Altered Mental Status: Improved overnight after admission with MAP >\n 65 following several fluid boluses and increased pressors. Most likely\n related to decreased perfusion of the brain, although ICU delirium is\n also a possibility given that pt has been in and out of ICU for past\n several months.. NCHCT negative.\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA neg and tamiflu stopped\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.4 today.\n - Continue to trend BUN/Cr\n - Renally dose meds\n - Hold furosemide unless patient becomes acutely dyspneic\n # Hyponatremia: Improved to 128 from 123 at discharge on . 129\n this am.. Will monitor with rehydration.\n # COPD: recent PFTs or overall disease status. Reported to be on\n home supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - blood as above\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increased to 50 mg hydrocortisone given stress of acute illness, will\n decrease to home dose tomorrow as has had 3 days at increased dose.\n # h/o PE, on coumadin: Remote chance that a transient PE could explain\n current presentation of hypoxia and hypotension.\n -continue coumadin with goal INR \n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time.\n - home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Diet: Regular, cardiac-heart healthy\n Glycemic Control: None\n Lines: Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2170-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711607, "text": "Cardiomyopathy, Other\n Assessment:\n Action:\n Less ect noted this pm\n Map\ns over 70.\n Cont.on dig.\n Coumadin this am. Inr 3.2\n Remains in paced rythym\n Response:\n improving\n Plan:\n Cont. to wean levophed. As tol.\n Altered mental status (not Delirium)\n Assessment:\n Confusion continues\n Action:\n Disorientated this am. Angry at times.\n Confusion improved this afternoon,\n But pt. has just awoken and is again confused.\n Very angry about losing his independence. Swearing at times.\n Wants to football game. Can\nt understand why he can\n Unable to talk him out of it.\n Social: daughter into visit. Son called from .\n Response:\n Plan:\n Co nt. To observe. Will need close observation during the night.\n Shock, septic\n Assessment:\n Cont. to require levophed.\n Action:\n Maps 70\ns throughout the day.\n Triple lumen catheter is slightly kinked at the insertion sight.\n When levo off for short time-map drops to los 60\n Levophed being tapered slowly.\n Hem: hct 23.4. given 1u pc\n Endoc: k+ 3.7\n repleted with 20meq kcl.\n Gi: tol. Diet. Refusing dinner.\n Incont. And using bedpan for several bouts of diarrhea.\n Id: stool sent for c-diff. temp 101,5 ax at noon. Pan cultured. Given\n Tylenol.\n 2hrs later temp 99.6.\n Cont.on antibiotics.\n Renal: adequate u/o\n Neuro: slept in naps throughout the day.\n Access: triple lumen drsg . Cont. to bleed.\n Response:\n Improving slowly\n Plan:\n Cont. to wean levo as tol.\n Tylenol for temp.\n Await culture results\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711920, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted\n Response:\n BP stable\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for \n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Ongoing assessment\n Integrity\n Assessment:\n Healing stage II pressue ulcer R buttocks (1cm 0.3cm). Mepilex sg\n intact. L buttocks with ecchymosed areas. Pt endorses he fell at home &\n hit that particular r area. L & R great toes with small scabbed over\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Waffle boots to LE. OOB to chair\n Response:\n Area surrounding l buttock pressure ulcer no longer reddened. Area\n surrounding L& R great toes scabs much less errythematous.\n Plan:\n Ongoing assessment. Waffle boots to protect L&R great toes when in bed.\n PT consult. OOB to chair.\n" }, { "category": "Nursing", "chartdate": "2170-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711238, "text": "Shock, septic\n Assessment:\n Afebrile, Tmax 97. Occasional moist non productive cough noted. Spo2\n maintaining above 95% on 3LNC. Pt very lethargic at the beginning of\n the shift, oriented x1. Continues on levophed at 0.2mcg/kg/min , MAP\n maintaining around 60\ns. CVP 2-3. Currently receiving 1L fluid ( up at\n 1830 hrs).\n ABG done: 7.29/39/125/-. Mixed venous sat 78.\n LOS + 3.8L as of 00hrs, fluid balance _ve 38cc.\n Action:\n Levophed increased to 0.25mcg/kg/min to achieve a goal of MAP above\n 65. Received 1L fluid this shift for low UOP and low CVP. Continues on\n Vancomycin and meropenem.\n Response:\n UOP improved with fluids., maintaining above 35cc/hr. CVP up to 8.\n MAP above 65 with current dose of 0.25mcg levophed. As night\n progressed, pt\ns mental status improved . Alert, verbal, oriented x3,\n able to talk to ICU Team regarding the events leading to his\n hospitalization yesterday.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics, tamiflu.\n Altered mental status (not Delirium)\n Assessment:\n Pt very lethargic at start of shift, having to shout at pt to open\n eyes. Oriented x1 .\n Action:\n 1L fluid bolus given for low UOP and low CVP.\n Response:\n Mental status improved as night progressed. Pt very awake, oriented\n x3 , talkative and asking for water. Remembers events leading to his\n hospitalization. Side rails up. Bed locked in low position.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\ns. S.K+ done 3.9.\n Action:\n 20mEq KCL given IV .\n Response:\n ongoing\n Plan:\n Continue to monitor. Follow up with labs.\n ~Continues on droplet precautions to r/o flu. Receiving Tamiflu.\n ~Albuterol neb given x1 for ins/exp wheeze with good effect.\n ~x3 episodes of loose BM, one large and small. Guaic negative. Stool\n sent for c/s and Cdiff.\n ~Productive cough this a.m. ( white thick secretions) LS with rhonchi.\n Sputum sent for culture.\n" }, { "category": "Physician ", "chartdate": "2170-11-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711224, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 09:30 AM\n ARTERIAL LINE - START 12:00 PM\n -cards interrogated pacer; in a fib, no episodes of VT since ,\n having ectopy now (pacing with pvcs in bigeminal pattern)\n -rec'd fluid boluses, low UOP, received total of 3.5 L IV fluid; CVP\n came up from 2 to 8 and mixed venous sat 78%.\n -loose stool x 2, guaiac neg, sent for c diff\n -pt woke up at midnight, completely lucid (minimally arousable earlier\n in the day)\n -social work consult ordered\n -bubble study ordered because ABGs suggestive of shunt, possibly\n cardiac\n -NCHCT prelim: no hemorrhage. no acute intracranial process.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 10:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 05:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36\nC (96.8\n HR: 93 (70 - 114) bpm\n BP: 106/44(57) {101/38(51) - 135/58(71)} mmHg\n RR: 17 (15 - 26) insp/min\n SpO2: 100%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 8 (2 - 10)mmHg\n Mixed Venous O2% Sat: 78 - 78\n Total In:\n 4,523 mL\n 379 mL\n PO:\n 100 mL\n 150 mL\n TF:\n IVF:\n 4,423 mL\n 229 mL\n Blood products:\n Total out:\n 665 mL\n 225 mL\n Urine:\n 515 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,858 mL\n 154 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.29/39/125/19/-6\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 414 K/uL\n 8.2 g/dL\n 123 mg/dL\n 1.7 mg/dL\n 19 mEq/L\n 4.3 mEq/L\n 29 mg/dL\n 103 mEq/L\n 132 mEq/L\n 25.0 %\n 11.7 K/uL\n [image002.jpg]\n 11:15 AM\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n WBC\n 10.9\n 11.7\n Hct\n 32\n 143\n 25.1\n 25.0\n Plt\n 381\n 414\n Cr\n 2.0\n 1.7\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 24\n 23\n 20\n Glucose\n 121\n 123\n Other labs: PT / PTT / INR:25.8/55.0/2.5, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.4 mg/dL, Mg++:2.0\n mg/dL, PO4:4.9 mg/dL\n B Cx pend\n U Cx pend\n Resp viral screen pend\n C diff and stool Cx pend\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CARDIOMYOPATHY, OTHER\n HYPERTENSION, BENIGN\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n SHOCK, SEPTIC\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711587, "text": "Cardiomyopathy, Other\n Assessment:\n Cont. with runs of vt\n Action:\n Less ect noted this pm\n Map\ns over 70.\n Cont.on dig.\n Coumadin this am. Inr 3.2\n Remains in paced rythym\n Response:\n improving\n Plan:\n Cont. to wean levophed. As tol.\n Altered mental status (not Delirium)\n Assessment:\n Confusion continues\n Action:\n Disorientated this am. Angry at times.\n Confusion improved this afternoon,\n But pt. has just awoken and is again confused.\n Very angry about losing his independence. Swearing at times.\n Wants to football game. Can\nt understand why he can\n Unable to talk him out of it.\n Social: daughter into visit. Son called from .\n Response:\n Plan:\n Co nt. To observe. Will need close observation during the night.\n Shock, septic\n Assessment:\n Cont. to require levophed.\n Action:\n Maps 70\ns throughout the day.\n Triple lumen catheter is slightly kinked at the insertion sight.\n When levo off for short time-map drops to los 60\n Levophed being tapered slowly.\n Hem: hct 23.4. given 1u pc\n Endoc: k+ 3.7\n repleted with 20meq kcl.\n Gi: tol. Diet. Refusing dinner.\n Incont. And using bedpan for several bouts of diarrhea.\n Id: stool sent for c-diff. temp 101,5 ax at noon. Pan cultured. Given\n Tylenol.\n 2hrs later temp 99.6.\n Cont.on antibiotics.\n Renal: adequate u/o\n Neuro: slept in naps throughout the day.\n Access: triple lumen drsg . Cont. to bleed.\n Response:\n Improving slowly\n Plan:\n Cont. to wean levo as tol.\n Tylenol for temp.\n Await culture results.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711973, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted Continues\n on vanco, meropenem, doxy\n Response:\n BP stable. Good response to lasix but approx equal fld balance with PO\n intake.\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for .\n Will likely need additional lasix this eve. Continue antibiotics\n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Ongoing assessment\n Alteration in Skin integrity\n Assessment:\n Healing stage II pressue ulcer R buttocks (1cm 0.3cm). Mepilex sg\n intact. L buttocks with ecchymosed areas. Pt endorses he fell at home &\n hit that particular r area. L & R great toes with small scabbed over\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Waffle boots to LE. OOB to chair X2 for several hrs.\n Response:\n Area surrounding l buttock pressure ulcer no longer reddened. Area\n surrounding L& R great toes scabs much less errythematous.\n Plan:\n Ongoing assessment. Waffle boots to protect L&R great toes when in bed.\n PT consult. OOB to chair.\n INR 4.1. Coumadin held\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE;COPD EXACERBATION\n Code status:\n Height:\n Admission weight:\n 67.2 kg\n Daily weight:\n 67.2 kg\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Precautions:\n PMH: Anemia, Smoker\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: PE, , MRSA, PNA, EF 15%, hyperlipidemia,\n osteoarthritis, S/P knee surgery, spinal stenosis, S/Pback surgery,\n subclavian artery stenosis causing chronic low left arm BP, rosacea,\n smoking HX, none .36 yrs\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:50\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,090 mL\n 24h total out:\n 1,870 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 04:35 AM\n Potassium:\n 4.3 mEq/L\n 04:35 AM\n Chloride:\n 104 mEq/L\n 04:35 AM\n CO2:\n 22 mEq/L\n 04:35 AM\n BUN:\n 19 mg/dL\n 04:35 AM\n Creatinine:\n 1.3 mg/dL\n 04:35 AM\n Glucose:\n 96 mg/dL\n 04:35 AM\n Hematocrit:\n 24.8 %\n 04:35 AM\n Finger Stick Glucose:\n 149\n 12:00 PM\n Valuables / Signature\n Patient valuables: bag clother, eye glasses, upper & lower dentures,\n cellphone with charger. Rosary beads.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: N/A\n Jewelry:\n Transferred from: 4\n Transferred to: 3\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711160, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--2 liter IVF given in Levophed and Meropenem\n started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n Continues on Levophed at .2 mcg/kg/min. MAP\ns 60-70\n. Oliguric\n throughout shift. No response to NS 500 cc X2. On meropenem, vanco,\n tamiflu . Afeb. No cough\n Action:\n No change in Levophed dose. Receiving third (total) NS 500 cc bolus. On\n droplet precautions for R/O flu. R/O flu. Nasal swab to r/o flu\n obtained\n Response:\n Will assess\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics, tamiflu\n Altered mental status (not Delirium)\n Assessment:\n MS waxing & from awake & oriented (briefly) to having to shout\n at pt to open eyes. Primarily lethargic most of the shift. ABG\n 154/47/7.30/24/-3. BS\n Action:\n Head Ct scan done. Three rails up. Bed locked & low position. Ongoing\n assessment\n Response:\n Remains very lethargic.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n HX AF. HR 70\ns-80\ns V paced with frequent PVC\ns, bigemity\n Action:\n Ongoing assessment. EKG done to confirm rhythm. Cardiology in to\n interrogate pacer\n Response:\n BP stable on levophed\n Plan:\n Ongoing assessment\n" }, { "category": "Nursing", "chartdate": "2170-12-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711640, "text": "Shock, septic\n Assessment:\n Remains afebrile, this shift. Tmax 97. Pan cultured yesterday. WBC\n O2 3LNC , spo2 maintaining above 95%. Occasional moist productive\n cough, bringing out thick white secretions. LS rhoncherous. Continues\n on levophed , was on 0.15mcg/kg/min at start of shift. BP stable with\n MAP above 65. UOP above 30cc/hr.\n No fluid boluses this shift.\n Received 1unit blood for a crit of 23.4\n Action:\n . Continues on Vancomycin , meropenem. ID team in to visit.\n Doxycycline 100mg IV q12hrs started. Levophed dose titrated for a\n goal of MAP above 65.\n Response:\n Levo dose titrated , Bp remains stable. Afebrile this shift. Post\n transfusion crit. 26.8\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate and wean\n Levophed as tolerated to MAP >65. Cont antibiotics. Pan cultured\n yesterday. Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X1, sleeping for most part of the shift, irritable and angry\n upon awakening.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Frequently redirected.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65.\n Action:\n Contnues on digoxin. Magnesium sulfate 2gms repleted this shift.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711792, "text": "Shock, septic\n Assessment:\n Remains afebrile, this shift. Tmax 97. Pan cultured yesterday. WBC\n O2 3LNC , spo2 maintaining above 95%. Occasional moist productive\n cough, bringing out thick white secretions. LS rhoncherous. Continues\n on levophed , was on 0.15mcg/kg/min at start of shift. BP stable with\n MAP above 65. UOP above 30cc/hr.\n No fluid boluses this shift.\n Received 1unit blood for a crit of 23.4\n Action:\n . Continues on Vancomycin , meropenem. ID team in to visit.\n Doxycycline 100mg IV q12hrs started. Levophed dose titrated for a\n goal of MAP above 65.\n Response:\n Levo dose titrated , Bp remains stable. Afebrile this shift. Post\n transfusion crit. 26.8\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate and wean\n Levophed as tolerated to MAP >65. Cont antibiotics. Pan cultured\n yesterday. Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X1, sleeping for most part of the shift, irritable and angry\n upon awakening.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Frequently redirected.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65.\n Action:\n Contnues on digoxin. Magnesium sulfate 2gms repleted this shift.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711794, "text": "Shock, septic\n Assessment:\n Afebrile this shift. Continues on O2 3LNC , spo2 maintaining above\n 95%. Occasional moist productive cough, bringing out thick white\n secretions. LS rhoncherous.\n Off levophed since 6a.m. yesterday. BP stable with MAP above goal of\n 65.\n Received 1unit blood for a crit of 23.4 during the weekened. HCT stable\n since then.\n No bowel movements this shift. UOP adequate above30 cc/hr.\n Action:\n Continues on Vancomycin , meropenem and Doxycycline ( Started as per\n ID rec )\n Response:\n Remains off levophed with stable BP>\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate and wean\n Levophed as tolerated to MAP >65. Cont antibiotics. Pan cultured\n yesterday. Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X1, sleeping for most part of the shift, irritable and angry\n upon awakening.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Frequently redirected.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65.\n Action:\n Contnues on digoxin. Magnesium sulfate 2gms repleted this shift.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Very fragile areas on both arms\n Action:\n Pt. bleeding interm. On right arm.\n Mepiplex replaced on coccyx this pm.\n Both toe areas remain the same. Pt. does c/o slight discomfort when\n Toes covered. turned\n Response:\n Plan:\n Use paper tape only.\n Shock, septic\n Assessment:\n Cont. not to require Levophed.\n Action:\n Resp: pt. with strong cough. Able to cough and raise.\n Sputum thick yellow-brown.\n Pt. cont. to be rhoncherous. Sats 100% on 4L.\n Gi: improved appetite. Stool x2 guaiac +.\n Renal: u/o\ns 30-50cc/hr. output dropped this pm, but foley noted to be\n kinked.\n Neuro: attitude much improved. Daughter into visit. Attorney to see pt.\n tomorrow.\n Cv: hemodynamically stable today. Far less ect noted. Remains in paced\n rythym.\n Art bp was 112/48 mean of 71 and cuff was 120/54 mean of 64.\n Id: afebrile. Today. Cont. on antibiotics.\n Access: a-line d/c\n Coags: coumadin held this pm.\n Endoc: k= repleted.\n Activity: up in chair for 1hr.\n Social: daughter explained that her father has a difficult time talking\n about end of life.\n He may open up to someone like our social worker.\n Response:\n Cont. to improve\n Plan:\n Hold coumadin if inr >3,0. needs palliative care consult. Needs social\n service consult to handle end of life issues.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711875, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted\n Response:\n BP stable\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for \n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n Integrity\n Assessment:\n Healing stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with ecchymosed areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small scabbed\n over areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE. OOB to chair\n Response:\n No change\n Plan:\n Ongoing assessment. Waffle boots to protect L&R great toes when in bed.\n PT consult. OOB to chair.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711966, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted\n Response:\n BP stable\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for \n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Ongoing assessment\n Integrity\n Assessment:\n Healing stage II pressue ulcer R buttocks (1cm 0.3cm). Mepilex sg\n intact. L buttocks with ecchymosed areas. Pt endorses he fell at home &\n hit that particular r area. L & R great toes with small scabbed over\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Waffle boots to LE. OOB to chair\n Response:\n Area surrounding l buttock pressure ulcer no longer reddened. Area\n surrounding L& R great toes scabs much less errythematous.\n Plan:\n Ongoing assessment. Waffle boots to protect L&R great toes when in bed.\n PT consult. OOB to chair.\n INR 4.1. Coumadin held\n Demographics\n Attending MD:\n S.\n Admit diagnosis:\n CONGESTIVE HEART FAILURE;COPD EXACERBATION\n Code status:\n Height:\n Admission weight:\n 67.2 kg\n Daily weight:\n 67.2 kg\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Precautions:\n PMH: Anemia, Smoker\n CV-PMH: Arrhythmias, CHF, Hypertension\n Additional history: PE, , MRSA, PNA, EF 15%, hyperlipidemia,\n osteoarthritis, S/P knee surgery, spinal stenosis, S/Pback surgery,\n subclavian artery stenosis causing chronic low left arm BP, rosacea,\n smoking HX, none .36 yrs\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:117\n D:50\n Temperature:\n 96\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 22 insp/min\n Heart Rate:\n 74 bpm\n Heart rhythm:\n V Paced\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 1,090 mL\n 24h total out:\n 1,870 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 04:35 AM\n Potassium:\n 4.3 mEq/L\n 04:35 AM\n Chloride:\n 104 mEq/L\n 04:35 AM\n CO2:\n 22 mEq/L\n 04:35 AM\n BUN:\n 19 mg/dL\n 04:35 AM\n Creatinine:\n 1.3 mg/dL\n 04:35 AM\n Glucose:\n 96 mg/dL\n 04:35 AM\n Hematocrit:\n 24.8 %\n 04:35 AM\n Finger Stick Glucose:\n 149\n 12:00 PM\n Valuables / Signature\n Patient valuables: bag clother, eye glasses, upper & lower dentures,\n cellphone with charger. Rosary beads.\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: N/A\n Jewelry:\n Transferred from: 4\n Transferred to: 3\n Date & time of Transfer: \n" }, { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711157, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--2 liter IVF given in Levophed and Meropenem\n started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Shock, septic\n Assessment:\n Continues on Levophed at .2 mcg/kg/min. MAP\ns 60-70\n. Oliguric\n throughout shift. No response to NS 500 cc X2. On meropenem, vanco,\n tamiflu . Afeb. No cough\n Action:\n No change in Levophed dose. Receiving third (total) NS 500 cc bolus. On\n droplet precautions for R/O flu. R/O flu. Nasal swab to r/o flu\n obtained\n Response:\n Will assess\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics, tamiflu\n Altered mental status (not Delirium)\n Assessment:\n MS waxing & from awake & oriented (briefly) to having to shout\n at pt to open eyes. Primarily lethargic most of the shift. ABG\n 154/47/7.30/24/-3. BS\n Action:\n Head Ct scan done. Three rails up. Bed locked & low position. Ongoing\n assessment\n Response:\n Remains very lethargic.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n HX AF. HR 70\ns-80\ns V paced with frequent PVC\ns, bigemity\n Action:\n Ongoing assessment. EKG done to confirm rhythm\n Response:\n BP stable on levophed\n Plan:\n Cardiology to interrogate pacer.\n" }, { "category": "Nursing", "chartdate": "2170-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711206, "text": "Shock, septic\n Assessment:\n Afebrile, Tmax 97. Occasional moist non productive cough noted. Spo2\n maintaining above 95% on 3LNC. Pt very lethargic at the beginning of\n the shift, oriented x1. Continues on levophed at 0.2mcg/kg/min , MAP\n maintaining around 60\ns. CVP 2-3. Currently receiving 1L fluid ( up at\n 1830 hrs).\n ABG done: 7.29/39/125/-. Mixed venous sat 78.\n LOS + 3.8L as of 00hrs, fluid balance _ve 38cc.\n Action:\n Levophed increased to 0.25mcg/kg/min to achieve a goal of MAP above 65.\n Received 1L fluid this shift for low UOP and low CVP. Continues on\n Vancomycin and meropenem.\n Response:\n UOP improved with fluids., maintaining above 35cc/hr. CVP up to 8.\n MAP above 65 with current dose of 0.25mcg levophed. As night\n progressed, pt\ns mental status improved . Alert, verbal, oriented x3,\n able to talk to ICU Team regarding the events leading to his\n hospitalization yesterday.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics, tamiflu.\n Altered mental status (not Delirium)\n Assessment:\n Pt very lethargic at start of shift, having to shout at pt to open\n eyes. Oriented x1 .\n Action:\n 1L fluid bolus given for low UOP and low CVP.\n Response:\n Mental status improved as night progressed. Pt very awake, oriented\n x3 , talkative and asking for water. Remembers events leading to his\n hospitalization. Side rails up. Bed locked in low position.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\ns. S.K+ done 3.9.\n Action:\n 20mEq KCL given IV .\n Response:\n ongoing\n Plan:\n Continue to monitor. Follow up with labs.\n ~Continues on droplet precautions to r/o flu. Receiving Tamiflu.\n ~Albuterol neb given x1 for ins/exp wheeze with good effect.\n ~x2 episodes of loose BP, one large and small. Guaic negative. Stool\n sent for c/s and Cdiff.\n" }, { "category": "Nursing", "chartdate": "2170-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711340, "text": "Shock, septic\n Assessment:\n Afebrile, Tmax 97. Congested cough. Productive of white secretions. O2\n sats 93-97% maintaining above 95% on 2LNC. Able to wean Levophed to\n .08 mck/kg/min,. CVP 10. UO 35-50 cc hr. No further fluid boluses\n given.\n Ruled out flu\n Action:\n Able to wean levo to .08 mcg/kg/min to achieve a goal of MAP above 65.\n Continues on Vancomycin and meropenem. Digoxin restared. Tamiflu &\n droplet precautions d/c\n Response:\n UOP improved, maintaining above 35cc/hr. CVP up to 10\n MAP above 65 with current dose of 0.15mcg levophed.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3. Appitite good.\n Action:\n Ongoing assessment\n Response:\n Mental status back to baseline. Side rails up. Bed locked in low\n position.\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\n Action:\n Digoxin restarted\n Response:\n Ongoing assessment. Continnues to have large amount VEA with AF\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Heeling stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with echymotic areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small open\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE\n Response:\n No change\n Plan:\n Ongoing assessment. ? vascular to see pt for eval of L&R great toes.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711795, "text": "Shock, septic\n Assessment:\n Afebrile this shift. Continues on O2 3LNC , spo2 maintaining above\n 95%. Occasional moist productive cough, bringing out thick white\n secretions. LS rhoncherous.\n Off levophed since 6a.m. yesterday. BP stable with MAP above goal of\n 65.\n Received 1unit blood for a crit of 23.4 during the weekened. HCT stable\n since then.\n No bowel movements this shift. UOP adequate above30 cc/hr.\n Action:\n Continues on Vancomycin , meropenem and Doxycycline ( Started as\n per ID rec )\n Response:\n Remains off levophed with stable BP with MAP at goal of 65.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status. Continue antibiotics. Pan\n cultured on for elevated temp . Follow up with culture reports.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3, sleeping for most part of the shift, pleasant and\n compliant with care.\n Action:\n Ongoing assessment. Side rails up. Bed locked in low position.\n Response:\n Ongoing\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with less frequent PVC\ns than yesterday. Paced rhythm. BP\n maintining with MAP above 65. Off levophed since yesterday .\n Action:\n Contnues on digoxin.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n No BM this shift. BS +. Abdomen soft.\n Pt\ns Attorney will be in to visit today.\n Social work consult given.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711876, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted\n Response:\n BP stable\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for \n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Integrity\n Assessment:\n Healing stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with ecchymosed areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small scabbed\n over areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE. OOB to chair\n Response:\n No change\n Plan:\n Ongoing assessment. Waffle boots to protect L&R great toes when in bed.\n PT consult. OOB to chair.\n" }, { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711156, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--2 liter IVF given in Levophed and Meropenem\n started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Shock, septic\n Assessment:\n Continues on Levophed at .2 mcg/kg/min. MAP\ns 60-70\n. Oliguric\n throughout shift. No response to NS 500 cc X2. On meropenem, vanco .\n Afeb\n Action:\n No change in Levophed dose. Receiving third (total) NS 500 cc bolus\n Response:\n Will assess\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics\n Altered mental status (not Delirium)\n Assessment:\n MS waxing & from awake & oriented (briefly) to having to shout\n at pt to open eyes. Primarily lethargic most of the shift. ABG\n 154/47/7.30/24/-3. BS\n Action:\n Head Ct scan done. Three rails up. Bed locked & low position. Ongoing\n assessment\n Response:\n Remains very lethargic.\n Plan:\n Cont to assess MS. . Safety precautions\n Atrial fibrillation (Afib)\n Assessment:\n HX AF. HR 70\ns-80\ns V paced with frequent PVC\ns, bigemity\n Action:\n Ongoing assessment. EKG done to confirm rhythm\n Response:\n BP stable on levophed\n Plan:\n Cardiology to interrogate pacer. ? eti of SX at home\n" }, { "category": "Physician ", "chartdate": "2170-12-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711482, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:35 AM\n - restarted on coumadin\n - off precautions and d/'c tamiflu as flu neg\n - restarted digoxin\n - CV sat at 5pm was 58 (suggesting more cardiogenic shock then septic)\n with good UOP so increased pressors and at 8pm it was 70.\n if goes into arrythmia, may consider change to dobutamine\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Albuterol 0.083% Neb Soln 4. Digoxin 5. Fluticasone-Salmeterol Diskus\n (250/50) 6. Fluticasone Propionate 110mcg\n 7. Hydrocortisone Na Succ. 8. Meropenem 9. Norepinephrine 10. Sodium\n Chloride 0.9% Flush 11. Sodium Chloride 0.9% Flush\n 12. Tiotropium Bromide 13. Vancomycin 14. Warfarin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 86 (75 - 116) bpm\n BP: 106/44(57) {0/0(0) - 0/0(0)} mmHg\n RR: 29 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 7 (7 - 16)mmHg\n Mixed Venous O2% Sat: 70 - 70\n Total In:\n 2,495 mL\n 420 mL\n PO:\n 1,460 mL\n 100 mL\n TF:\n IVF:\n 1,035 mL\n 320 mL\n Blood products:\n Total out:\n 1,045 mL\n 490 mL\n Urine:\n 1,045 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,450 mL\n -70 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/34/73./20/-3\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 322 K/uL\n 7.7 g/dL\n 123 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 102 mEq/L\n 129 mEq/L\n 23.4 %\n 13.9 K/uL\n [image002.jpg]\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n WBC\n 10.9\n 11.7\n 13.9\n Hct\n 32\n 143\n 25.1\n 25.0\n 23.4\n Plt\n 381\n 414\n 322\n Cr\n 2.0\n 1.7\n 1.4\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n Other labs: PT / PTT / INR:32.0/48.6/3.2, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.0 mg/dL\n Imaging: TTE \n Possible very small ASD or stretched PFO. Moderately dilately and\n globally hypokinetic left ventricle. Mildlly dilated RV with borderline\n normal function. Moderate mitral and tricuspid regurgitation. Moderate\n pulmonary hypertension.\n Compared with the prior study (images reviewed) of , overall\n left ventricular systolic function is more vigorous. Estimated\n pulmonary artery pressures are higher. The severity of mitral\n regurgitation has increased and mild aortic stenosis is now present.\n EF30%\n Microbiology: blood 12/3 pending\n urine neg\n cdiff negative\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CARDIOMYOPATHY, OTHER\n HYPERTENSION, BENIGN\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n SHOCK, SEPTIC\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presents to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n .\n # Hypotension: Given patient's acute kidney injury (with FeUrea of\n 26%), complaint of thirst, low urine output, and physical exam\n consistent with dehydration, his hypotension could be solely attributed\n to hypovolemia. In setting of fever to 103 in ED, leukocystosis to\n 12.6, and recent admissions for sepsis, this seems the most likely\n cause of his hypotension. We are currently targeting therapy to prior\n ESBL organism with vanc and meropenem. C diff is another possible\n source, as patient with recent antibiotic course for PNA and several\n episodes loose stools. There is also the concern for a cardiogenic\n component of hypotension, but with preserved central venous O2 sat this\n would seem to be less likely. With his hypotension we will have to\n continue to titrate down pressors and maintain an effective cardiac\n output.\n - Norepinephrine to keep MAPs > 65\n - Gently hydrate with 500 mL boluses given EF of 15% and history of\n volume overload, as well as DNR/DNI status\n - continue empiric vancomycin and meropenem pending culture results\n - Follow-up blood, urine cultures, stool and sputum Cx\n - f/u c diff\n - restart home dose digoxin with the hope of improving cardiac output\n .\n # Hypoxemic respiratory failure:\n Patient was not initially complaining of dyspnea while at home. Upon\n transit to the ED was noted to have a low oxygen sat in the 70s and was\n placed on NRB and subsequently was placed on BiPAP in the ED. While in\n the emergency department, oxygen sats recovered and supplemental oxygen\n was titrated down. On the floor was maintaining oxygen sat of 100% on\n RA; however, initial ABG showed a pO2 of 56. 100% facemask was applied\n and sat increased appropriately to 441. A-a gradient difficult to\n calculate given unknown exact oxygen percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n - TTE with bubble study to rule-out intracardiac shunt as cause of his\n odd ABG findings of low pO2 despite observed normal sat\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n .\n # Altered Mental Status: Improved overnight with MAP > 65 following\n several fluid boluses and increased pressors. Most likely related to\n decreased perfusion of the brain, although ICU delirium is also a\n possibility given that pt has been in and out of ICU for past several\n months. Will continue to monitor. NCHCT negative.\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n .\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA neg and tamiflu stopped\n .\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.7 today.\n - Continue to trend BUN/Cr\n - Renally dose meds\n - Hold furosemide unless patient becomes acutely dyspneic\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . 132 this AM. Will\n monitor with rehydration.\n - Trend sodium\n # COPD:\n recent PFTs or overall disease status. Reported to be on home\n supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - Trend with rehydration\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increase to 50 mg hydrocortisone given stress of acute illness (day 2\n today)\n # h/o PE, on coumadin: Remote chance that a transient PE could explain\n current presentation of hypoxia and hypotension.\n -continue coumadin with goal INR \n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time. Digoxin 0.5 on\n admission labs.\n - Restart digoxin today as above\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2170-12-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711515, "text": "Chief Complaint:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:35 AM\n - restarted on coumadin\n - off precautions and d/'c tamiflu as flu neg\n - restarted digoxin\n - CV sat at 5pm was 58 (suggesting more cardiogenic shock then septic)\n with good UOP so increased pressors and at 8pm it was 70.\n if goes into arrythmia, may consider change to dobutamine\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 06:00 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Albuterol 0.083% Neb Soln 4. Digoxin 5. Fluticasone-Salmeterol Diskus\n (250/50) 6. Fluticasone Propionate 110mcg\n 7. Hydrocortisone Na Succ. 8. Meropenem 9. Norepinephrine 10. Sodium\n Chloride 0.9% Flush 11. Sodium Chloride 0.9% Flush\n 12. Tiotropium Bromide 13. Vancomycin 14. Warfarin\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: no pain, appropriate in conversation, no respiratory\n complaints\n Flowsheet Data as of 07:39 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.8\n Tcurrent: 36.3\nC (97.4\n HR: 86 (75 - 116) bpm\n BP: 106/44(57) {0/0(0) - 0/0(0)} mmHg\n RR: 29 (20 - 30) insp/min\n SpO2: 95%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 7 (7 - 16)mmHg\n Mixed Venous O2% Sat: 70 - 70\n Total In:\n 2,495 mL\n 420 mL\n PO:\n 1,460 mL\n 100 mL\n TF:\n IVF:\n 1,035 mL\n 320 mL\n Blood products:\n Total out:\n 1,045 mL\n 490 mL\n Urine:\n 1,045 mL\n 490 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,450 mL\n -70 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: 7.38/34/73./20/-3\n Physical Examination\n Gen: NAD\n CV: rrr no murmurs\n Pulm: end expiratory wheezes/squeaks at bases b/l\n Abd: +BS soft ntnd\n Ext: no edema, chronic VSD, small ulcers tops of b/l 1^st toes\n Labs / Radiology\n 322 K/uL\n 7.7 g/dL\n 123 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 102 mEq/L\n 129 mEq/L\n 23.4 %\n 13.9 K/uL\n [image002.jpg]\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n WBC\n 10.9\n 11.7\n 13.9\n Hct\n 32\n 143\n 25.1\n 25.0\n 23.4\n Plt\n 381\n 414\n 322\n Cr\n 2.0\n 1.7\n 1.4\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n Other labs: PT / PTT / INR:32.0/48.6/3.2, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.0 mg/dL\n Imaging: TTE \n Possible very small ASD or stretched PFO. Moderately dilately and\n globally hypokinetic left ventricle. Mildlly dilated RV with borderline\n normal function. Moderate mitral and tricuspid regurgitation. Moderate\n pulmonary hypertension.\n Compared with the prior study (images reviewed) of , overall\n left ventricular systolic function is more vigorous. Estimated\n pulmonary artery pressures are higher. The severity of mitral\n regurgitation has increased and mild aortic stenosis is now present.\n EF30%\n Microbiology: blood 12/3 pending\n urine neg\n cdiff negative\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CARDIOMYOPATHY, OTHER\n HYPERTENSION, BENIGN\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n SHOCK, SEPTIC\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presents to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n .\n # Hypotension: Given patient's acute kidney injury (with FeUrea of\n 26%), complaint of thirst, low urine output, and physical exam\n consistent with dehydration, his hypotension could be solely attributed\n to hypovolemia at initial presentation. In setting of fever to 103 in\n ED, leukocystosis to 12.6, and recent admissions for sepsis, this seems\n the most likely cause of his hypotension. We are currently targeting\n therapy to prior ESBL organism with vanc and meropenem. C diff is\n another possible source, as patient with recent antibiotic course for\n PNA and several episodes loose stools. There is also the concern for a\n cardiogenic component of hypotension. With his hypotension we will\n have to continue to titrate down pressors and maintain an effective\n cardiac output.\n - give 1U and then another PRBC if tolerates to increase intravascular\n volume\n - Norepinephrine to keep MAPs > 65: try to wean today\n - continue empiric vancomycin and meropenem pending culture results\n (curbside ID about choices and if has enough coverage)\n - Follow-up blood, urine cultures, stool and sputum Cx\n - f/u c diff\n - restarted home digoxin on \n .\n # Hypoxemic respiratory failure:\n Patient was not initially complaining of dyspnea while at home. Upon\n transit to the ED was noted to have a low oxygen sat in the 70s and was\n placed on NRB and subsequently was placed on BiPAP in the ED. While in\n the emergency department, oxygen sats recovered and supplemental oxygen\n was titrated down. On the floor was maintaining oxygen sat of 100% on\n RA; however, initial ABG showed a pO2 of 56. 100% facemask was applied\n and sat increased appropriately to 441. A-a gradient difficult to\n calculate given unknown exact oxygen percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n (is on home oxygen-unclear why, so keep on if needed)\n - continue prn albuterol nebs\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n .\n # Altered Mental Status: Improved overnight after admission with MAP >\n 65 following several fluid boluses and increased pressors. Most likely\n related to decreased perfusion of the brain, although ICU delirium is\n also a possibility given that pt has been in and out of ICU for past\n several months.. NCHCT negative.\n - Continue rehydration and with prn fluid boluses to maintain UOP > 30\n cc/hr and MAP > 65.\n .\n # Fever: Patient noted to be febrile to 103 rectally in the ED.\n Possible that this is component of sepsis with unknown primary source\n vs influenza. No fevers since that time.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA neg and tamiflu stopped\n .\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%. Cr improved to 1.4 today.\n - Continue to trend BUN/Cr\n - Renally dose meds\n - Hold furosemide unless patient becomes acutely dyspneic\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . 129 this am.. Will\n monitor with rehydration.\n # COPD: recent PFTs or overall disease status. Reported to be on\n home supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - blood as above\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increased to 50 mg hydrocortisone given stress of acute illness, will\n decrease to home dose tomorrow as has had 3 days at increased dose.\n # h/o PE, on coumadin: Remote chance that a transient PE could explain\n current presentation of hypoxia and hypotension.\n -continue coumadin with goal INR \n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time.\n - home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Nutrition: diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition: icu for now given pressors\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711791, "text": "Impaired Skin Integrity\n Assessment:\n Very fragile areas on both arms\n Action:\n Pt. bleeding interm. On right arm.\n Mepiplex replaced on coccyx this pm.\n Both toe areas remain the same. Pt. does c/o slight discomfort when\n Toes covered. turned\n Response:\n Plan:\n Use paper tape only.\n Shock, septic\n Assessment:\n Cont. not to require Levophed.\n Action:\n Resp: pt. with strong cough. Able to cough and raise.\n Sputum thick yellow-brown.\n Pt. cont. to be rhoncherous. Sats 100% on 4L.\n Gi: improved appetite. Stool x2 guaiac +.\n Renal: u/o\ns 30-50cc/hr. output dropped this pm, but foley noted to be\n kinked.\n Neuro: attitude much improved. Daughter into visit. Attorney to see pt.\n tomorrow.\n Cv: hemodynamically stable today. Far less ect noted. Remains in paced\n rythym.\n Art bp was 112/48 mean of 71 and cuff was 120/54 mean of 64.\n Id: afebrile. Today. Cont. on antibiotics.\n Access: a-line d/c\n Coags: coumadin held this pm.\n Endoc: k= repleted.\n Activity: up in chair for 1hr.\n Social: daughter explained that her father has a difficult time talking\n about end of life.\n He may open up to someone like our social worker.\n Response:\n Cont. to improve\n Plan:\n Hold coumadin if inr >3,0. needs palliative care consult. Needs social\n service consult to handle end of life issues.\n" }, { "category": "Nursing", "chartdate": "2170-12-03 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 711874, "text": "75yo M complicated PMH of adrenal insufficiency, severe cardiomyopathy,\n spent in hospital with Klebsiella pneumonia sepsis and CHF.\n H/O PE/afib on coumadin p/w malaise and decreased PO at home, T 103,\n syncope and hypoxemia, hypotension requiring pressors. Negative for\n flu, empiric vanc/. V-paced with afib, frequent bigeminy. Cards\n interrogated his pacer, no complications.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n SBP 120\ns. HR 70\ns V-paced rhythm. Positive fld balance 6 liter LOS.\n BS ronchi. Rare VEA\n Action:\n On digoxin. Lasix 40 mg IVP. Magnesium & potassium repleted\n Response:\n BP stable\n Plan:\n Follow BP, rhythm. Goal negative fld balance 1-2 liters for \n Altered mental status (not Delirium)\n Assessment:\n A&O X3. Spirits good. Interactive\n Action:\n Ongoing assessment\n Response:\n At baseline MS\n :\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2170-11-29 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 711150, "text": "Chief Complaint: Hypoxia and hypotension\n HPI:\n 75 yo M with h/o cardiomyopathy (EF 15%), atrial fibrillation,\n pulmonary embolism (on coumadin), adrenal insufficiency, and s/p\n several recent admissions following episode of Klebsilella pneumonia\n complicated by respiratory failure and septic shock. Presents to\n hospital today after he was found to be hypoxic to the 70s by EMS after\n patient fell in bathroom at home. Patient initially somnolent upon\n presentation to the ICU, though after awakening he reports that he\n notes that he was very tired in the last two days since dischare from\n the hospital, though has no other symptoms. He awoke in the early\n morning to use the bathroom and after getting up from the toilet felt\n very fatigued and fell to the ground. Does not know if he lost\n consciousness, though he feels he did not hit his head. He could not\n get up from the floor on his own and his sister could not assist him.\n An ambulance was then called. He denies chest pain, dyspnea, fever,\n chills, dysuria, or cough at home.\n Of note, he has been hospitalized three times recently ( - ,\n - , - ). According to his son, he refused\n discharge to rehab on and was at home with his sister until this\n morning.\n In the ED, initial VS were: T 103, HR 72, BP 112/80, RR 21, O2Sat 85%\n on 15L. He was placed on BiPAP with improvement in his O2 sats, but his\n SBP dropped to 75-80. He was given 1L of IV fluids and started on\n meropenem given his history of resistant Klebsiella PNA. A central line\n was placed, and he was transferred to the for further care.\n ROS:\n (+)ve: fatigue, syncope, loss of appetite, low urine output, thirst\n (-)ve: fever, chills, night sweats, chest pain, palpitations,\n rhinorrhea, nasal congestion, sore throat, cough, sputum production,\n hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea,\n vomiting, diarrhea, constipation, hematochezia, melena, dysuria,\n urinary frequency, urniary urgency, focal numbness, focal weakness,\n myalgias, arthralgias\n Allergies:\n Bactrim -- hives\n Vancomycin -- reports diarrhea, but tolerated during admission \n Augmentin -- not known\n Keflex -- not known\n IV dye -- not known\n Ambien -- not known\n MEDICATIONS: *per DC summary*\n 1) Ertapenem 1 gram IV daily until .\n 2) Hydrocortisone 10 mg daily\n 3) Digoxin 125 mcg daily\n 4) Warfarin 5 mg daily\n 5) Furosemide 60 mg daily\n 6) Metoprolol Succinate 100 mg daily\n 7) Losartan 25 mg daily\n 8) Atorvastatin 10 mg daily\n 9) Guaifenesin 600 mg prn cough\n 10) Albuterol Sulfate neb prn\n 11) Tiotropium Bromide 18 mcg daily\n 12) Fluticasone-Salmeterol 500-50 \n 13) Docusate Sodium 100 mg \n 14) Senna 8.6 mg prn\n 15) Ascorbic Acid 500 mg \n 16) Multivitamin daily\n 17) Acetaminophen 325 mg Q6H prn\n Past medical history:\n Family history:\n Social History:\n 1) Hypertension\n 2) Hyperlipidemia\n 3) Dilated cardiomyopathy. EF 15% per TEE , s/p 7304\n InSync pacer/ICD placement in \n 4) Atrial fibrillation s/p DCCV x 2 w/ reccurence and ablation \n 5) Chronic Systolic CHF, dry weight 196 lbs\n 6) Adrenal Insufficiency\n 7) h/o pulmonary embolism, on coumadin\n 8) Rectal adenocarcinoma s/p transanal excision \n 9) s/p umbilical hernia repair with mesh\n 10) LLE venous insufficiency? (unclear from records)\n 11) Osteoarthritis s/p knee surgery\n ) Spinal stenosis s/p back surgery\n ) Allergic rhinitis\n 14) s/p nasal surgery\n ) Rosacea\n 16) Actinic keratosis\n 17) h/o psychogenic polydipsia\n 18) h/o SIADH\n 19) Subclavian artery stenosis causing chronic low BPs\n Brother deceased in 70's.\n No family history of early cardiac disease.\n Lives at home and takes care of his sister. Divorced with three adult\n children. Has a history of smoke inhalation while working as a\n firefighter.\n Tobacco: 40 pack year smoking history but quit many years ago\n EtOH: Drinks a few beers a couple nights a week\n Illicits: Denies\n Physical Examination\n VS: T 97.9, HR 85, BP 135/58, RR 17, O2Sat 100% 2L\n GENERAL: Somnolent, minimally interactive, no apparent respiratory\n distress\n HEENT: Normocephalic, atraumatic, oral mucosa extremely dry, PERRL\n NECK: Supple, No , no thyromegaly, no appreciable JVP elevation\n CARDIAC: RR, nl S1, nl S2, II/VI RUSB without appreciable radiation to\n carotids\n LUNGS: CTAB posteriorly with good air movement and without any\n appreciable crackles or wheezes\n ABDOMEN: Thin, BS+, soft, NT, ND\n EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis, posterior tibial\n pulses, hemosiderin stained appearance\n SKIN: No rashes/lesions, ecchymoses, skin is thin and dry with several\n tears apparent\n NEURO: Initially somnolent and slow to answer questions, was oriented x\n 3, later in assessment was more alert and communicative with CN II-XII\n grossly intact, srength in upper and lower extremities bilaterally\n equal, deferred gait assessment\n PSYCH: Mood and affect appropriate\n Labs / Radiology\n COMPLETE BLOOD COUNT\n WBC\n RBC\n Hgb\n Hct\n MCV\n MCH\n MCHC\n RDW\n Plt Ct\n [1] 05:35AM\n 12.6*#\n 3.49*\n 9.3*\n 28.7*\n 82\n 26.6*\n 32.3\n 16.1*\n 449*\n BASIC COAGULATION (PT, PTT, PLT, INR)\n PT\n PTT\n Plt Smr\n Plt Ct\n INR(PT)\n [2] 05:35AM\n 27.2*\n 40.4*\n 2.7*\n CPK ISOENZYMES\n CK-MB\n cTropnT\n [3] 05:35AM\n 5\n 0.04*[1]\n RENAL & GLUCOSE\n Glucose\n UreaN\n Creat\n Na\n K\n Cl\n HCO3\n AnGap\n [4] 05:35AM\n 85\n 34*\n 2.5*#\n 128*\n 4.8\n 89*\n 27\n 17\n CARDIAC/PULMONARY\n Digoxin\n [5] 05:35AM\n 0.5*\n BLOOD GASES\n Type\n Temp\n Rates\n Tidal V\n PEEP\n FiO2\n O2 Flow\n pO2\n pCO2\n pH\n calTCO2\n Base XS\n Intubat\n Comment\n [6] 01:31PM\n ART\n 36.6\n /16\n 441*\n 48*\n 7.28*\n 24\n -4\n NOT INTUBA[1]\n [7] 11:39AM\n ART\n 36.6\n 60*\n 43\n 7.33*\n 24\n -3\n NOT INTUBA[1]\n [8] 11:15AM\n ART\n 36.6\n 56*[3]\n 44\n 7.33*\n 24\n -2\n NOT INTUBA[1]\n CHEST (PORTABLE AP) :\n A bedside upright radiograph of the chest excludes the right\n costophrenic angle from the field-of-view. Moderate cardiomegaly is\n unchanged. Mediastinal and hilar contours are also unchanged. A\n pacer/AICD device is unchanged. The left costophrenic angle appears\n blunt, unchanged from the comparison study. Pulmonary edema seen\n previously is improved. There is no pneumothorax.\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presents to hospital with\n syncope, hypoxia, and hypotension.\n # Hypoxemic respiratory failure:\n Patient was not initially complaining of dyspnea while at home. Upon\n transit to the ED was noted to have a low oxygen sat in the 70s and was\n placed on NRB and subsequently was placed on BiPAP in the ED. While in\n the emergency department, oxygen sats recovered and supplemental oxygen\n was titrated down. On the floor was maintaining oxygen sat of 100% on\n RA; however, initial ABG showed a pO2 of 56. 100% facemask was applied\n and sat increased appropriately to 441. A-a gradient difficult to\n calculate given unknown exact oxygen percent delivery with face mask.\n - Maintain patient on supplemental 3L NC and reassess ABG for\n acceptable pO2 later in day\n - TTE with bubble study to rule-out intracardiac shunt as cause of his\n odd ABG findings of low pO2 despite observed normal sat\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n # Hypotension:\n Given patient's acute kidney injury (with FeUrea of 26%), complaint of\n thirst, low urine output, and physical exam consistent with\n dehydration, his hypotension could be solely attributed to hypovolemia.\n Additionally supporting hypovolemia as cause of hypotension is fact\n that his blood pressure dropped with positive pressure non-invasive\n ventilation in ED, which would have decreased his right heart filling\n pressures causing transient sever hypotension. In setting of fever to\n 103 in ED, leukocystosis to 12.6, and recent admissions for sepsis,\n must consider that patient septic as cause of his hypotension. Given\n this, it is reasonable to empirically treat with vancomycin and\n meropenem (target toward ESBL Klebsiella identified in prior\n admission). Slightly reassuring that lactate of 1.9 initially trended\n down to 0.9 with initial ABG in MICU. Will consider whether untreated\n stenotrophomonas from sputum sample should be treated.\n - Norepinephrine to keep MAPs > 65\n - Gently hydrate with 500 mL boluses given EF of 15% and history of\n volume overload, as well as DNR/DNI status\n - Emiric vancomycin and meropenem pending culture results\n - Follow-up blood and urine cultures\n # Fever:\n Patient noted to be febrile to 103 rectally in the ED. Possible that\n this is component of sepsis with unknown primary source vs influenza.\n - Empiric vancomycin and meropenem (need to readjust meds as renal\n function worsens or improves)\n - Nasopharyngeal swab for influenza DFA\n - Empiric oseltamivir 75 daily for 5 days pending influenza DFA\n - If continues to have altered mental status\n # Syncope:\n Patient's enciting event for hospitalization was fall at home today. No\n known head trauma and unclear history of fall at home, though patient\n sank to ground and felt like he may have lost consciousness.\n - Continuous cardiac monitoring\n - Pacer interrogation\n - Hold digoxin while in \n - Head CT given unclear fall history and systemic anticoagulation\n - Treat hypotension as above\n # Acute kidney injury:\n Recent baseline Cr 1.1 - 1.3 upon discharge on . At\n presentation to the ED was Cr 2.5. Urine lytes performed in ED revealed\n a FeUrea of 26%.\n - Reassess Cr and UOP with hydration\n - Renally dose meds and hold digoxin\n - Hold furosemide\n # Hyponatremia:\n Improved to 128 from 123 at discharge on . Should monitor with\n rehydration.\n - Trend sodium\n # COPD:\n recent PFTs or overall disease status. Reported to be on home\n supplemental oxygen, though unknown when this was started.\n - Investigate indications for home oxygen and history of COPD\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, current Hct 28.7:\n Likely elevated from baseline because of hemoconcentration.\n - Maintain active type and screen\n - Trend with rehydration\n # Adrenal insufficiency:\n Patient on 10 mg hydrocortisone at home.\n - Increase to 50 mg hydrocortisone given stress of acute illness\n # h/o PE, on coumadin:\n Remote chance that a transient PE could explain current presentation of\n hypoxia and hypotension.\n # Atrial fibrillation:\n Stable v-paced rhythm on telemetry at this time. Digoxin 0.5 on\n admission labs.\n - Hold digoxin while in acute kidney injury\n - Hold metoprolol while hypotensive\n # Hypertension:\n - Hold home antihypertensives\n # Hyperlipidemia:\n - Hold atorvastatin\n ICU Care\n Nutrition: NPO while altered mental status\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n -DVT ppx with systemic anticoagulation, INR = 2.7\n -Bowel regimen\n Communication: With patient and children as below\n Duramd, daughter and HCP, cell \n , : home , cell \n Code status: DNR/DNI confirmed with health care proxy\n Disposition: ICU for stabilization\nReferences\n 1. JavaScript:parent.POPUP(self,%22_WEBTAG=_1%22);\n 2. JavaScript:parent.POPUP(self,%22_WEBTAG=_5%22);\n 3. JavaScript:parent.POPUP(self,%22_WEBTAG=_9%22);\n 4. JavaScript:parent.POPUP(self,%22_WEBTAG=_6%22);\n 5. JavaScript:parent.POPUP(self,%22_WEBTAG=_11%22);\n 6. JavaScript:parent.POPUP(self,%22_WEBTAG=_13%22);\n 7. JavaScript:parent.POPUP(self,%22_WEBTAG=_14%22);\n 8. JavaScript:parent.POPUP(self,%22_WEBTAG=_15%22);\n" }, { "category": "Physician ", "chartdate": "2170-12-01 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 711505, "text": "Chief Complaint: hypoxemia, shock, renal failure, arrhythmia, CHF\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 75yo M complicated PMH of adrenal insufficiency, spent in\n hospital with Klebsiella pneumonia sepsis and CHF. H/O PE/afib on\n coumadin p/w malaise and decreased PO at home, T 103, syncope and\n hypoxemia. Norepinephrine. Likely mainly hypovolemic shock with slight\n persistent vasodilatory shock. Negative for flu, empiric vanc/.\n V-paced with afib, frequent bigeminy. Cards interrogated his pacer and\n looks fine.\n Major issue is multifactorial shock: hypovolemic, cardiogenic,\n +/-septic.\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 08:35 AM\n Biventricular hypokinesis, EF ~15%. No bubble study done but possibly\n small PFO/ASD.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Meropenem - 06:00 AM\n Vancomycin - 09:23 AM\n Infusions:\n Norepinephrine - 0.15 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Cough\n Pain: No pain / appears comfortable\n Flowsheet Data as of 11:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.4\nC (99.3\n Tcurrent: 37.4\nC (99.3\n HR: 80 (75 - 116) bpm\n BP: 106/44(57) {0/0(0) - 0/0(0)} mmHg\n RR: 29 (20 - 30) insp/min\n SpO2: 97%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 5 (4 - 16)mmHg\n Mixed Venous O2% Sat: 70 - 70\n Total In:\n 2,495 mL\n 1,034 mL\n PO:\n 1,460 mL\n 370 mL\n TF:\n IVF:\n 1,035 mL\n 664 mL\n Blood products:\n Total out:\n 1,045 mL\n 770 mL\n Urine:\n 1,045 mL\n 770 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,450 mL\n 265 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 97%\n ABG: 7.38/34/73./20/-3\n Physical Examination\n General Appearance: Well nourished, No acute distress, Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: Difficult to hear due to loud lung sounds.\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Wheezes : exp wheezes ,\n Rhonchorous: insp squeek)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: no edema\n Skin: Warm, Rash: chronic venous stasis, chronic toe ulcerations\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, appropriate, Oriented (to): x3, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 7.7 g/dL\n 322 K/uL\n 123 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.7 mEq/L\n 23 mg/dL\n 102 mEq/L\n 129 mEq/L\n 23.4 %\n 13.9 K/uL\n [image002.jpg]\n 11:39 AM\n 01:31 PM\n 03:20 PM\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n WBC\n 10.9\n 11.7\n 13.9\n Hct\n 32\n 143\n 25.1\n 25.0\n 23.4\n Plt\n 381\n 414\n 322\n Cr\n 2.0\n 1.7\n 1.4\n TropT\n 0.02\n TCO2\n 24\n 24\n 24\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n Other labs: PT / PTT / INR:32.0/48.6/3.2, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.7 %, Lymph:10.2 %,\n Mono:4.9 %, Eos:0.1 %, Lactic Acid:0.9 mmol/L, Ca++:7.9 mg/dL, Mg++:2.0\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n Shock\n 1U PRBC/4 hrs.\n Vanc/meropenem empirically for septic shock for ESBL klebsiella and\n stenotrophomonas bacteremia. (Discuss antibiotic choice with ID.)\n Continues on norepinephrine. Restarted dig yesterday.\n Hypoxemia, resp failure. Likely has undiagnosed COPD as well as\n possible cardiac shunt. Supplemental oxygen is close to home dose.\n afib, Vpaced.\n Renal failure improved.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: DNR / DNI\n Disposition :ICU\n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711575, "text": "Cardiomyopathy, Other\n Assessment:\n Cont. with runs of vt\n Action:\n Levophed being tapered.\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, septic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2170-12-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 711860, "text": "Chief Complaint: Septic shock\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 24 Hour Events:\n ARTERIAL LINE - STOP 12:02 PM\n SPUTUM CULTURE - At 05:02 PM\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Meropenem - 05:58 AM\n Doxycycline - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fatigue\n Ear, Nose, Throat: No(t) Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, Edema, No(t)\n Tachycardia, Orthopnea\n Nutritional Support: No(t) NPO\n Respiratory: Cough, Dyspnea, Tachypnea\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Genitourinary: No(t) Dysuria, Foley, No(t) Dialysis\n Musculoskeletal: No(t) Joint pain, No(t) Myalgias\n Integumentary (skin): No(t) Jaundice, No(t) Rash\n Endocrine: No(t) Hyperglycemia, No(t) History of thyroid disease\n Heme / Lymph: No(t) Lymphadenopathy, Anemia, No(t) Coagulopathy\n Neurologic: No(t) Numbness / tingling, No(t) Headache, No(t) Seizure\n Psychiatric / Sleep: No(t) Agitated, No(t) Suicidal, No(t) Delirious,\n No(t) Daytime somnolence\n Allergy / Immunology: No(t) Immunocompromised, No(t) Influenza vaccine\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 35.9\nC (96.7\n HR: 75 (70 - 83) bpm\n BP: 123/62(76) {102/38(54) - 130/62(76)} mmHg\n RR: 26 (19 - 31) insp/min\n SpO2: 99%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 221 (221 - 230)mmHg\n Total In:\n 1,793 mL\n 450 mL\n PO:\n 870 mL\n 200 mL\n TF:\n IVF:\n 923 mL\n 250 mL\n Blood products:\n Total out:\n 1,075 mL\n 570 mL\n Urine:\n 1,075 mL\n 570 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n -120 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 99%\n ABG: ///22/\n Physical Examination\n General Appearance: Well nourished, No(t) No acute distress, No(t)\n Overweight / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)\n Cervical adenopathy\n Cardiovascular: (PMI No(t) Normal, No(t) Hyperdynamic), (S1: Normal),\n (S2: Normal), (Murmur: Systolic), holosyst\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric, No(t) Paradoxical),\n (Percussion: Resonant : , No(t) Hyperresonant: , No(t) Dullness : ),\n (Breath Sounds: Crackles : scattered, No(t) Bronchial: , No(t) Wheezes\n : , No(t) Diminished: , No(t) Absent : , No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Trace, Left lower extremity\n edema: Trace, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: Muscle wasting, No(t) Unable to stand\n Skin: Warm, pressure injury both great toes\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): x3, Movement: Not assessed, No(t) Sedated,\n No(t) Paralyzed, Tone: Not assessed\n Labs / Radiology\n 8.1 g/dL\n 270 K/uL\n 96 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 19 mg/dL\n 104 mEq/L\n 132 mEq/L\n 24.8 %\n 9.5 K/uL\n [image002.jpg]\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n 04:35 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n 9.5\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n 24.8\n Plt\n 381\n 414\n 322\n 284\n 270\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n 96\n Other labs: PT / PTT / INR:39.3/65.0/4.1, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.2 mg/dL, Mg++:1.7\n mg/dL, PO4:2.1 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY\n ATRIAL FIBRILLATION (AFIB)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n CARDIOMYOPATHY, OTHER\n HYPERTENSION, BENIGN\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n SHOCK, SEPTIC\n He is gradually improving. States his breathing is near baseline but\n SOB with min exertion. Still 6L over adm weight. CXR has worsened over\n last several days as his I&O have been positive. We are restarting\n furosemide, with aim of neg 1-2 L today. Will also restart losartan if\n he tolerates lasix. need a furosemide gtt to achieve adequate\n diuresis. Suspect his MR is significant so might tolerate lower BP to\n achieve afterload reduction. Will repeat echo when stable. Needs good\n plan for increased home services prior to discharge.\n ICU Care\n Nutrition:\n Comments: full diet\n Glycemic Control:\n Lines:\n Multi Lumen - 09:30 AM\n 18 Gauge - 04:00 AM\n 20 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: DNR / DNI\n Disposition :Transfer to floor to \n Total time spent: 35 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2170-11-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711314, "text": "Shock, septic\n Assessment:\n Afebrile, Tmax 97. Congested cough. Productive of white secretions. O2\n sats 93-97% maintaining above 95% on 2LNC. Able to wean Levophed to\n .15 mck/kg/min,. CVP 10. UO 35-50 cc hr. No further fluid boluses\n given.\n Ruled out flu\n Action:\n Able to wean levo to .15mcg/kg/min to achieve a goal of MAP above 65.\n Continues on Vancomycin and meropenem. Digoxin restared. Tamiflu &\n droplet precautions d/c\n Response:\n UOP improved, maintaining above 35cc/hr. CVP up to 10\n MAP above 65 with current dose of 0.15mcg levophed.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3. Appitite good.\n Action:\n Ongoing assessment\n Response:\n Mental status back to baseline. Side rails up. Bed locked in low\n position.\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\n Action:\n Digoxin restarted\n Response:\n Ongoing assessment. Continnues to have large amount VEA with AF\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Heeling stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with echymotic areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small open\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE\n Response:\n No change\n Plan:\n Ongoing assessment. ? vascular to see pt for eval of L&R great toes.\n" }, { "category": "Nursing", "chartdate": "2170-11-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711143, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--2 liter IVF given in Levophed and Meropenem\n started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n" }, { "category": "Physician ", "chartdate": "2170-12-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 711845, "text": "TITLE: Resident Progress Note\n Chief Complaint:\n 24 Hour Events:\n -Changed to home dose of Hydrocort\n -Sent sputum cx\n -Fe studies ordered\n -D/c'd A line\n -I/O +500 cc at 2100, but no lasix ordered b/c still maps 55-60.\n -coumadin held for high INR\n -plan for goals of care discussion and palliative care consult on\n monday\n -plan to speak with PCP on monday as well\n ARTERIAL LINE - STOP 12:02 PM\n SPUTUM CULTURE - At 05:02 PM\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Nausea/Vomiting\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 09:23 AM\n Doxycycline - 08:00 PM\n Meropenem - 05:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 08:24 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.2\nC (97.2\n Tcurrent: 36.2\nC (97.2\n HR: 83 (70 - 88) bpm\n BP: 130/56(71) {102/38(54) - 130/57(71)} mmHg\n RR: 25 (19 - 31) insp/min\n SpO2: 93%\n Heart rhythm: V Paced\n Wgt (current): 67.2 kg (admission): 67.2 kg\n CVP: 221 (221 - 230)mmHg\n Total In:\n 1,793 mL\n 250 mL\n PO:\n 870 mL\n 100 mL\n TF:\n IVF:\n 923 mL\n 150 mL\n Blood products:\n Total out:\n 1,075 mL\n 450 mL\n Urine:\n 1,075 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n 718 mL\n -200 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 93%\n ABG: ///22/\n Physical Examination\n Gen: NAD, alert and conversant, daughter at bedside\n CV: no murmurs\n Pulm: Subtantial rhonchi and expiratory wheezes/squeaks throughout lung\n fields bilaterally, also with productive wet cough\n Abd: +BS soft, NT, ND\n Ext: no edema, chronic hyperpigmentation and venous stasis changes, no\n tenderness, small ulcers tops of b/l 1^st toes, has right A-line\n Labs / Radiology\n 270 K/uL\n 8.1 g/dL\n 96 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.3 mEq/L\n 19 mg/dL\n 104 mEq/L\n 132 mEq/L\n 24.8 %\n 9.5 K/uL\n [image002.jpg]\n Hct at baseline\n 05:00 PM\n 05:02 PM\n 06:54 PM\n 10:59 PM\n 03:38 AM\n 05:29 PM\n 03:37 AM\n 09:17 PM\n 04:05 AM\n 04:35 AM\n WBC\n 10.9\n 11.7\n 13.9\n 11.7\n 9.5\n Hct\n 143\n 25.1\n 25.0\n 23.4\n 26.8\n 25.2\n 24.8\n Plt\n 381\n 414\n 322\n 284\n 270\n Cr\n 2.0\n 1.7\n 1.4\n 1.3\n 1.2\n 1.3\n TropT\n 0.02\n TCO2\n 23\n 20\n 21\n Glucose\n 121\n 123\n 123\n 144\n 103\n 96\n Other labs: PT / PTT / INR:39.3/65.0/4.1, CK / CKMB /\n Troponin-T:890/11/0.02, Differential-Neuts:84.3 %, Lymph:10.2 %,\n Mono:5.3 %, Eos:0.2 %, Lactic Acid:0.9 mmol/L, Ca++:8.2 mg/dL, Mg++:1.7\n mg/dL, PO4:2.1 mg/dL\n Iron: 16\n calTIBC: 215\n Ferritn: 288\n TRF: 165\n 3:00 pm SPUTUM Site: EXPECTORATED\n Source: Expectorated.\n **FINAL REPORT **\n GRAM STAIN (Final ):\n <10 PMNs and >10 epithelial cells/100X field.\n Gram stain indicates extensive contamination with upper respiratory\n secretions. Bacterial culture results are invalid.\n PLEASE SUBMIT ANOTHER SPECIMEN.\n RESPIRATORY CULTURE (Final ):\n TEST CANCELLED, PATIENT CREDITED.\n and Blood cultures pending\n Urine culture pending\n C Diff negative\n Assessment and Plan\n 75 yo M with h/o cardiomyopahy (EF 15%), atrial fibrillation, pulmonary\n embolism (on coumadin), adrenal insufficiency, and s/p several recent\n admissions following episode of Klebsilella pneumonia complicated by\n respiratory failure and septic shock. Presented to hospital with\n syncope, hypoxia, hypotension and altered mental status.\n # Hypotension: Felt to most likely have combination septic and\n cardiogenic shock with low SvO2 two days ago. Sepsis most likely a\n pulmonary source with h/o ESBL PNA. Has been hemodynamically stable\n since admission and weaned off pressors. Has been C Diff negative.\n Got 1 unit PRBC\ns yesterday with good effect and appropriate hct bump.\n - Maintain MAP>60-65, will attempt without pressors today\n - Continue empiric vancomycin and meropenem pending culture results for\n likely pulmonary source, have added doxycycline to try to cover\n Stenotrophomonas (today is day 3 of doxy, day 5 of vanc/)\n - Follow-up blood, urine cultures, and sputum culture\n - restarted home digoxin on \n # Hypoxemic respiratory failure: Likely related to recurrent\n pneumonias.\n - Maintain patient on supplemental 3L NC and titrate down as tolerated\n - continue prn albuterol nebs\n - Consider CT chest in future to rule-out possibility of organizing\n pneumonia causing A-a gradient\n # Altered Mental Status: Has improved with IV fluid resuscitation and\n blood pressure improvement.\n - Continue to monitor\n # Acute renal failure: Creatinine has decreased to 1.3 from 2.0 on\n admission. Most liekly improving with better cardiovascular status.\n - Renally dose meds\n # Hyponatremia: Improved to 134 at this time, will monitor\n # COPD: Unknown recent PFTs or overall disease status. Reported to be\n on home supplemental oxygen, though unknown when this was started.\n - Continue home albuterol, tiotropium, fluticasone/salmeterol\n # Anemia with baseline Hct 24, currently close to baseline although\n given 1 unit PRBC\ns yesterday with appropriate bump\n - Maintain active type and screen\n - Guaiac positive stools, will investigate if he has had GI w/u in the\n past\n # Adrenal insufficiency: Patient on 10 mg hydrocortisone at home and\n was getting 50mg IV hydrocort x 3 days here for stress of acute\n illness.\n - Start back on home dose\n # H/o PE, on coumadin: INR elevated today so will hold Coumadin dose\n today. Unclear risk vs benefit of Coumadin for this patient\n - Will confirm goals of care and readdress Coumadin necessity\n # Atrial fibrillation: Stable v-paced rhythm on telemetry at this time.\n - On home digoxin\n - Hold metoprolol while hypotensive\n # Hypertension: Holding home antihypertensives\n # Hyperlipidemia: Holding atorvastatin\n # Goals of care: Will discuss with family today\n - Palliative care consult\n ICU Care\n Diet: Regular, cardiac-heart healthy\n Glycemic Control: None\n Lines: Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n will d/c A-line today\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments: With patient and daughter\n status: DNR/DNI\n Disposition: ICU for now\n" }, { "category": "Nursing", "chartdate": "2170-12-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 711469, "text": "Patient with recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue , fell on the floor of the\n bathroom . 911 called. En route--patient with SaO2-70% and with BIPAP\n pressure decreased and CVL placed--2 liter IVF given in Levophed and\n Meropenem started. Trans to 4 for further care.\n Of note pt allso has HX of subclavian artery stenosis causing chronic\n low left arm BP\n Pt is DNR/DNI\n Shock, septic\n Assessment:\n Afebrile, although WBC trending up 13.9 this a.m ( 10.9 upon\n admission), Tmax 97. Continues to have congested cough expectorating\n white thick sputum. Has been ruled out for flu.\n On NC 2L, spo2 maintaining above 93%. LS rhoncherous. On Levophed\n 0.15 mcg/kg/min,. CVP 8- 10. UO 35-50 cc hr. Had received fluid\n boluses on day of admission. None over 24hrs.\n Action:\n . Continues on Vancomycin and meropenem. Continues on levophed 0.15 for\n a MAP of goal above 65..\n Response:\n UOP improved, maintaining above 35cc/hr. CVP up to 10\n MAP above 65 with current dose of 0.15mcg levophed.\n Plan:\n Follow UO, BUN, creat BS, fld/volume status, Titrate Levophed to MAP\n >65. Cont antibiotics.\n Altered mental status (not Delirium)\n Assessment:\n Pt A&O X3 , waxes and wanes on and off. Sometimes very appropriate,\n other times trying to pick at EKG cable. WBC trending up 13.9 this a.m\n Action:\n Ongoing assessment\n Response:\n Mental status back to baseline with periods of confusion on and off. .\n Side rails up. Bed locked in low position.\n Plan:\n Cont to assess MS. . Safety precautions.\n Atrial fibrillation (Afib)\n Assessment:\n V- Paced with frequent PVC\ns. Was followed up by cardiology\n yesterday.\n Action:\n Digoxin restarted yesterday.\n Response:\n Ongoing assessment.\n Plan:\n Continue to monitor. Follow up with labs.\n Impaired Skin Integrity\n Assessment:\n Heeling stage II pressue ulcer R buttocks (1cm 0.3cm). 3X6 CM area\n surrounding ulcer red, blanchable. Covered with Mepilex. R buttocks\n with echymotic areas, ? Deep tissue injury. Pt endorses he fell at\n home & hit that particular r area. L & R great toes with small open\n areas on tips. (L- 0.8cm X 1 cm, R 0.8 cm X 0.8cm)\n Action:\n R buttocks covered with mepilex. L buttocks open to air. Turned side\n to side. Wqaffle boots to LE\n Response:\n No change\n Plan:\n Ongoing assessment. ? vascular to see pt for eval of L&R great toes.\n" }, { "category": "Physician ", "chartdate": "2170-11-29 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 711133, "text": "Chief Complaint: Respiratory Distress\n Sepsis\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 recent Klebsiella Pneumonia with prolonged hospital course\n complicated by significant CHF and now with D/C on to home.\n At home--patient with increased fatigue and this morning patient to\n bathroom and felt substantial weakness and fell to floor and 911\n called. En route--patient with SaO2-70% and with BIPAP pressure\n decreased and CVL placed--1 liter IVF given in Levophed and Meropenem\n started.\n Patient to ICU for further care-->\n Here-->\n -Patient with increased thirst and decreased urine output\n -No N/V\n -T=103 but BP and HR is stable\n -85% on 15 lpm but rapidly weaned to nasal cannula at 2 liters with\n improved oxygen saturation.\n -Levophed required for hypotension\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n Hives;\n Vancomycin\n Diarrhea;\n Ambien (Oral) (Zolpidem Tartrate)\n Unknown;\n Augmentin (Oral) (Amox Tr/Potassium Clavulanate)\n Unknown;\n Cephalexin\n Unknown;\n IV Dye\n Iodine Containing\n Unknown;\n Last dose of Antibiotics:\n Vancomycin - 12:45 PM\n Meropenem - 02:15 PM\n Infusions:\n Norepinephrine - 0.2 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Cardiomyopathy--EF=15%\n PE\n A-Fib\n Adrenal Insufficiency\n HTN\n Hyperlipidemia\n Rectal Adenocarcinoma\n Arthritis\n PVD--subclavian artery stenosis\n Hyponatremia\n Non-contributory\n Occupation: ret'd\n Drugs: None\n Tobacco: None\n Alcohol: 2 beers 3 nights per week\n Other:\n Review of systems:\n Constitutional: Fatigue, Fever\n Respiratory: Tachypnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: No(t) Dysuria\n Neurologic: No(t) Headache\n Psychiatric / Sleep: No(t) Agitated, Daytime somnolence\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 03:17 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.8\n HR: 85 (70 - 86) bpm\n BP: 106/44(57) {101/38(51) - 135/58(71)} mmHg\n RR: 21 (17 - 23) insp/min\n SpO2: 100%\n Wgt (current): 67.2 kg (admission): 67.2 kg\n Total In:\n 1,585 mL\n PO:\n 100 mL\n TF:\n IVF:\n 1,485 mL\n Blood products:\n Total out:\n 0 mL\n 215 mL\n Urine:\n 65 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 1,370 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.28/48/441//-4\n Physical Examination\n General Appearance: Thin, No(t) Anxious\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Distant), (Murmur: Systolic), \n RUSB--no radiation\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: No(t) Crackles : , No(t) Wheezes : , Diminished: ), No\n obvious respiratory distress\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right lower extremity edema: 2+, Left lower extremity\n edema: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 28.7\n 2.5 (Baseline=1.1)\n 34\n 27\n 89\n 4.8\n 128\n 12.6 (from 6)\n [image002.jpg]\n 11:15 AM\n 11:39 AM\n 01:31 PM\n Hct\n 32\n TC02\n 24\n 24\n 24\n Other labs: CK / CKMB / Troponin-T:312/5/0.04, Lactic Acid:0.9 mmol/L\n (1.8)\n Fluid analysis / Other labs: AG-12\n U/A-no LE\n FeUrea=26%\n 7.33/44/56--RA\n 7.33/43/60\n 7.28/48/441\n CoHgB-1\n Met=0\n Imaging: CXR-No focal infiltrates--Pacer/AICD wires in place--mild\n cephalization of vessels\n Microbiology: Sputum-Stenotrophomonas and Klebsiella in past admission\n Flu-neg \n Cultures-Pending\n Flu Swab-Pending\n Assessment and Plan\n 75 yo male with multi-day history of CHF and recent prolonged hospital\n course for pneumonia now returning with fall following bowel movement\n this morning and found to have high fever, hypotension and hypoxia\n which has been transient.\n 1)Hypoxemic Respiratory Failure--Did have SaO2 of 70% and then initial\n PaO2 of 56 on room air--this did come up with facemask O2 for now. He\n did have a very confusing picture on initial blood gas findings--he had\n modest elevation of PCO2. He has had stabilization of oxygenation\n following admission but retains an A-a gradient. This may well be\n pulmonary inifiltrate or recurrent PE based upon findings in history\n and certainly an interstitial pnumonitis may be driving picture. He\n may have some organizing pneumonitis following prolonged pneumonia.\n -Vanco/Meropenem in place\n -Will check for influenza\n -Follow up with CXR\n -Will have to consider CT for worsening or oxygenation or evolution of\n infiltrate on CXR\n -Will not pursue ECHO given stability and previous findings\n -Will have to wean O2 as possible\n -Will continue to Rx for COPD\n -Maintain systemic anticoagulation\n 2)Shock--likely hypovolemic shock with a complication of infection and\n vasodilatory shock. This has been emphasized by recent poor po intake,\n drop with positive intra-thoracic pressure increase and thirst and\n pre-renal state. With fever to 103 recurrence of acute infection is of\n concern.\n -Will provide IVF by bolus now\n -Will monitor for volume overload\n -Will treat for previous pathogens as defined in past\n -Will provide support with levophed as needed\n 3)Acute Renal Failure--Likely pre-renal failure\n -IVF as above\n -Follow urine output\n -HOld diuretics at this time\n 4)Altered Mental Status-\n - be hypo-perfusion related given LOC and fevers and this may be\n driven in part by heart rhythm disturbance, impaired EF and recent\n infection evolution\n -Head CT-Pending\n -Will interrogate pacer to evaluate for event and rhythm this morning\n with acute event\n -Follow exam as it tracks with blood pressure changes.\n ICU Care\n Nutrition: PO diet when return to full alertness\n Glycemic Control:\n Lines / Intubation:\n Multi Lumen - 09:30 AM\n 18 Gauge - 09:30 AM\n Arterial Line - 12:00 PM\n Comments:\n Prophylaxis:\n DVT: Coumadin in place with systemic anticoagulation\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR / DNI\n Disposition: ICU\n Total time spent: 45 minutes\n" }, { "category": "Echo", "chartdate": "2170-11-30 00:00:00.000", "description": "Report", "row_id": 96121, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 70\nWeight (lb): 170\nBSA (m2): 1.95 m2\nBP (mm Hg): 136/53\nHR (bpm): 74\nStatus: Inpatient\nDate/Time: at 09:06\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Elongated LA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. Normal interatrial septum. Color-flow imaging of\nthe interatrial septum raises the suspicion of an atrial septal defect, but\nthis could not be confirmed on the basis of this study.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV cavity. Moderately\ndepressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT\ngradient.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic\nfunction.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild AS (area\n1.2-1.9cm2). No AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. No MVP. Moderate\nmitral annular calcification. Moderate thickening of mitral valve chordae.\nCalcified tips of papillary muscles. Moderate (2+) MR. [Due to acoustic\nshadowing, the severity of MR may be significantly UNDERestimated.]\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. Moderate\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No PS. Mild\nPR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Frequent ventricular premature beats. Left pleural effusion.\n\nConclusions:\nThe left atrium is elongated. Color-flow imaging of the interatrial septum\nraises the suspicion of an atrial septal defect, but this could not be\nconfirmed on the basis of this study. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is moderately dilated. Overall left\nventricular systolic function is moderately depressed (LVEF= 30 %). Tissue\nDoppler imaging suggests an increased left ventricular filling pressure\n(PCWP>18mmHg). The right ventricular cavity is mildly dilated with borderline\nnormal free wall function. The aortic valve leaflets (3) are mildly thickened\nbut aortic stenosis is not present. There is mild aortic valve stenosis (valve\narea 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets\nare moderately thickened. There is no mitral valve prolapse. There is moderate\nthickening of the mitral valve chordae. Moderate (2+) mitral regurgitation is\nseen. [Due to acoustic shadowing, the severity of mitral regurgitation may be\nsignificantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Possible very small ASD or stretched PFO. Moderately dilately and\nglobally hypokinetic left ventricle. Mildlly dilated RV with borderline normal\nfunction. Moderate mitral and tricuspid regurgitation. Moderate pulmonary\nhypertension.\n\nCompared with the prior study (images reviewed) of , overall left\nventricular systolic function is more vigorous. Estimated pulmonary artery\npressures are higher. The severity of mitral regurgitation has increased and\nmild aortic stenosis is now present.\n\n\n" }, { "category": "ECG", "chartdate": "2170-11-29 00:00:00.000", "description": "Report", "row_id": 259545, "text": "Ventricular paced rhythm. Compared to the previous tracing of there is\nno diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2170-12-04 00:00:00.000", "description": "Report", "row_id": 259543, "text": "Ventricular paced rhythm. Atrial mechanism may be atrial fibrillation. Since\nthe previous tracing of ventricular ectopy is absent.\n\n" }, { "category": "ECG", "chartdate": "2170-11-29 00:00:00.000", "description": "Report", "row_id": 259544, "text": "Ventricular paced rhythm with fused ventricular premature depolarizations\nin a bigeminal type pattern. Compared to the previous tracing of \nventricular ectopy is new.\n\n" }, { "category": "Radiology", "chartdate": "2170-11-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1110547, "text": " 2:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with fall at home today in setting of therapeutic INR. No\n obvious head injury, but has waxing and mental status.\n REASON FOR THIS EXAMINATION:\n Any evidence of bleed?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:09 PM\n no hemorrhage. no acute intracranial process.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 75-year-old man status post fall at home and setting of\n therapeutic INR. No obvious head injury but has waxing and mental\n status. ? bleed\n\n COMPARISON: CT of the head .\n\n TECHNIQUE: Axially acquired images were obtained through the head without\n contrast.\n\n FINDINGS: There is no evidence of hemorrhage, edema, masses or mass effect.\n There is preservation of normal -white matter differentiation.\n Periventricular white matter hypodensities are most likely due to chronic\n small vessel ischemic changes. Hypodensities within the right basal ganglia\n are consistent with old lacunar infarcts, unchanged. There is dense\n calcification of the carotid siphons and vertebral arteries bilaterally. There\n is mild mucosal thickening of the frontal sinuses and ethmoid air cells. The\n mastoid air cells are clear.\n\n IMPRESSION: No acute hemorrhage. No acute intracranial process.\n\n" }, { "category": "Radiology", "chartdate": "2170-11-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110430, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with dyspnea\n REASON FOR THIS EXAMINATION:\n ?pna\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Dyspnea.\n\n COMPARISON: .\n\n A bedside upright radiograph of the chest excludes the right costophrenic\n angle from the field-of-view. Moderate cardiomegaly is unchanged.\n Mediastinal and hilar contours are also unchanged. A pacer/AICD device is\n unchanged. The left costophrenic angle appears blunt, unchanged from the\n comparison study. Pulmonary edema seen previously is improved. There is no\n pneumothorax.\n\n IMPRESSION: Improved pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2170-11-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110628, "text": " 5:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with COPD, hx of recent pna, here with sepsis.\n REASON FOR THIS EXAMINATION:\n please evaluate for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: Chest, portable AP.\n\n REASON FOR EXAM: History of COPD with pneumonia.\n\n FINDINGS: In comparison to the previous chest radiograph, atelectasis in the\n left lower lobe has increased and there could be superimposed consolidation\n depending on the clinical presentation.\n\n Upper lobe predominant interstitial process and perihilar haziness consistent\n with pulmonary edema, are slightly worse than on the previous chest\n radiograph, small bilateral pleural effusions are unchanged. Mild\n cardiomegaly. Mediastinal structures are stable, right internal jugular\n central venous line and permanent pacing wires are unchanged position.\n\n IMPRESSION:\n\n Increasing left retrocardiac atelectasis or consolidation, slight worsening of\n pulmonary edema.\n\n" }, { "category": "Radiology", "chartdate": "2170-11-29 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1110438, "text": " 8:01 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: ? line placement\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with new R IJ\n REASON FOR THIS EXAMINATION:\n ? line placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: New right IJ.\n\n Comparison is made with prior study performed 3 hours earlier.\n\n Right IJ catheter tip is not clearly visualized, is obscured by the pacer\n wires and at least is in the mid SVC. There is no pneumothorax. No other\n interval change from prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110950, "text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiomyopathy, Afib, PE, presented with respiratory\n failure and shock\n REASON FOR THIS EXAMINATION:\n ?interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Cardiomyopathy with respiratory failure.\n\n FINDINGS: In comparison with the study of , there is little change in the\n appearance of the central catheter and pacemaker device. The cardiac\n silhouette persists. Increasing bilateral diffuse pulmonary opacifications,\n which may reflect worsening pulmonary edema superimposed on multiple areas of\n consolidation. The left retrocardiac atelectasis is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2170-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1110811, "text": " 4:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with COPD, hx of recent pna, here with sepsis and continued\n hypotension.\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n Portable AP chest radiograph was compared to \n\n Portable chest radiograph is reviewed.\n\n The right internal jugular line tip is at the level of low SVC. The pacemaker\n leads are in unchanged position. Cardiomediastinal silhouette is unchanged\n including cardiomegaly. The patient has developed worsening opacities\n compared to the prior study that might represent a combination of worsening\n pulmonary edema superimposed on multiple consolidations. Asymmetric pulmonary\n edema is another possibility. Left retrocardiac atelectasis is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2170-12-06 00:00:00.000", "description": "ART EXT (REST ONLY)", "row_id": 1111626, "text": " 12:17 PM\n ART EXT (REST ONLY) Clip # \n Reason: evaluate circulation to feet\n Admitting Diagnosis: CONGESTIVE HEART FAILURE;COPD EXACERBATION\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiomyopathy, bilateral hallux ulcers and weak pulses.\n REASON FOR THIS EXAMINATION:\n evaluate circulation to feet\n ______________________________________________________________________________\n FINAL REPORT\n ARTERIAL DOPPLER LOWER EXTREMITY\n\n REASON: Ulcers.\n\n FINDINGS: Doppler evaluation was performed of both lower extremity arterial\n systems at rest. Due to noncompressible vessels, no ABIs could be calculated.\n Both femoral and popliteal arteries are triphasic, tibial arteries are\n monophasic. Pulse volume recordings show drop off at the ankle and metatarsal\n level.\n\n IMPRESSION: Moderate bilateral tibial artery occlusive disease.\n\n\n" } ]

[ { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367074, "text": "Renal failure, acute (Acute renal failure, ARF)\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": "2131-02-23 00:00:00.000", "description": "Intensivist Note", "row_id": 367281, "text": "SICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff, toxic megacolon\n PMHx:\n PMH: HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 19. Influenza Virus\n Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 2. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1053 20.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 3. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1322 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 4. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2050 22.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 5. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2141 23.\n Meropenem 500 mg IV Q12H Order date: @ 1053\n 6. 1000 mL LR\n Continuous at 150 ml/hr Order date: @ 2324 24. Midazolam 2 mg IV\n ONCE Duration: 1 Doses Order date: @ 1121\n 7. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 25. Midazolam 1-2 mg IV ONCE:PRN agitation Order date: @ 1548\n 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 26.\n Midazolam 0.5-2 mg IV Q2H:PRN Order date: @ 1635\n 9. Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses Order date:\n @ 1319 27. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO\n MAP > 60 Order date: @ 1111\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 2324 28. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Amiodarone 1 mg/min IV INFUSION x6 hours Order date: @ 2359\n 29. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1900\n 12. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 30. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order\n date: @ 1053\n 13. Calcium Gluconate IV Sliding Scale Order date: @ 1053 31.\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1053\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 32. Sodium Bicarbonate 50 mEq IV ONCE MR1 Duration: 1 Doses Order\n date: @ 1319\n 15. Famotidine 20 mg IV Q24H Order date: @ 1053 33. Sodium\n Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date: @ 1704\n 16. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 34. Vancomycin Oral Liquid 250 mg PO Q6H Order date: @ 1053\n 17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date:\n @ 1053 35. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or\n SBP > 95 Order date: @ 1053\n 18. Heparin 5000 UNIT SC TID Order date: @ 1053\n 24 Hour Events:\n OR RECEIVED - At 10:40 AM\n ARTERIAL LINE - START 12:25 PM\n for \n TRANSTHORACIC ECHO - At 01:51 PM\n TRANSTHORACIC ECHO - At 03:01 PM\n EKG - At 11:25 PM\n to OR, vasopressin added, placed, resuscitation, bicarb, albumin,\n amio gtt for RVR\n Post operative day:\n POD#1 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 12:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 05:24 PM\n Midazolam (Versed) - 07:58 PM\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 95 (92 - 170) bpm\n BP: 92/46(59) {71/39(50) - 137/62(88)} mmHg\n RR: 20 (14 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.6 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 14 (9 - 26) mmHg\n Total In:\n 12,767 mL\n 1,146 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,107 mL\n 1,086 mL\n Blood products:\n 500 mL\n Total out:\n 3,135 mL\n 385 mL\n Urine:\n 1,315 mL\n 385 mL\n NG:\n 1,300 mL\n Stool:\n Drains:\n Balance:\n 9,632 mL\n 761 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.32/38/114/18/-5\n Ve: 10 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, dressing c/d/i, ostomy not yet matured,\n somewhat dusky, sweat in bag\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 151 K/uL\n 9.6 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 106 mEq/L\n 133 mEq/L\n 27.2 %\n 10.0 K/uL\n [image002.jpg]\n 11:03 AM\n 12:00 PM\n 01:46 PM\n 04:19 PM\n 04:33 PM\n 09:33 PM\n 09:44 PM\n 11:29 PM\n 02:07 AM\n 02:28 AM\n WBC\n 7.4\n 8.6\n 10.0\n Hct\n 30.7\n 26.5\n 27.2\n Plt\n 136\n 139\n 151\n Creatinine\n 4.1\n 3.8\n 3.8\n Troponin T\n 0.04\n TCO2\n 18\n 14\n 16\n 17\n 20\n 20\n Glucose\n 131\n 114\n 124\n Other labs: PT / PTT / INR:15.9/34.4/1.4, CK / CK-MB / Troponin\n T:274/10/0.04, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.4 g/dL, Ca:7.7 mg/dL,\n Mg:2.4 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: Pain controlled, Wean propofol, titrate to light sedation.\n Cardiovascular: On amio for rate control, currently in NSR. Improved\n HD, but has room for more volume as . Wean vasopressin/levo\n as tolerated.\n Pulmonary: Cont ETT with protocol vent settings. P/F 228,\n ?developing ARDS. Esophageal balloon for closer monitoring.\n Gastrointestinal / Abdomen: Continue NGT to MCWS. NPO/IVF. Ostomy not\n yet matured -> as per primary team.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Lytes & Cr normalizing, but still in ARF ->\n resolving ATN.\n Hematology: Stable at 27.2 Likely hemodilutional. Transfuse 1U PRBC.\n Endocrine: RISS\n Infectious Disease: Check cultures. Continue , Flagyl.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR@150\n Consults: Trauma surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2131-02-23 00:00:00.000", "description": "Intensivist Note", "row_id": 367287, "text": "SICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff, toxic megacolon\n PMHx:\n PMH: HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 2. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1053 20.\n Insulin SC (per Insulin Flowsheet) Sliding Scale Order date: @\n 1053\n 3. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1322 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 4. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2050 22.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 5. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2141 23.\n Meropenem 500 mg IV Q12H Order date: @ 1053\n 6. 1000 mL LR Continuous at 150 ml/hr Order date: @ 2324 24.\n Midazolam 2 mg IV ONCE Duration: 1 Doses Order date: @ 1121\n 9. Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses Order date:\n @ 1319 27. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO\n MAP > 60 Order date: @ 1111\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 2324 28. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Amiodarone 1 mg/min IV INFUSION x6 hours Order date: @ 2359\n 29. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1900\n 12. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 30. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order\n date: @ 1053\n 13. Calcium Gluconate IV Sliding Scale Order date: @ 1053 31.\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1053\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 32. Sodium Bicarbonate 50 mEq IV ONCE MR1 Duration: 1 Doses Order\n date: @ 1319\n 15. Famotidine 20 mg IV Q24H Order date: @ 1053 33. Sodium\n Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date: @ 1704\n 16. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 34. Vancomycin Oral Liquid 250 mg PO Q6H Order date: @ 1053\n 17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date:\n @ 1053 35. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or\n SBP > 95 Order date: @ 1053\n 18. Heparin 5000 UNIT SC TID Order date: @ 1053\n 24 Hour Events:\n OR RECEIVED - At 10:40 AM\n ARTERIAL LINE - START 12:25 PM\n for \n TRANSTHORACIC ECHO - At 01:51 PM\n TRANSTHORACIC ECHO - At 03:01 PM\n EKG - At 11:25 PM\n to OR, vasopressin added, placed, resuscitation, bicarb, albumin,\n amio gtt for RVR\n Post operative day:\n POD#1 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 12:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 05:24 PM\n Midazolam (Versed) - 07:58 PM\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 95 (92 - 170) bpm\n BP: 92/46(59) {71/39(50) - 137/62(88)} mmHg\n RR: 20 (14 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.6 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 14 (9 - 26) mmHg\n Total In:\n 12,767 mL\n 1,146 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,107 mL\n 1,086 mL\n Blood products:\n 500 mL\n Total out:\n 3,135 mL\n 385 mL\n Urine:\n 1,315 mL\n 385 mL\n NG:\n 1,300 mL\n Stool:\n Drains:\n Balance:\n 9,632 mL\n 761 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.32/38/114/18/-5\n Ve: 10 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, dressing c/d/i, ostomy not yet matured,\n somewhat dusky, sweat in bag\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 151 K/uL\n 9.6 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 106 mEq/L\n 133 mEq/L\n 27.2 %\n 10.0 K/uL\n [image002.jpg]\n 11:03 AM\n 12:00 PM\n 01:46 PM\n 04:19 PM\n 04:33 PM\n 09:33 PM\n 09:44 PM\n 11:29 PM\n 02:07 AM\n 02:28 AM\n WBC\n 7.4\n 8.6\n 10.0\n Hct\n 30.7\n 26.5\n 27.2\n Plt\n 136\n 139\n 151\n Creatinine\n 4.1\n 3.8\n 3.8\n Troponin T\n 0.04\n TCO2\n 18\n 14\n 16\n 17\n 20\n 20\n Glucose\n 131\n 114\n 124\n Other labs: PT / PTT / INR:15.9/34.4/1.4, CK / CK-MB / Troponin\n T:274/10/0.04, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.4 g/dL, Ca:7.7 mg/dL,\n Mg:2.4 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: Pain controlled, Wean propofol, titrate to light sedation.\n Cardiovascular: On amio for rate control, currently in NSR. Improved\n HD, but has room for more volume as . Wean vasopressin/levo\n as tolerated.\n Pulmonary: Cont ETT with protocol vent settings. P/F 228,\n ?developing ARDS. Esophageal balloon for closer monitoring.\n Gastrointestinal / Abdomen: Continue NGT to MCWS. NPO/IVF. Ostomy not\n yet matured -> as per primary team.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Lytes & Cr normalizing, but still in ARF ->\n resolving ATN.\n Hematology: Stable at 27.2 Likely hemodilutional. Transfuse 1U PRBC.\n Endocrine: RISS\n Infectious Disease: Check cultures. Continue , Flagyl.\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR@150\n Consults: Trauma surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367371, "text": "73 y.o.m with C.diff colitis, sepsis, resp failure, ARF, toxic\n megacolon, s/p ex lap, total abd colectomy, end ileostomy .\n * Pt experienced SVT with runs of Afib last night, whereupon he was\n immediately started on an Amiodarone gtt. Gtt was d/c\nd at noon time on\n MD orders. Since then pt has been in SR with HR 70-80s.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low systemic BP requiring pressors for BP support. Continuous fluid\n requirement with significant third spacing- + anasarca. Metabolic\n acidosis secondary to ATN. in place for continuous hemodynamic\n monitoring.\n Action:\n Cont to hemodynamics Q1H, receiving LR at 150cc/hr, levophed\n weaned off, vasopressin weaned to 1.2 units/hr. Bedside ECHO performed.\n Response:\n Able to maintain MAP > 60 with levophed weaned off/vasopressin\n titrated, + anasarca. No changes noted from previous ECHO. Metabolic\n acidosis resolving, lactic decreased to 0.9. UOP improving.\n Plan:\n Cont to Q1H hemodynamics, wean pressors as tolerated, administer\n fluid boluses according to hemodynamics.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP remains > 30cc/hr. Creatinine 3.8, BUN 60. Ionized calcium 1.09, +\n anasarca.\n Action:\n Response:\n Plan:\n C Diff Colitis/ s/p total colectomy with end ileostomy\n Assessment:\n Abd firmly distended with midline abd incision s/p total coletomy with\n end ileostomy\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367365, "text": "Sepsis, Severe (with organ dysfunction)\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 Total colectomy w/ end ileostomy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367366, "text": "73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Sepsis, Severe (with organ dysfunction)\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 Total colectomy w/ end ileostomy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367367, "text": "73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n C Diff Colitis/ Total colectomy with end ileostomy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367370, "text": "73 y.o.m with C.diff colitis, sepsis, resp failure, ARF, toxic\n megacolon, s/p ex lap, total abd colectomy, end ileostomy .\n * Pt experienced SVT with runs of Afib last night, whereupon he was\n immediately started on an Amiodarone gtt. Gtt was d/c\nd at noon time on\n MD orders. Since then pt has been in SR with HR 70-80s.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low systemic BP requiring pressors for BP support. Continuous fluid\n requirement with significant third spacing- + anasarca. Metabolic\n acidosis secondary to ATN. in place for continuous hemodynamic\n monitoring.\n Action:\n Cont to hemodynamics Q1H, receiving LR at 150cc/hr, levophed\n weaned off, vasopressin weaned to 1.2 units/hr. Bedside ECHO performed.\n Response:\n Able to maintain MAP > 60 with levophed weaned off/vasopressin\n titrated, + anasarca. No changes noted from previous ECHO. Metabolic\n acidosis resolving, lactic decreased to 0.9. UOP improving.\n Plan:\n Cont to Q1H hemodynamics, wean pressors as tolerated, administer\n fluid boluses according to hemodynamics.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP remains > 30cc/hr. Creatinine 3.8, BUN 60. Ionized calcium 1.09, +\n anasarca.\n Action:\n Response:\n Plan:\n C Diff Colitis/ s/p total colectomy with end ileostomy\n Assessment:\n Abd firmly distended with midline abd incision s/p total coletomy with\n end ileostomy\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367169, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vancomycin. developed\n ARF and was making minimal urine with Cr newly elevated to 3.5. On\n he developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypotensive and tachycardiac with c diff colitis s/p colectomy with\n ileostomy, elevated renal function and vent dependent, extreme acidosis\n with normal lactate\n Action:\n monitoring initiated, vasopressin and norepinephrine started to\n maintain map>60, fluid bolused based on hemodynamics, Nahco3 amps given\n x2\n Response:\n Pt remains on vasopressin and low dosed norepinephrine maintaining maps\n of 60-70, acidosis beginning to resolve\n Plan:\n Continue to monitor hemodynamics, calibrate q8hours, titrate\n vasopressors and fluid as blood pressure tolerates.\n Cdiff colitis\n Assessment:\n Abdomen distended and firm, rising lactate, bladder pressures mid\n teens, +cdiff\n Action:\n Pt to or for colectomy and ileostomy, stoma not yet matured\n Response:\n Abdomen remains distended but less firm, lactate trending down\n Plan:\n Continue abdominal assessments, monitor stoma and output via OGT, will\n mature stoma at bedside in next 1-2 days per surgical team\n Impaired Skin Integrity\n Assessment:\n Coccyx/buttocks reddened and blanchable on admission\n Action:\n Pt turned side to side q2hours in swimmers position and barrier cream\n applied\n Response:\n Area remains red and blanchable\n Plan:\n Continue frequent repositioning and swimmers position\n" }, { "category": "Respiratory ", "chartdate": "2131-02-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367414, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 4\n Ideal body weight: 69.9\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Yes\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 6 mL / Air\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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 550x20/+15 peep/.5\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 Dysynchrony assessment: none noted\n Plan\n Next 24-48 hours: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures: RSBI held d/t peep level; MDI\ns as\n ordered\n" }, { "category": "Respiratory ", "chartdate": "2131-02-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367150, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\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:\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: Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains intubated and on mechanical ventilation, breath sounds\n bilaterally diminished, suctioned intermittently for very small amounts\n of thick tan secretions, got hypotensive at some point and desaturated,\n PEEP increased from 5 to 10, FiO2 from 50 to 70%, now weaned back to\n 50% but maintained PEEP, ABGs went from combined acidosis to acute\n metabolic acidosis but pH has improved since this morning, patient went\n to OR this morning where he has Ileostomy done, will continues to be\n followed.\n" }, { "category": "Physician ", "chartdate": "2131-02-22 00:00:00.000", "description": "Intensivist Note", "row_id": 367064, "text": "TSICU\n HPI:\n 73M weakness and lower abdominal pain. By report CT scan showed\n evidence of colitis. Stool was positive for C Diff. WBC was 44,000.\n He was admitted, hydrated, and started on PO vanco. Last night\n developed ARF and was making minimal urine with Cr newly elevated to\n 3.5. Then today he developed significant abdominal distension and\n SOB. Over a short periord this afternoon he quickly decompensated\n becoming hypotensive with respiratory distress. He was transfered to\n the ICU, intubated, had a central line placed, started on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here.\n Chief complaint:\n PMHx:\n HTN perforated Diverticulitis c/b sepsis, respiratory\n failure, ARF, A Fib transferred from OSH to Dr.\n care after initial colectomy/. s/p colectomy/Hartmann for\n perforated diverticulitis at an OSH c/b intra-abdominal abscess\n treated by IR drain s/p colostomy takedown/ reversal \n () ?recurrent diverticulitis SBO - managed\n non-operatively ex-lap, small bowel resection and lysis of adhesions.\n () for recurrent SBO caused by an inflammatory mass s/p\n left inguinal hernia repair Prostate Ca\n COPD h/o CVA\n Current medications:\n 1. IV access: Peripheral line Order date: @ 1846 15. Magnesium\n Sulfate IV Sliding Scale Order date: @ 2327\n 2. 1000 mL NS\n Continuous at 100 ml/hr Order date: @ 2255 16. MetRONIDAZOLE\n (FLagyl) 500 mg IV Q8H Order date: @ 2145\n 3. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0107 17.\n Meropenem 1000 mg IV ONCE Duration: 1 Doses Order date: @ 2202\n 4. 500 mL NS Bolus 500 ml Over 30 mins Order date: @ 0333 18.\n Meropenem 500 mg IV Q12H *Awaiting ID Approval* Order date: @\n 2202\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 2254\n 19. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP > 60\n Order date: @ 2254\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 2254 20.\n Potassium Chloride IV Sliding Scale Order date: @ 2327\n 7. Calcium Gluconate IV Sliding Scale Order date: @ 2327 21.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 2254\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 2324 22. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 2323\n 9. Famotidine 20 mg IV Q24H Order date: @ 2254 23. Sodium\n Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1846\n 10. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 2254\n 24. Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: @\n 2145\n 11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date:\n @ 2254 25. Vancomycin 1000 mg IV X1 Duration: 1 Doses Order date:\n @ 2145\n 12. Heparin 5000 UNIT SC TID Order date: @ 2254 26. Vancomycin\n Oral Liquid 250 mg PO Q6H *Awaiting ID Approval* Order date: @\n 2202\n 13. Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844 27. Vancomycin Oral Liquid 250 mg PO ONCE Duration: 1\n Doses Start: Order date: @ 2232\n 14. Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2327\n 24 Hour Events:\n MULTI LUMEN - START 07:59 PM\n from osh\n INVASIVE VENTILATION - START 08:15 PM\n ARTERIAL LINE - START 08:32 PM\n MULTI LUMEN - START 08:45 PM\n EKG - At 09:00 PM\n BLOOD CULTURED - At 11:00 PM\n BLOOD CULTURED - At 11:23 PM\n MULTI LUMEN - STOP 12:02 AM\n from osh\n TRANSTHORACIC ECHO - At 02:52 AM\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 10:30 PM\n Metronidazole - 02:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:10 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: 105 (92 - 117) bpm\n BP: 99/45(61) {87/42(16) - 123/54(71)} mmHg\n RR: 16 (14 - 19) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.8 kg (admission): 78 kg\n CVP: 11 (0 - 13) mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 4,831 mL\n 1,920 mL\n PO:\n Tube feeding:\n IV Fluid:\n 801 mL\n 1,920 mL\n Blood products:\n Total out:\n 430 mL\n 755 mL\n Urine:\n 130 mL\n 155 mL\n NG:\n 300 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n 4,401 mL\n 1,165 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 10 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.29/37/113/18/-7\n Ve: 9.9 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: tense\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 180 K/uL\n 13.3 g/dL\n 119 mg/dL\n 4.5 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 70 mg/dL\n 100 mEq/L\n 131 mEq/L\n 39.2 %\n 10.8 K/uL\n [image002.jpg]\n 08:19 PM\n 08:39 PM\n 02:03 AM\n 02:18 AM\n WBC\n 10.1\n 10.8\n Hct\n 42.9\n 39.2\n Plt\n 161\n 180\n Creatinine\n 4.8\n 4.5\n Troponin T\n 0.02\n TCO2\n 20\n 19\n Glucose\n 128\n 119\n Other labs: PT / PTT / INR:14.6/29.4/1.3, CK / CK-MB / Troponin\n T:645/32/0.02, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, Ca:7.2 mg/dL,\n Mg:3.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M weakness and lower abdominal pain.\n Neurologic: Neuro checks Q: 4 stable, propfol on sedation\n Pain: Fentanyl\n Cardiovascular: On levophed, for fluid resistant hypotension\n Pulmonary: VDRF, intubated, on Q var, albuterol. No signs of\n consolidation\n Gastrointestinal / Abdomen: Distended loops of bowl, secondary to c\n diff colitis, to the O.R today for ex lap\n Nutrition: NPO\n Renal: Marginal Urine output, resolving ARF\n Hematology: stable anemia\n Endocrine: RISS\n Infectious Disease: meropenem, vancomycin, flagyl,\n Lines / Tubes / Drains: L TLC, A line, PIV ETT, Foley\n Wounds: None\n Imaging: CT Abdomen, CXR\n Fluids: NS @ 100\n Consults: Trauma\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\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: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2131-02-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367059, "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: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\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 Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Erratic exhaled Tidal Volumes\n Plan\n Next 24-48 hours:\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 CT\n 12AM\n Transported to CT and back to unit w/o difficulty.\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367154, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypotensive and tachycardiac with c diff colitis s/p colectomy with\n ileostomy, elevated renal function and vent dependent\n Action:\n monitoring initiated, vasopressin and norepinephrine started to\n maintain map>60, fluid bolused based on hemodynamics\n Response:\n Pt remains on vasopressin and low dosed norepinephrine maintaining maps\n of 60-70\n Plan:\n Continue to monitor hemodynamics, calibrate q8hours, titrate\n vasopressors and fluid as blood pressure tolerates.\n Cdiff colitis\n Assessment:\n Abdomen distended and firm, rising lactate\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367155, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypotensive and tachycardiac with c diff colitis s/p colectomy with\n ileostomy, elevated renal function and vent dependent\n Action:\n monitoring initiated, vasopressin and norepinephrine started to\n maintain map>60, fluid bolused based on hemodynamics\n Response:\n Pt remains on vasopressin and low dosed norepinephrine maintaining maps\n of 60-70\n Plan:\n Continue to monitor hemodynamics, calibrate q8hours, titrate\n vasopressors and fluid as blood pressure tolerates.\n Cdiff colitis\n Assessment:\n Abdomen distended and firm, rising lactate, bladder pressures mid\n teens, +cdiff\n Action:\n Pt to or for colectomy and ileostomy\n Response:\n Abdomen remains distended but less firm, lactate trending down\n Plan:\n Continue abdominal assessments, monitor stoma and output via OGT\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367236, "text": "73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Supraventricular tachycardia (SVT)\n Assessment:\n Sinus rhythm rate 100-120 with occasional apcs, bp on vasopressin and\n levophed maintained with map 60. Had SVT with rate to 170\ns with small\n drop in bp\n Action:\n Amio bolus of 150 mg given, followed later by amio gtt per protocol.\n Lytes sent, enzymes cycled, ekg completed.\n Response:\n Currently in nsr with rate in the 80\ns and occasional pacs. Continues\n on vasopressin and levophed\n Plan:\n Decrease amio to 0.5mg/min after 6 hours, follow rate and rhythm\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Continues to show multiorgan disfunction with low systemic blood\n pressure, third spacing of fluid and vasopressor requirement. Metabolic\n acidosis, anasarca. in place for hemodynamic measurements,\n intubated. Cvp12-14\n Action:\n Q 1 hour hemodynamic measurements, fluid boluses and administration,\n renal function monitoring, antibiotic administration\n Response:\n Continues to require vasopressin and levophed to maintain map but has\n adequate urine output and cr has decreased to 3.8. Metabolic acidosis\n has improved slightly. Lactate level 1.0\n Plan:\n Continue to maintain map, administer antibiotics, follow hemodynamics.\n C diff colitis\n Assessment:\n s/p total colectomy with end ileostomy yesterday. Ileostomy red with\n minimal bloody drainage. On contact precautions. Absent bowel sounds,\n distended firm abdomen but less than yesterday\n Action:\n Vanco per og, iv flagyl and iv meropenum given. Fluid rescitation,\n careful abdominal assessments completed\n Response:\n No return of bowel function s/p total colectomy with end ileostomy, wbc\n 10.0, low grade fever of 100.4\n Plan:\n Continue antibiotics, frequent assessments\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Cr 4.3, BUN 60\ns, lytes wnl after calcium repletion, +12L yesterday\n with 5.5 kg weight gain. ++anasarca, urine output 50-100cc/hr, CVP\n 12-14\n Action:\n Pressors titrated to keep map >60, meds dosed for current renal\n function, q 1 hour urine outputs and hemodynamic measurements.\n Receiving fluids at 150cc/hr plus two boluses of 500cc LR each\n Response:\n Cr down to 3.8 this am, BUN remains elevated in 60\ns, urine output\n 30-125cc/hr\n Plan:\n Continue to closely monitor fluid status and renal function.\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367156, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Pt hypotensive and tachycardiac with c diff colitis s/p colectomy with\n ileostomy, elevated renal function and vent dependent\n Action:\n monitoring initiated, vasopressin and norepinephrine started to\n maintain map>60, fluid bolused based on hemodynamics\n Response:\n Pt remains on vasopressin and low dosed norepinephrine maintaining maps\n of 60-70\n Plan:\n Continue to monitor hemodynamics, calibrate q8hours, titrate\n vasopressors and fluid as blood pressure tolerates.\n Cdiff colitis\n Assessment:\n Abdomen distended and firm, rising lactate, bladder pressures mid\n teens, +cdiff\n Action:\n Pt to or for colectomy and ileostomy\n Response:\n Abdomen remains distended but less firm, lactate trending down\n Plan:\n Continue abdominal assessments, monitor stoma and output via OGT\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367137, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Cdiff colitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367139, "text": "73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n *********PT TO OR TODAY FOR EX LAP WITH COLECTOMY AND ILEOSTOMY****\n Sepsis, Severe (with organ dysfunction)\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 Cdiff colitis\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2131-02-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367216, "text": "Demographics\n Day of intubation: 3\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\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 / 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:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Physician ", "chartdate": "2131-02-24 00:00:00.000", "description": "Intensivist Note", "row_id": 367461, "text": "TSICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n abdominal pain\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n Flagyl 500 mg IV Q8H, Meropenem 500 mg IV Q12H, Albuterol-Ipratropium\n PUFF IH Q6H:PRN, Albuterol Inhaler 2 PUFF IH Q4H:PRN,\n Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Calcium Gluconate IV\n Sliding Scale, Pantoprazole 40 mg IV Q24H, Potassium Chloride IV\n Sliding Scale, Magnesium sulfate sliding scale, Fentanyl Citrate 25-100\n mcg IV Q2H:PRN, Propofol 5-20 mcg/kg/min, Heparin 5000 UNIT SC TID,\n Qvar *NF* 80 mcg/Actuation Inhalation , Insulin SC Vasopressin 2.4\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 09:56 AM\n placed per ARDS net protocol- to optimize peep\n TRANSTHORACIC ECHO - At 03:18 PM\n bedside echo performed by fellow Dr. & Dr. \n \n : Off levophed, titrating down vasopressin. Bladder pressures\n range 14-20.\n Post operative day:\n POD#2 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 12:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:42 AM\n Fentanyl - 08:15 PM\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:30 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 (98.8\n HR: 88 (74 - 93) bpm\n BP: 116/50(67) {102/49(64) - 142/62(85)} mmHg\n RR: 10 (10 - 20) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.6 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 11 (10 - 19) mmHg\n Bladder pressure: 20 (16 - 20) mmHg\n Total In:\n 5,557 mL\n 1,182 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,087 mL\n 1,182 mL\n Blood products:\n 350 mL\n Total out:\n 1,730 mL\n 590 mL\n Urine:\n 1,700 mL\n 390 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,827 mL\n 592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 32 cmH2O\n Plateau: 21 cmH2O\n Compliance: 91.7 cmH2O/mL\n SPO2: 97%\n ABG: 7.39/34/142/20/-3\n Ve: 11.6 L/min\n PaO2 / FiO2: 284\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: transmitted upper airway sounds bilaterally. ET\n tube in place\n Abdominal: Soft, mildly distended, tender to palpation, colostomy tube\n in place\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Sedated\n Labs / Radiology\n 141 K/uL\n 9.6 g/dL\n 104 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 106 mEq/L\n 136 mEq/L\n 26.9 %\n 11.2 K/uL\n [image002.jpg]\n 11:29 PM\n 02:07 AM\n 02:28 AM\n 08:03 AM\n 10:50 AM\n 02:36 PM\n 05:21 PM\n 05:29 PM\n 01:59 AM\n 05:30 AM\n WBC\n 10.0\n 11.3\n 11.2\n Hct\n 27.2\n 29.0\n 26.9\n Plt\n 151\n 157\n 141\n Creatinine\n 3.8\n 3.8\n 3.2\n 2.9\n Troponin T\n 0.04\n 0.03\n 0.03\n TCO2\n 20\n 19\n 22\n 21\n Glucose\n 114\n 124\n 108\n 104\n Other labs: PT / PTT / INR:15.5/33.7/1.4, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, Ca:8.1 mg/dL,\n Mg:2.5 mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ),\n SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED SKIN INTEGRITY, SEPSIS,\n SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n NEURO: wean propofol to off today, fentanyl. Following commands,\n comfortable.\n CVS: off levophed + vasopressin + amiodarone. Shock resolved. KVO\n fluids. Bolus as needed.\n PULM: by P/F. Esophageal balloon placed and PEEP increased to 15.\n decr PEEP to 10.\n GI: NPO/IVF. Ileostomy site to be matured. Bladder pressure most\n recently 20, but no change in exam, continue to monitor.\n RENAL: ARF on CRI (baseline 2.1). Currently Cr: 2.9, improved from\n yesterday. Metabolic acidosis resolved.\n HEME: stable on anemia. Transfused yesterday 1unit prbc. continue to\n monitor.\n ENDO: RISS\n ID: leukocytosis improved on vanc//Flagyl, f/u cx. f/u vanco level.\n TLD: L TLC, Aline, PIV, ETT, Foley, axillary fem line monitor\n FLUIDS: kvo\n CONSULTS: general/trauma surgery\n BILLING DIAGNOSIS: resp failure\n ICU CARE:\n GLYCEMIC CONTROL:\n PROPHYLAXIS: SQH, boots, famotidine, VAP bundle\n COMMUNICATIONS:\n ICU Consent: in chart\n CODE STATUS: FULL\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 AM\n Prophylaxis:\n DVT:\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": "Physician ", "chartdate": "2131-02-23 00:00:00.000", "description": "Intensivist Note", "row_id": 367215, "text": "SICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff, toxic megacolon\n PMHx:\n PMH: HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 19. Influenza Virus\n Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 2. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1053 20.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 3. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 1322 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 4. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2050 22.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 5. 1000 mL LR Bolus 500 ml Over 30 mins Order date: @ 2141 23.\n Meropenem 500 mg IV Q12H Order date: @ 1053\n 6. 1000 mL LR\n Continuous at 150 ml/hr Order date: @ 2324 24. Midazolam 2 mg IV\n ONCE Duration: 1 Doses Order date: @ 1121\n 7. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 25. Midazolam 1-2 mg IV ONCE:PRN agitation Order date: @ 1548\n 8. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 26.\n Midazolam 0.5-2 mg IV Q2H:PRN Order date: @ 1635\n 9. Albumin 5% (25g / 500mL) 25 g IV ONCE Duration: 1 Doses Order date:\n @ 1319 27. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO\n MAP > 60 Order date: @ 1111\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 2324 28. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Amiodarone 1 mg/min IV INFUSION x6 hours Order date: @ 2359\n 29. Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date:\n @ 1900\n 12. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 30. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order\n date: @ 1053\n 13. Calcium Gluconate IV Sliding Scale Order date: @ 1053 31.\n Sodium Chloride 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1053\n 14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 32. Sodium Bicarbonate 50 mEq IV ONCE MR1 Duration: 1 Doses Order\n date: @ 1319\n 15. Famotidine 20 mg IV Q24H Order date: @ 1053 33. Sodium\n Bicarbonate 50 mEq IV ONCE Duration: 1 Doses Order date: @ 1704\n 16. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 34. Vancomycin Oral Liquid 250 mg PO Q6H Order date: @ 1053\n 17. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date:\n @ 1053 35. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or\n SBP > 95 Order date: @ 1053\n 18. Heparin 5000 UNIT SC TID Order date: @ 1053\n 24 Hour Events:\n OR RECEIVED - At 10:40 AM\n ARTERIAL LINE - START 12:25 PM\n for \n TRANSTHORACIC ECHO - At 01:51 PM\n TRANSTHORACIC ECHO - At 03:01 PM\n EKG - At 11:25 PM\n to OR, vasopressin added, placed, resuscitation, bicarb, albumin,\n amio gtt for RVR\n Post operative day:\n POD#1 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 12:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Vasopressin - 2.4 units/hour\n Norepinephrine - 0.14 mcg/Kg/min\n Propofol - 20 mcg/Kg/min\n Amiodarone - 1 mg/min\n Other ICU medications:\n Sodium Bicarbonate 8.4% (Amp) - 05:24 PM\n Midazolam (Versed) - 07:58 PM\n Famotidine (Pepcid) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 02:00 AM\n Other medications:\n Flowsheet Data as of 04:14 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.3\n T current: 37.7\nC (99.8\n HR: 95 (92 - 170) bpm\n BP: 92/46(59) {71/39(50) - 137/62(88)} mmHg\n RR: 20 (14 - 26) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.6 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 14 (9 - 26) mmHg\n Total In:\n 12,767 mL\n 1,146 mL\n PO:\n Tube feeding:\n IV Fluid:\n 12,107 mL\n 1,086 mL\n Blood products:\n 500 mL\n Total out:\n 3,135 mL\n 385 mL\n Urine:\n 1,315 mL\n 385 mL\n NG:\n 1,300 mL\n Stool:\n Drains:\n Balance:\n 9,632 mL\n 761 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 50%\n RSBI Deferred: PEEP > 10\n PIP: 30 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.32/38/114/18/-5\n Ve: 10 L/min\n PaO2 / FiO2: 228\n Physical Examination\n General Appearance: intubated, sedated\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Distended, dressing c/d/i, ostomy not yet matured,\n somewhat dusky, sweat in bag\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 151 K/uL\n 9.6 g/dL\n 124 mg/dL\n 3.8 mg/dL\n 18 mEq/L\n 4.5 mEq/L\n 63 mg/dL\n 106 mEq/L\n 133 mEq/L\n 27.2 %\n 10.0 K/uL\n [image002.jpg]\n 11:03 AM\n 12:00 PM\n 01:46 PM\n 04:19 PM\n 04:33 PM\n 09:33 PM\n 09:44 PM\n 11:29 PM\n 02:07 AM\n 02:28 AM\n WBC\n 7.4\n 8.6\n 10.0\n Hct\n 30.7\n 26.5\n 27.2\n Plt\n 136\n 139\n 151\n Creatinine\n 4.1\n 3.8\n 3.8\n Troponin T\n 0.04\n TCO2\n 18\n 14\n 16\n 17\n 20\n 20\n Glucose\n 131\n 114\n 124\n Other labs: PT / PTT / INR:15.9/34.4/1.4, CK / CK-MB / Troponin\n T:274/10/0.04, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.0 mmol/L, Albumin:2.4 g/dL, Ca:7.7 mg/dL,\n Mg:2.4 mg/dL, PO4:6.4 mg/dL\n Assessment and Plan\n IMPAIRED SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL\n FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER\n DESCRIPTION IN COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: Pain controlled, Wean propofol with intermittent midaz.\n Cardiovascular: On amio for rate control, currently in NSR. Wean\n vasopressin/levo as tolerated.\n Pulmonary: Cont ETT\n Gastrointestinal / Abdomen: Continue NGT to MCWS. NPO/IVF. Ostomy not\n yet matured.\n Nutrition: NPO\n Renal: Foley, Adequate UO, Good UOP. Lytes & Cr normalizing, but still\n in ARF.\n Hematology: Stable at 27.2 Likely hemodilutional.\n Endocrine: RISS\n Infectious Disease: Check cultures\n Lines / Tubes / Drains: Foley, NGT, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: LR\n Consults: Trauma surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op),\n Post-op hypotension, (Shock: Septic), Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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 Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2131-02-23 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 367330, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 78 kg\n 84.6 kg ( 12:00 AM)\n +6.6 kg d/t fluid\n 26.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 112%\n Diagnosis: ARF\n PMH : HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO, sigmoid\n colectomy/Hartmanns (), colostomy reversal (), ex lap/SBR/LOA\n (), LIHR\n Food allergies and intolerances: tree nuts, soybeans, peanuts\n Pertinent medications: norepinehprine, propofol, vaopressin, Ca\n Gluconate, LR, RISS, heparin, protonix, others noted\n Labs:\n Value\n Date\n Glucose\n 124 mg/dL\n 02:07 AM\n Glucose Finger Stick\n 134\n 02:00 PM\n BUN\n 63 mg/dL\n 02:07 AM\n Creatinine\n 3.8 mg/dL\n 02:07 AM\n Sodium\n 133 mEq/L\n 02:07 AM\n Potassium\n 4.5 mEq/L\n 02:07 AM\n Chloride\n 106 mEq/L\n 02:07 AM\n TCO2\n 18 mEq/L\n 02:07 AM\n PO2 (arterial)\n 137 mm Hg\n 10:50 AM\n PCO2 (arterial)\n 34 mm Hg\n 10:50 AM\n pH (arterial)\n 7.34 units\n 10:50 AM\n pH (urine)\n 5.0 units\n 11:37 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:50 AM\n Albumin\n 2.4 g/dL\n 08:19 PM\n Calcium non-ionized\n 7.7 mg/dL\n 02:07 AM\n Phosphorus\n 6.4 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.06 mmol/L\n 10:50 AM\n Magnesium\n 2.4 mg/dL\n 02:07 AM\n ALT\n 30 IU/L\n 02:03 AM\n Alkaline Phosphate\n 75 IU/L\n 02:03 AM\n AST\n 37 IU/L\n 02:03 AM\n Total Bilirubin\n 0.6 mg/dL\n 02:03 AM\n WBC\n 11.3 K/uL\n 02:36 PM\n Hgb\n 10.2 g/dL\n 02:36 PM\n Hematocrit\n 29.0 %\n 02:36 PM\n Current diet order / nutrition support: NPO\n GI: soft, distended\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: 1872-2184 ( 24-28 cal/kg)\n Protein: 78 (1 g/kg)\n Fluid: per team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate d/t NPO status\n Specifics: 73 year old male c/o weakness and lower abd pain, CT scan\n showed colitis pt was c-diff+. Pt developed ARF with increase of Creat\n to 3.5, developed abd distention and SOB became hypotensive with\n respiratory distress and intubated. Pt went to OR on for ex-lap\n total colectomy and end ileostomy. Pt with NGT to suction and has no\n return of bowel function after OR. Current propofol rate provides 248\n kcals. If pt remains NPO and TPN is initiated recs are below.\n Medical Nutrition Therapy Plan - Recommend the Following\n TPN recommendations:\n Start with Day 1 standard TPN pending glycemic control advance to\n goal TPN 1.7 L (345 g dex/80 g AA/40 g fat) 1893 kcals\n Omit lipids from TPN is propofol is running\n Check chem. 10 daily and adjust lytes per am labs\n Check TG level hold if >400\n Will follow POC page with questions\n" }, { "category": "Respiratory ", "chartdate": "2131-02-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367340, "text": "Demographics\n Day of mechanical ventilation: 3\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Scant\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n 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: Utilize ARDSnet protocol; Comments: Esophageal\n balloon placed today; Peep increased by 5cm to obtain optimal Peep.\n Continue to obtain daily measurements.\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Pleural pressure measurement (1000)\n" }, { "category": "Nutrition", "chartdate": "2131-02-23 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 367329, "text": "Subjective\n intubated\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 78 kg\n 84.6 kg ( 12:00 AM)\n +6.6 kg d/t fluid\n 26.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 112%\n Diagnosis: ARF\n PMH :\n Food allergies and intolerances: tree nuts, soybeans, peanuts\n Pertinent medications: norepinehprine, propofol, vaopressin, Ca\n Gluconate, LR, RISS, heparin, protonix, others noted\n Labs:\n Value\n Date\n Glucose\n 124 mg/dL\n 02:07 AM\n Glucose Finger Stick\n 134\n 02:00 PM\n BUN\n 63 mg/dL\n 02:07 AM\n Creatinine\n 3.8 mg/dL\n 02:07 AM\n Sodium\n 133 mEq/L\n 02:07 AM\n Potassium\n 4.5 mEq/L\n 02:07 AM\n Chloride\n 106 mEq/L\n 02:07 AM\n TCO2\n 18 mEq/L\n 02:07 AM\n PO2 (arterial)\n 137 mm Hg\n 10:50 AM\n PCO2 (arterial)\n 34 mm Hg\n 10:50 AM\n pH (arterial)\n 7.34 units\n 10:50 AM\n pH (urine)\n 5.0 units\n 11:37 PM\n CO2 (Calc) arterial\n 19 mEq/L\n 10:50 AM\n Albumin\n 2.4 g/dL\n 08:19 PM\n Calcium non-ionized\n 7.7 mg/dL\n 02:07 AM\n Phosphorus\n 6.4 mg/dL\n 02:07 AM\n Ionized Calcium\n 1.06 mmol/L\n 10:50 AM\n Magnesium\n 2.4 mg/dL\n 02:07 AM\n ALT\n 30 IU/L\n 02:03 AM\n Alkaline Phosphate\n 75 IU/L\n 02:03 AM\n AST\n 37 IU/L\n 02:03 AM\n Total Bilirubin\n 0.6 mg/dL\n 02:03 AM\n WBC\n 11.3 K/uL\n 02:36 PM\n Hgb\n 10.2 g/dL\n 02:36 PM\n Hematocrit\n 29.0 %\n 02:36 PM\n Current diet order / nutrition support: NPO\n GI: soft, distended\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: -2184 (BEE x or / 25-28 cal/kg)\n Protein: 78 (1 g/kg)\n Fluid: per team\n Estimation of previous intake: Adequate\n Estimation of current intake: Inadequate\n Specifics:\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367378, "text": "73 y.o.m with C.diff colitis, sepsis, resp failure, ARF, toxic\n megacolon, s/p ex lap, total abd colectomy, end ileostomy .\n * Pt experienced SVT with runs of Afib last night, whereupon he was\n immediately started on an Amiodarone gtt. Gtt was d/c\nd at noon time on\n MD orders. Since then pt has been in SR with HR 70-80s.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CMV, FiO2 50%, RR 20,\n Action:\n Response:\n Plan:\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low systemic BP requiring pressors for BP support. Hct 26.Continuous\n fluid requirement with significant third spacing- + anasarca. Metabolic\n acidosis secondary to ATN. in place for continuous hemodynamic\n monitoring. CVP 10-15. CI 2.8-3.6. SVV .\n Action:\n Cont to hemodynamics Q1H, receiving LR at 150cc/hr, levophed\n weaned off, vasopressin weaned to 1.2 units/hr. 1 unit PRBCs\n administered. Bedside ECHO performed. Cardiac enzymes cycled.\n Response:\n Able to maintain MAP > 60 with levophed weaned off/vasopressin\n titrated, + anasarca. Hct 29. No changes noted from previous ECHO.\n Metabolic acidosis resolving, lactic decreased to 0.8. UOP improving.\n Plan:\n Cont to Q1H hemodynamics, wean pressors as tolerated, administer\n fluid boluses according to hemodynamics, transfuse with blood products\n if Hct cont to fall.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n UOP remains > 30cc/hr. Creatinine 3.8, BUN 60. Ionized calcium 1.09, +\n anasarca.\n Action:\n Pt being hydrated with 150cc/hr, calcium repleted with 2gm calcium\n gluconate, chem 7 obtained this afternoon.\n Response:\n Creatinine improving- now 3.2, BUN 60. UOP 50-80cc/hr.\n Plan:\n Cont hydration with fluid resuscitation, fluid status & renal\n function.\n C Diff Colitis/ s/p total colectomy with end ileostomy\n Assessment:\n Abd firmly distended with midline abd incision s/p total coletomy with\n end ileostomy\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367381, "text": "73 y.o.m with C.diff colitis, sepsis, resp failure, ARF, toxic\n megacolon, s/p ex lap, total abd colectomy, end ileostomy .\n * Pt experienced SVT with runs of Afib last night, whereupon he was\n immediately started on an Amiodarone gtt. Gtt was d/c\nd at noon time on\n MD orders. Since then pt has been in SR with HR 70-80s.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CMV, FiO2 50%, 550x 20, peep 10. ARDS NET protocol initiated for acute\n lung injury. + b/l plural effusion. LS clear bilaterally with\n occasionally diminished bases. SpO2 97-99%.\n Action:\n ARDS NET protocol, esophageal balloon placed to optimize vent settings,\n peep increased to 15, no other vent settings changes made today. ABG\n obtained. Pt sxned for scant white thick secretions.\n Response:\n Pt tolerating vent settings well, LS remain clear. SpO2 98-100%.\n Plan:\n resp status, cont ARDS net protocol, ? wean peep tomorrow\n according to esophageal balloon pressures. Cont VAP care per protocol.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low systemic BP requiring pressors for BP support. Hct 26.Continuous\n fluid requirement with significant third spacing- + anasarca. Metabolic\n acidosis secondary to ATN. in place for continuous hemodynamic\n monitoring. CVP 10-15. CI 2.8-3.6. SVV .\n Action:\n Cont to hemodynamics Q1H, receiving LR at 150cc/hr, levophed\n weaned off, vasopressin weaned to 1.2 units/hr. 1 unit PRBCs\n administered. Bedside ECHO performed. Cardiac enzymes cycled.\n Response:\n Able to maintain MAP > 60 with levophed weaned off/vasopressin\n titrated, + anasarca. Hct 29. No changes noted from previous ECHO.\n Metabolic acidosis resolving, lactic decreased to 0.8. UOP improving.\n Plan:\n Cont to Q1H hemodynamics, wean pressors as tolerated, administer\n fluid boluses according to hemodynamics, transfuse with blood products\n if Hct cont to fall.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Slight metabolic acidosis. UOP remains > 30cc/hr. Creatinine 3.8, BUN\n 60. Ionized calcium 1.09, + anasarca.\n Action:\n Pt being hydrated with 150cc/hr, calcium repleted with 2gm calcium\n gluconate, chem 7 obtained this afternoon.\n Response:\n Creatinine improving- now 3.2, BUN 60. K 4.5, all other lytes wnl.\n Metabolic acidosis resolving. UOP 50-80cc/hr.\n Plan:\n Cont hydration with fluid resuscitation, fluid status & renal\n function. Replete lytes as necessary.\n C Diff Colitis/ s/p total colectomy with end ileostomy\n Assessment:\n Abd firmly distended with hypoactive BS, abd tender with palpation.\n Midline abd incision covered with primary OR dsg, no drainage noted,\n s/p total colectomy with end ileostomy. Immature ileostomy red,\n sanguinous drainage oozing from around ileostomy site.\n Action:\n Bladder pressure obtained as abd felt firmer this evening than early\n am, fentanyl administered ivp prn for pain control, propofol gtt\n infusing at 20mcg/kg/min for light sedation.\n Response:\n Bladder pressures 16-18, abd remains firmly distended, ileostomy bright\n red, scant drainage oozing from around site. No drainage noted on\n midline abd dsg.\n Plan:\n Cont to abd, bladder pressure, ileostomy site, tomorrow Dr.\n will mature (open) ileostomy at bedside. Administer fentanyl\n prn, titrate propofol gtt to maintain adequate sedation.\n" }, { "category": "Nursing", "chartdate": "2131-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367444, "text": "73 y.o.m with C.diff colitis, sepsis, resp failure, ARF, toxic\n megacolon, s/p ex lap, total abd colectomy, end ileostomy .\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n CMV, FiO2 50%, 550x 20, peep 10. ARDS NET protocol initiated for acute\n lung injury. + b/l plural effusion. LS clear bilaterally with\n occasionally diminished bases. SpO2 97-99%.\n Action:\n ARDS NET protocol. No vent changes overnight.\n Response:\n Good ABG this am. LS remain clear. SpO2 98-100%.\n Plan:\n resp status, cont ARDS net protocol, ? wean peep tomorrow\n according to esophageal balloon pressures. Cont VAP care per protocol.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n Low systemic BP requiring vasopressin. Continuous fluid requirement\n with significant third spacing- + anasarca\n Action:\n Cont to monitor hemodynamics. LR at 150cc/hr, Vasopressin weaned off.\n MAP maintained >60.\n Response:\n Able to maintain MAP > 60. Vasopressin off since 0430hrs.+ anasarca.\n UOP >90ml/hr.\n Plan:\n Cont to monitor hemodynamics.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Urine output >90ml/hr.\n Action:\n Pt being hydrated with 150cc/hr.\n Response:\n Creatinine improving.\n Plan:\n Cont hydration and monitor fluid status & renal function.\n C Diff Colitis/ s/p total colectomy with end ileostomy\n Assessment:\n Abd firmly distended with hypoactive/absent BS, abd tender with\n palpation. Midline abd incision covered with primary OR dsg, no\n drainage noted, s/p total colectomy with end ileostomy. Immature\n ileostomy red, sanguinous drainage.\n Action:\n Bladder pressure 17-20 overnight. PRN fentanyl for pain control,\n propofol 20mcg/kg/min for light sedation.\n Response:\n Bladder pressures 17-20, abd remains firmly distended, ileostomy bright\n red. No drainage noted on midline abd dsg. OGT bilious drainage.\n Plan:\n Cont to abd, bladder pressure, ileostomy site, Dr. will\n mature (open) ileostomy at bedside today. Administer fentanyl prn,\n titrate propofol gtt to maintain adequate sedation.\n" }, { "category": "Physician ", "chartdate": "2131-02-22 00:00:00.000", "description": "Intensivist Note", "row_id": 367108, "text": "TSICU\n HPI:\n 73M weakness and lower abdominal pain. By report CT scan showed\n evidence of colitis. Stool was positive for C Diff. WBC was 44,000.\n He was admitted, hydrated, and started on PO vanco. Last night\n developed ARF and was making minimal urine with Cr newly elevated to\n 3.5. Then today he developed significant abdominal distension and\n SOB. Over a short periord this afternoon he quickly decompensated\n becoming hypotensive with respiratory distress. He was transfered to\n the ICU, intubated, had a central line placed, started on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here.\n Chief complaint:\n PMHx:\n HTN perforated Diverticulitis c/b sepsis, respiratory\n failure, ARF, A Fib transferred from OSH to Dr.\n care after initial colectomy/. s/p colectomy/Hartmann for\n perforated diverticulitis at an OSH c/b intra-abdominal abscess\n treated by IR drain s/p colostomy takedown/ reversal \n () ?recurrent diverticulitis SBO - managed\n non-operatively ex-lap, small bowel resection and lysis of adhesions.\n () for recurrent SBO caused by an inflammatory mass s/p\n left inguinal hernia repair Prostate Ca\n COPD h/o CVA\n Current medications:\n 1000 mL NSContinuous at 100 ml/hr. MetRONIDAZOLE (FLagyl) 500 mg IV\n Q8H Meropenem 500 mg IV Q12H Albuterol-Ipratropium PUFF IH\n Q6H:PRN Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP >\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Chlorhexidine Gluconate 0.12%\n Oral Rinse 15 ml ORAL Qvar *NF* 80 mcg/Actuation Inhalation B ID\n Famotidine 20 mg IV Q24H Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order\n date: @ 2254 24. Vancomycin 1000 mg IV ONCE Duration: 1 Doses\n Order date: @ 2145\n Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date: \n @ 2254 25. Vancomycin 1000 mg IV X1 Duration: Doses Order date: @\n 2145\n Heparin 5000 UNIT SC TID Order date. Vancomycin Oral Liquid 250 mg PO\n Q6H. Vancomycin Oral Liquid 250 mg PO ONCE Duration: 1 Doses Start:\n 1Insulin SC (per Insulin Flowsheet)\n 24 Hour Events:\n MULTI LUMEN - START 07:59 PM\n from osh\n INVASIVE VENTILATION - START 08:15 PM\n ARTERIAL LINE - START 08:32 PM\n MULTI LUMEN - START 08:45 PM\n EKG - At 09:00 PM\n BLOOD CULTURED - At 11:00 PM\n BLOOD CULTURED - At 11:23 PM\n MULTI LUMEN - STOP 12:02 AM\n from osh\n TRANSTHORACIC ECHO - At 02:52 AM\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 10:30 PM\n Metronidazole - 02:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:10 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: 105 (92 - 117) bpm\n BP: 99/45(61) {87/42(16) - 123/54(71)} mmHg\n RR: 16 (14 - 19) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.8 kg (admission): 78 kg\n CVP: 11 (0 - 13) mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 4,831 mL\n 1,920 mL\n PO:\n Tube feeding:\n IV Fluid:\n 801 mL\n 1,920 mL\n Blood products:\n Total out:\n 430 mL\n 755 mL\n Urine:\n 130 mL\n 155 mL\n NG:\n 300 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n 4,401 mL\n 1,165 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 10 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.29/37/113/18/-7\n Ve: 9.9 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: tense\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 180 K/uL\n 13.3 g/dL\n 119 mg/dL\n 4.5 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 70 mg/dL\n 100 mEq/L\n 131 mEq/L\n 39.2 %\n 10.8 K/uL\n [image002.jpg]\n 08:19 PM\n 08:39 PM\n 02:03 AM\n 02:18 AM\n WBC\n 10.1\n 10.8\n Hct\n 42.9\n 39.2\n Plt\n 161\n 180\n Creatinine\n 4.8\n 4.5\n Troponin T\n 0.02\n TCO2\n 20\n 19\n Glucose\n 128\n 119\n Other labs: PT / PTT / INR:14.6/29.4/1.3, CK / CK-MB / Troponin\n T:645/32/0.02, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, Ca:7.2 mg/dL,\n Mg:3.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M weakness and lower abdominal pain, septic\n shock.\n Neurologic: Neuro checks Q: 4 stable, propfol on sedation\n Pain: Fentanyl\n Cardiovascular: Shock on levophed, for fluid resistant hypotension,\n given 3 litre bolus at outside hospital, and 2 litre overnight, will\n place monitoring\n Pulmonary: VDRF, intubated, on Q var, albuterol. No signs of\n consolidation\n Gastrointestinal / Abdomen: Distended loops of bowl, secondary to c\n diff colitis, to the O.R today for ex lap and total colectomy, no free\n air on xray.\n Nutrition: NPO\n Renal: Marginal Urine output, resolving ARF prerenal progressing to ATN\n improving urine output\n Hematology: stable anemia secondary to dilution\n Endocrine: RISS\n Infectious Disease: meropenem, vancomycin, flagyl cultures pending.\n Lines / Tubes / Drains: L TLC, A line, PIV ETT, Foley\n Wounds: None\n Imaging: CT Abdomen, CXR\n Fluids: NS @ 100\n Consults: Trauma\n Billing Diagnosis: Respiratory failure, acute renal failure, septic\n shock\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\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: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 40 minutes\n" }, { "category": "Physician ", "chartdate": "2131-02-24 00:00:00.000", "description": "Intensivist Note", "row_id": 367437, "text": "TSICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n abdominal pain\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n Flagyl 500 mg IV Q8H, Meropenem 500 mg IV Q12H, Albuterol-Ipratropium\n PUFF IH Q6H:PRN, Albuterol Inhaler 2 PUFF IH Q4H:PRN,\n Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP, Calcium Gluconate IV\n Sliding Scale, Pantoprazole 40 mg IV Q24H, Potassium Chloride IV\n Sliding Scale, Magnesium sulfate sliding scale, Fentanyl Citrate 25-100\n mcg IV Q2H:PRN, Propofol 5-20 mcg/kg/min, Heparin 5000 UNIT SC TID,\n Qvar *NF* 80 mcg/Actuation Inhalation , Insulin SC Vasopressin 2.4\n 24 Hour Events:\n ESOPHOGEAL BALLOON - At 09:56 AM\n placed per ARDS net protocol- to optimize peep\n TRANSTHORACIC ECHO - At 03:18 PM\n bedside echo performed by fellow Dr. & Dr. \n \n : Off levophed, titrating down vasopressin. Bladder pressures\n range 14-20.\n Post operative day:\n POD#2 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 12:00 AM\n Metronidazole - 02:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:42 AM\n Fentanyl - 08:15 PM\n Pantoprazole (Protonix) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:30 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 (98.8\n HR: 88 (74 - 93) bpm\n BP: 116/50(67) {102/49(64) - 142/62(85)} mmHg\n RR: 10 (10 - 20) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 84.6 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 11 (10 - 19) mmHg\n Bladder pressure: 20 (16 - 20) mmHg\n Total In:\n 5,557 mL\n 1,182 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,087 mL\n 1,182 mL\n Blood products:\n 350 mL\n Total out:\n 1,730 mL\n 590 mL\n Urine:\n 1,700 mL\n 390 mL\n NG:\n 200 mL\n Stool:\n Drains:\n Balance:\n 3,827 mL\n 592 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 15 cmH2O\n FiO2: 50%\n PIP: 32 cmH2O\n Plateau: 21 cmH2O\n Compliance: 91.7 cmH2O/mL\n SPO2: 97%\n ABG: 7.39/34/142/20/-3\n Ve: 11.6 L/min\n PaO2 / FiO2: 284\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: transmitted upper airway sounds bilaterally. ET\n tube in place\n Abdominal: Soft, mildly distended, tender to palpation, colostomy tube\n in place\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, Sedated\n Labs / Radiology\n 141 K/uL\n 9.6 g/dL\n 104 mg/dL\n 2.9 mg/dL\n 20 mEq/L\n 4.4 mEq/L\n 63 mg/dL\n 106 mEq/L\n 136 mEq/L\n 26.9 %\n 11.2 K/uL\n [image002.jpg]\n 11:29 PM\n 02:07 AM\n 02:28 AM\n 08:03 AM\n 10:50 AM\n 02:36 PM\n 05:21 PM\n 05:29 PM\n 01:59 AM\n 05:30 AM\n WBC\n 10.0\n 11.3\n 11.2\n Hct\n 27.2\n 29.0\n 26.9\n Plt\n 151\n 157\n 141\n Creatinine\n 3.8\n 3.8\n 3.2\n 2.9\n Troponin T\n 0.04\n 0.03\n 0.03\n TCO2\n 20\n 19\n 22\n 21\n Glucose\n 114\n 124\n 108\n 104\n Other labs: PT / PTT / INR:15.5/33.7/1.4, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, Ca:8.1 mg/dL,\n Mg:2.5 mg/dL, PO4:5.8 mg/dL\n Assessment and Plan\n ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS, ACUTE LUNG INJURY, ),\n SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED SKIN INTEGRITY, SEPSIS,\n SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE, ACUTE (ACUTE RENAL\n FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n NEURO: wean propofol, fentanyl\n CVS: off levophed, vasopressin currently. Off amio gtt, and tolerated\n well. Using monitor for\n PULM: vented. Esophageal balloon placed and PEEP increased to 15.\n GI: NPO/IVF, abx. Bladder pressure most recently 20, but no change in\n exam, continue to monitor.\n RENAL: ARF. Currently Cr: 2.9, improved from yesterday.\n HEME: follow Hct--trending down. Hct 26 (from 29 yesterday), continue\n to monitor.\n ENDO: RISS\n ID: vanc//Flagyl, f/u cx\n TLD: L TLC, Aline, PIV, ETT, Foley, axillary fem line monitor\n FLUIDS: LR@125\n CONSULTS: general/trauma surgery\n BILLING DIAGNOSIS: resp failure\n ICU CARE:\n GLYCEMIC CONTROL:\n PROPHYLAXIS: SQH, boots, famotidine, VAP bundle\n COMMUNICATIONS:\n ICU Consent: in chart\n CODE STATUS: FULL\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 AM\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": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367086, "text": "TSICU\n HPI:\n 73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n PMHx:\n HTN\n Perforated Diverticulitis c/b sepsis, respiratory failure, ARF,\n A Fib, multiple abscess formation after colectomy and hartmann\ns pouch\n at OSH. Transferred to Dr. \ns care after initial colectomy\n and multiple complications occurred at OSH\n s/p colostomy takedown/ reversal \n Recurrent diverticulitis \n SBO - managed non-operatively\n Ex-lap, small bowel resection and lysis of adhesions for\n recurrent SBO caused by an inflammatory mass\n S/p left inguinal hernia repair\n Prostate Ca\n COPD\n H/o CVA\n Renal failure, acute (Acute renal failure, ARF)\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": "2131-02-22 00:00:00.000", "description": "Intensivist Note", "row_id": 367094, "text": "TSICU\n HPI:\n 73M weakness and lower abdominal pain. By report CT scan showed\n evidence of colitis. Stool was positive for C Diff. WBC was 44,000.\n He was admitted, hydrated, and started on PO vanco. Last night\n developed ARF and was making minimal urine with Cr newly elevated to\n 3.5. Then today he developed significant abdominal distension and\n SOB. Over a short periord this afternoon he quickly decompensated\n becoming hypotensive with respiratory distress. He was transfered to\n the ICU, intubated, had a central line placed, started on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here.\n Chief complaint:\n PMHx:\n HTN perforated Diverticulitis c/b sepsis, respiratory\n failure, ARF, A Fib transferred from OSH to Dr.\n care after initial colectomy/. s/p colectomy/Hartmann for\n perforated diverticulitis at an OSH c/b intra-abdominal abscess\n treated by IR drain s/p colostomy takedown/ reversal \n () ?recurrent diverticulitis SBO - managed\n non-operatively ex-lap, small bowel resection and lysis of adhesions.\n () for recurrent SBO caused by an inflammatory mass s/p\n left inguinal hernia repair Prostate Ca\n COPD h/o CVA\n Current medications:\n 1000 mL NS\n Continuous at 100 ml/hr. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H\n Meropenem 500 mg IV Q12H Albuterol-Ipratropium PUFF IH Q6H:PRN\n Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP > 6.\n Albuterol Inhaler 2 PUFF IH Q4H:PRN Calcium Gluconate IV Propofol\n 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: @ 2254\n 8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Qvar *NF* 80\n mcg/Actuation Inhalation B ID Famotidine 20 mg IV Q24H Order date:\n @ 2254 23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush\n Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN.\n Order date: @ 1846\n Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 2254 24.\n Vancomycin 1000 mg IV ONCE Duration: 1 Doses Order date: @ 2145\n . Fluticasone-Salmeterol Diskus (250/50) 1 INH IH Order date:\n @ 2254 25. Vancomycin 1000 mg IV X1 Duration: Doses Order date:\n @ 2145\n Heparin 5000 UNIT SC TID Order date. Vancomycin Oral Liquid 250 mg PO\n Q6H *Awaiting ID Approval* Order date: @ 2202\n . Vancomycin Oral Liquid 250 mg PO ONCE Duration: 1 Doses Start:\n 1Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 2327\n 24 Hour Events:\n MULTI LUMEN - START 07:59 PM\n from osh\n INVASIVE VENTILATION - START 08:15 PM\n ARTERIAL LINE - START 08:32 PM\n MULTI LUMEN - START 08:45 PM\n EKG - At 09:00 PM\n BLOOD CULTURED - At 11:00 PM\n BLOOD CULTURED - At 11:23 PM\n MULTI LUMEN - STOP 12:02 AM\n from osh\n TRANSTHORACIC ECHO - At 02:52 AM\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Vancomycin - 10:00 PM\n Meropenem - 10:30 PM\n Metronidazole - 02:00 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Norepinephrine - 0.18 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 06:10 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: 105 (92 - 117) bpm\n BP: 99/45(61) {87/42(16) - 123/54(71)} mmHg\n RR: 16 (14 - 19) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 78.8 kg (admission): 78 kg\n CVP: 11 (0 - 13) mmHg\n Bladder pressure: 14 (14 - 18) mmHg\n Total In:\n 4,831 mL\n 1,920 mL\n PO:\n Tube feeding:\n IV Fluid:\n 801 mL\n 1,920 mL\n Blood products:\n Total out:\n 430 mL\n 755 mL\n Urine:\n 130 mL\n 155 mL\n NG:\n 300 mL\n 600 mL\n Stool:\n Drains:\n Balance:\n 4,401 mL\n 1,165 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability\n PIP: 10 cmH2O\n Plateau: 19 cmH2O\n SPO2: 96%\n ABG: 7.29/37/113/18/-7\n Ve: 9.9 L/min\n PaO2 / FiO2: 226\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Expansion: Symmetric)\n Abdominal: tense\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Responds to: Noxious stimuli), Moves all extremities,\n Sedated\n Labs / Radiology\n 180 K/uL\n 13.3 g/dL\n 119 mg/dL\n 4.5 mg/dL\n 18 mEq/L\n 4.3 mEq/L\n 70 mg/dL\n 100 mEq/L\n 131 mEq/L\n 39.2 %\n 10.8 K/uL\n [image002.jpg]\n 08:19 PM\n 08:39 PM\n 02:03 AM\n 02:18 AM\n WBC\n 10.1\n 10.8\n Hct\n 42.9\n 39.2\n Plt\n 161\n 180\n Creatinine\n 4.8\n 4.5\n Troponin T\n 0.02\n TCO2\n 20\n 19\n Glucose\n 128\n 119\n Other labs: PT / PTT / INR:14.6/29.4/1.3, CK / CK-MB / Troponin\n T:645/32/0.02, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:1.1 mmol/L, Albumin:2.4 g/dL, Ca:7.2 mg/dL,\n Mg:3.2 mg/dL, PO4:7.2 mg/dL\n Assessment and Plan\n Assessment and Plan: 73M weakness and lower abdominal pain, sepsis.\n Neurologic: Neuro checks Q: 4 stable, propfol on sedation\n Pain: Fentanyl\n Cardiovascular: Shock on levophed, for fluid resistant hypotension,\n given 3 litre bolus at outside hospital, and 2 litre overnight, will\n place monitoring\n Pulmonary: VDRF, intubated, on Q var, albuterol. No signs of\n consolidation\n Gastrointestinal / Abdomen: Distended loops of bowl, secondary to c\n diff colitis, to the O.R today for ex lap and total colectomy, no free\n air on xray.\n Nutrition: NPO\n Renal: Marginal Urine output, resolving ARF prerenal progressing to ATN\n improving urine output\n Hematology: stable anemia secondary to dilution\n Endocrine: RISS\n Infectious Disease: meropenem, vancomycin, flagyl cultures pending.\n Lines / Tubes / Drains: L TLC, A line, PIV ETT, Foley\n Wounds: None\n Imaging: CT Abdomen, CXR\n Fluids: NS @ 100\n Consults: Trauma\n Billing Diagnosis: (Shock: Unspecified)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\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: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367099, "text": "TSICU\n HPI:\n 73 male with weakness and lower abdominal pain presented to outside\n hospital . (had been on antibiotics previously for COPD flare) . CT\n scan showed evidence of colitis and stool was positive for C Diff. He\n was admitted, hydrated, and started on PO vanco. developed ARF and\n was making minimal urine with Cr newly elevated to 3.5. On he\n developed significant abdominal distension and SOB. He quickly\n decompensated becoming hypotensive with respiratory distress. He was\n transferred to the ICU, intubated, had a central line placed, started\n on\n vasopressors, and was given 3L IVF and meropenem/flagyl IV.\n Arrangements were then made for transfer here by his family\ns request\n PMHx:\n HTN\n Perforated Diverticulitis c/b sepsis, respiratory failure, ARF,\n A Fib, multiple abscess formation after colectomy and hartmann\ns pouch\n at OSH. Transferred to Dr. \ns care after initial colectomy\n and multiple complications occurred at OSH\n s/p colostomy takedown/ reversal \n Recurrent diverticulitis \n SBO - managed non-operatively\n Ex-lap, small bowel resection and lysis of adhesions for\n recurrent SBO caused by an inflammatory mass\n S/p left inguinal hernia repair\n Prostate Ca\n COPD\n H/o CVA\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Normal renal function by report prior to this hospitalization .\n Admission cr 4.9 with low urine output. Received 3000L fluid pta\n Action:\n Gentle hydration with 3 fluid boluses and maintenance fluid. Adjustment\n of meds for renal function, close monitoring of fluid status and renal\n function\n Response:\n Cr down to 4.5, urine output up marginally. Lytes wnl.\n Plan:\n Follow renal function, fluid balance.\n C Diff Colitis\n Assessment:\n Abdomen large firm, tender to palpation, bladder pressures 14-18, C\n diff positive at outside hospital, wbc 10, CVP 8-10, on levophed to\n maintain map >60, intubated at osh for respiratory distress. ABG show\n metabolic acidosis but normal lactate.\n Action:\n CT of abdomen obtained after pt. received 30cc of gastrografin diluted\n in 1000cc. Fluid boluses of 500cc X 3 and maintenance fluid of 100cc/hr\n given. Flagyl, po vanc, iv vanc, meropenum given. Blood cultures X 2,\n urine culture and UA sent. New central line placed, art line placed.\n Levophed titrated to keep map >60, bladder pressures followed\n Response:\n Abdomen large, firm, absent bowel sounds. CT shows large dilated small\n and large bowel. No stool, Low urine output, stable abgs, CXR,\n continues to be hydrophilic and require levophed to maintain MAP\n Plan:\n Pt. to OR for total colectomy and end ileostomy with Dr. .\n Postop will require fluid recesitation and careful hemodynamic\n monitoring.\n" }, { "category": "Physician ", "chartdate": "2131-02-27 00:00:00.000", "description": "Intensivist Note", "row_id": 367851, "text": "SICU\n HPI:\n 73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff colitis/toxic metacolon, sepsis, resp failure, ARF\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol-Ipratropium 5. Albuterol\n Inhaler 6. Albuterol 0.083% Neb Soln\n 7. Albumin 5% (12.5g / 250mL) 8. Amiodarone 9. Aspirin EC 10. Calcium\n Gluconate 11. Ciprofloxacin HCl\n 12. Famotidine 13. Fentanyl Citrate 14. HYDROmorphone (Dilaudid) 15.\n Heparin 16. Influenza Virus Vaccine\n 17. Insulin 18. Ipratropium Bromide Neb 19. Lorazepam 20. Magnesium\n Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Metoprolol Tartrate 23. Metoprolol Tartrate 24. Nystatin Oral\n Suspension 25. Potassium Chloride\n 26. Qvar 27. Simvastatin 28. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Started on nystatin swish and swallow for po thrush. Meropenem d/c,\n Cipro started for ?wound infection.\n Post operative day:\n POD#5 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:24 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 05:30 PM\n Metoprolol - 10:45 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:41 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: 37.2\nC (98.9\n HR: 92 (84 - 112) bpm\n BP: 134/59(86) {70/38(35) - 202/79(117)} mmHg\n RR: 18 (12 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 79.5 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 4 (1 - 14) mmHg\n Total In:\n 1,710 mL\n 455 mL\n PO:\n 960 mL\n 300 mL\n Tube feeding:\n IV Fluid:\n 750 mL\n 155 mL\n Blood products:\n Total out:\n 2,715 mL\n 1,300 mL\n Urine:\n 1,745 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,005 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n appropriately, Erythema inferior to incision\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (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 262 K/uL\n 10.0 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 112 mEq/L\n 147 mEq/L\n 28.2 %\n 14.0 K/uL\n [image002.jpg]\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n 05:52 PM\n 06:02 PM\n 02:01 AM\n 02:00 PM\n 01:57 AM\n WBC\n 14.3\n 12.1\n 14.0\n Hct\n 27.8\n 26.6\n 28.2\n Plt\n 200\n 232\n 262\n Creatinine\n 2.1\n 1.7\n 1.2\n 1.1\n 0.9\n TCO2\n 21\n 26\n 26\n 26\n Glucose\n 92\n 97\n 88\n 101\n 94\n 126\n 173\n 113\n Other labs: PT / PTT / INR:20.1/51.8/1.9, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:1.9 g/dL, Ca:7.6 mg/dL,\n Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis/toxic metacolon, sepsis,\n resp failure, ARF, s/p ex lap, total abd colectomy, end ileostomy .\n Neurologic: Pain well controlled, Change Diluadid PCA to percocet PO.\n Cardiovascular: Aspirin, Beta-blocker\n increase to 50 mg tid, Statins,\n Post op AF\n Patient currently in sinus Rhythm. Hemodynamically stable.\n ASA and Statin started yesterday. Continue po Amio, titrate up po\n Lopressor as tolerated. (advance to 50 mg po tid today). Get echo per\n cardiology (AF).\n Pulmonary: IS, agressive pulm toliet. OOB\n chair\n Gastrointestinal / Abdomen: Clears, will advance diet as tolerated as\n per primary team. F/u LFTs as INR and PTT is increasing.\n Nutrition: will advance diet as tolerated as per primary team\n Renal: Foley, Adequate UO, Patient auto-diuresing.patient approaching\n dry weight. d/c foley.\n Hematology: Stable Anemia\n Endocrine: RISS, FS fairly well controlled. Goal FS <150\n Infectious Disease: Check cultures, Started on Cipro for wound\n infection . Meropenem d/c. Continue Flagyl for C.diff\n Lines / Tubes / Drains: Foley\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 367862, "text": "Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Total colectomy w/ end ileostomy\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 367640, "text": "TITLE:\n Date of service: \n Initial consultation: Inpatient\n Presenting complaint: Arrhythmia\n History of present illness: 73 year old male with h/o HTN, CVA and\n C.diff colitis with toxic megacolon, septic shock was transferred to\n from OSH where he presented with weakness and lower abdominal\n pain. He received a total colectomy with endileostomy on . Since\n then he developed acute renal failure and narrow complex tachycardia.\n We were consulted to help with the management of this supraventricular\n tachycardia. The SVT started on . Amiodarone iv was started\n which helped control the heart rate and eventually converted him to\n sinus. When amiodarone was stopped today he reverted to his SVT.\n Past medical history: HTN, perforated diverticulitis c/b sepsis, resp\n failure ARF; A fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA),\n SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: Yes), (Quit: Yes), (Discontinue tobacco: 40 years ago)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Current medications: 1. IV access: Temporary central access (ICU)\n Location: Left Subclavian, Date inserted: Order date: @\n 1053 15. Heparin 5000 UNIT SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Syncope\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea, Edema,\n Palpitations, Presyncope, Lightheadedness, TIA / CVA, Pulmonary\n embolism, DVT, Claudication, Exertional buttock pain, Exertional calf\n pain\n Review of Systems\n Organ system ROS abnormal\n Constitutional, Respiratory, Gastrointestinal, Allergy / Immune\n Signs and symptoms present\n Recent fevers, Cough\n Organ system ROS normal\n Eyes, ENT, Endocrine, Hematology / Lymphatic, Genitourinary,\n Musculoskeletal, Integumentary, Neurological, Psychiatric\n Signs and symptoms absent\n Chills, Rigors, Hemoptysis, Black / red stool, Bleeding during surgery\n Social History\n Marital status: lives with wife in RI\n (Alcohol: No), (Recreational drug use: No)\n Family history: emphysema in his father and brain cancer in his mother\n Physical Exam\n : 68 Inch, 173 cm\n Weight: 84.1 kg\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible), (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: Abnormal, crackles b/l)\n Cardiac: (Rhythm: Regular, tachycardic), (Palpation / PMI: WNL),\n (Auscultation: S1: WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: Abnormal, hyperactive),\n (Bruits: No), (Pulsatile mass: No), (Hepatosplenomegaly: No), (Other\n abnormalities: jejunostomy)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: +, Left: +), (Posterior tibial artery: Right: +, Left: +),\n (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 200\n 10.1\n 88\n 1.7\n 25\n 4.2\n 55\n 111\n 143\n 27.8\n 14.3\n [image002.jpg]\n 02:07 AM\n 08:03 AM\n 02:36 PM\n 05:21 PM\n 01:59 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n WBC\n 10.0\n 11.3\n 11.2\n 14.3\n Hgb\n 9.6\n 10.2\n 9.6\n 10.1\n Hct (Serum)\n 27.2\n 29.0\n 26.9\n 27.8\n Plt\n 151\n 157\n 141\n 200\n INR\n 1.4\n 1.4\n 1.5\n PTT\n 34.4\n 33.7\n 34.1\n Na+\n 133\n 134\n 136\n 139\n 143\n K + (Serum)\n 4.5\n 4.5\n 4.4\n 4.0\n 4.2\n K + (Whole blood)\n 3.7\n Cl\n 106\n 107\n 106\n 108\n 111\n HCO3\n 18\n 17\n 20\n 21\n 25\n BUN\n 63\n 60\n 63\n 57\n 55\n Creatinine\n 3.8\n 3.2\n 2.9\n 2.1\n 1.7\n Glucose\n 124\n 108\n 104\n 92\n 97\n 88\n CK\n 329\n 265\n CK-MB\n 7\n 5\n Troponin T\n 0.03\n 0.03\n O2 sat (arterial)\n 98\n ABG: 7.36 / 44 / 106 / / 0 Values as of 10:33 AM\n Tests\n ECG: : NSR with APCs LAE\n : narrow complex tachycardia likely long RP tachycardia possibly\n atrial tachycardia\n Telemetry: Several episodes of atrial tachycardia with variable block\n and one episode of atrial flutter otherwise sinus tachycardia\n Echocardiogram: (Date: ), The views are quite limited. The\n left atrium is normal in size. Left ventricular wall thicknesses are\n normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is probably normal (LVEF>55%). Given the\n limited views, it is difficult to be sure but it appears that there are\n no wall motion abnormalities. Right ventricular chamber size and free\n wall motion are normal. The aortic root is mildly dilated. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n mildly thickened. No mitral regurgitation is seen. There is no\n pericardial effusion.\n Assessment and Plan\n Mr is a 73 year old man with h/o severe C.diff colitis s/p total\n colectomy with jejunostomie now with atrial tachycardia responsive to\n amiodarone.\n Atrial tachycardia: start lopressor 25 QID PO, continue amiodarone 400\n for now, no anticoagulation needed for now since atrial tachycardia\n not Afib, if patient develops Afib consider coumadin since CHADS score\n 2\n Sinus tachycardia: continue pain medication and rehydration with\n crystalline solutions\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 367642, "text": "TITLE:\n Date of service: \n Initial consultation: Inpatient\n Presenting complaint: Arrhythmia\n History of present illness: 73 year old male with h/o HTN, CVA and\n C.diff colitis with toxic megacolon, septic shock was transferred to\n from OSH where he presented with weakness and lower abdominal\n pain. He received a total colectomy with endileostomy on . Since\n then he developed acute renal failure and narrow complex tachycardia.\n We were consulted to help with the management of this supraventricular\n tachycardia. The SVT started on . Amiodarone iv was started\n which helped control the heart rate and eventually converted him to\n sinus. When amiodarone was stopped today he reverted to his SVT.\n Past medical history: HTN, perforated diverticulitis c/b sepsis, resp\n failure ARF; A fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA),\n SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: Yes), (Quit: Yes), (Discontinue tobacco: 40 years ago)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Current medications: 1. IV access: Temporary central access (ICU)\n Location: Left Subclavian, Date inserted: Order date: @\n 1053 15. Heparin 5000 UNIT SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Syncope\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea, Edema,\n Palpitations, Presyncope, Lightheadedness, TIA / CVA, Pulmonary\n embolism, DVT, Claudication, Exertional buttock pain, Exertional calf\n pain\n Review of Systems\n Organ system ROS abnormal\n Constitutional, Respiratory, Gastrointestinal, Allergy / Immune\n Signs and symptoms present\n Recent fevers, Cough\n Organ system ROS normal\n Eyes, ENT, Endocrine, Hematology / Lymphatic, Genitourinary,\n Musculoskeletal, Integumentary, Neurological, Psychiatric\n Signs and symptoms absent\n Chills, Rigors, Hemoptysis, Black / red stool, Bleeding during surgery\n Social History\n Marital status: lives with wife in RI\n (Alcohol: No), (Recreational drug use: No)\n Family history: emphysema in his father and brain cancer in his mother\n Physical Exam\n : 68 Inch, 173 cm\n Weight: 84.1 kg\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible), (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: Abnormal, crackles b/l)\n Cardiac: (Rhythm: Regular, tachycardic), (Palpation / PMI: WNL),\n (Auscultation: S1: WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: Abnormal, hyperactive),\n (Bruits: No), (Pulsatile mass: No), (Hepatosplenomegaly: No), (Other\n abnormalities: jejunostomy)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: +, Left: +), (Posterior tibial artery: Right: +, Left: +),\n (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 200\n 10.1\n 88\n 1.7\n 25\n 4.2\n 55\n 111\n 143\n 27.8\n 14.3\n [image002.jpg]\n 02:07 AM\n 08:03 AM\n 02:36 PM\n 05:21 PM\n 01:59 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n WBC\n 10.0\n 11.3\n 11.2\n 14.3\n Hgb\n 9.6\n 10.2\n 9.6\n 10.1\n Hct (Serum)\n 27.2\n 29.0\n 26.9\n 27.8\n Plt\n 151\n 157\n 141\n 200\n INR\n 1.4\n 1.4\n 1.5\n PTT\n 34.4\n 33.7\n 34.1\n Na+\n 133\n 134\n 136\n 139\n 143\n K + (Serum)\n 4.5\n 4.5\n 4.4\n 4.0\n 4.2\n K + (Whole blood)\n 3.7\n Cl\n 106\n 107\n 106\n 108\n 111\n HCO3\n 18\n 17\n 20\n 21\n 25\n BUN\n 63\n 60\n 63\n 57\n 55\n Creatinine\n 3.8\n 3.2\n 2.9\n 2.1\n 1.7\n Glucose\n 124\n 108\n 104\n 92\n 97\n 88\n CK\n 329\n 265\n CK-MB\n 7\n 5\n Troponin T\n 0.03\n 0.03\n O2 sat (arterial)\n 98\n ABG: 7.36 / 44 / 106 / / 0 Values as of 10:33 AM\n Tests\n ECG: : NSR with APCs LAE\n : narrow complex tachycardia likely long RP tachycardia possibly\n atrial tachycardia\n Telemetry: Several episodes of atrial tachycardia with variable block\n and one episode of atrial flutter otherwise sinus tachycardia\n Echocardiogram: (Date: ), The views are quite limited. The\n left atrium is normal in size. Left ventricular wall thicknesses are\n normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is probably normal (LVEF>55%). Given the\n limited views, it is difficult to be sure but it appears that there are\n no wall motion abnormalities. Right ventricular chamber size and free\n wall motion are normal. The aortic root is mildly dilated. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n mildly thickened. No mitral regurgitation is seen. There is no\n pericardial effusion.\n Assessment and Plan\n Mr is a 73 year old man with h/o severe C.diff colitis s/p total\n colectomy with jejunostomie now with atrial tachycardia responsive to\n amiodarone.\n Atrial tachycardia: start lopressor 25 QID PO, continue amiodarone 400\n for now, no anticoagulation needed for now since atrial tachycardia\n not Afib, if patient develops Afib consider coumadin since CHADS score\n 2\n Sinus tachycardia: continue pain medication and rehydration with\n crystalline solutions\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367827, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n EVENTS: Minimal sleep overnight.\n PCA used minimally. ? DC and change to PRN po\n analgesia.\n ? Tx to floor with tele..\n Clear liquid tolerated well.\n Atrial fibrillation (Afib)\n Assessment:\n Pt in SR.\n Action:\n Metoprolol PO TID. Amiodarone 400mg .\n Response:\n Pt remained in SR with HR 90\n Plan:\n Continue to monitor for increased BP and HR, medicate as needed.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Nasal cannula 4 L O2. LS clear with diminished in bases. Able to CDB\n comfortably.\n Action:\n Incentive spirometry used, OOB to chair early AM.Pt Stood and turned\n assisted by 2, chest PT and back rubs.\n Response:\n Sats >96% on 4 L O2 NC.\n Plan:\n Continue to encourage aggressive pulmonary hygiene and increase\n activity as tolerated.\n Impaired Skin Integrity\n Assessment:\n Abdominal wound dressing to lower aspect of wound with serosanginous\n drainage. Remaining wound stapled and open to air. Ostomy bag intact.\n Action:\n Abdominal wound dressing changed. Ostomy bag left intact-liquid green\n drainage.\n Response:\n Open areas to abdominal wound pink with minimal drainage.\n Plan:\n Continue to assess skin. Monitor for drainage/inflammation.\n" }, { "category": "Respiratory ", "chartdate": "2131-02-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367578, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 69.9\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 6 mL / Air\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 / Small\n Ventilation Assessment\n Level of breathing assistance: PSV5/8/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures: RSBI 31\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Intensivist Note", "row_id": 367580, "text": "TSICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 15. Heparin 5000 UNIT\n SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n 24 Hour Events:\n PAN CULTURE - At 09:30 PM\n FEVER - 101.1\nF - 08:00 PM\n Post operative day:\n POD#3 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 03:13 PM\n Furosemide (Lasix) - 04:15 PM\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:20 AM\n Fentanyl - 05:49 AM\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: 38.4\nC (101.1\n T current: 37.6\nC (99.7\n HR: 102 (88 - 165) bpm\n BP: 170/80(111) {78/44(55) - 174/80(111)} mmHg\n RR: 23 (0 - 38) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84.1 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 12 (10 - 68) mmHg\n Total In:\n 2,226 mL\n 360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,226 mL\n 360 mL\n Blood products:\n Total out:\n 6,870 mL\n 1,200 mL\n Urine:\n 4,870 mL\n 950 mL\n NG:\n 850 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -4,644 mL\n -840 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 697 (633 - 719) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 12\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n SPO2: 97%\n ABG: 7.45/36/123/25/2\n Ve: 8.1 L/min\n PaO2 / FiO2: 246\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Distended, ileostomy\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 200 K/uL\n 10.1 g/dL\n 97 mg/dL\n 1.7 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 55 mg/dL\n 111 mEq/L\n 143 mEq/L\n 27.8 %\n 14.3 K/uL\n [image002.jpg]\n 10:50 AM\n 02:36 PM\n 05:21 PM\n 05:29 PM\n 01:59 AM\n 05:30 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n WBC\n 11.3\n 11.2\n 14.3\n Hct\n 29.0\n 26.9\n 27.8\n Plt\n 157\n 141\n 200\n Creatinine\n 3.2\n 2.9\n 2.1\n 1.7\n Troponin T\n 0.03\n TCO2\n 19\n 22\n 21\n 21\n 26\n Glucose\n 108\n 104\n 92\n 97\n Other labs: PT / PTT / INR:16.5/34.1/1.5, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, Ca:7.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: off sedation, AOE x 3, Ativan PRN\n Cardiovascular: off levophed, vasopressin currently. On amio gtt for a\n fib with RVR. Using monitor for titration\n Pulmonary: vented. Esophageal balloon placed and PEEP increased to\n 15. On CPAP/PSV. Lasix negative 4 Litres for 24 hours\n Gastrointestinal / Abdomen: NPO/IVF, abx. mature ostomy at bedside\n Nutrition: NPO\n Renal: ARF. on CKD resolved, Currently Cr: 1.7, improved from\n yesterday. Overall negative 4 litres\n Hematology: Stable anemia.\n Endocrine: RISS\n Infectious Disease: vanc//Flagyl, f/u cx, sputum culture yeast\n consider coverage\n Lines / Tubes / Drains: L TLC, Aline, PIV, ETT, Foley, axillary fem\n line monitor\n Wounds:\n Imaging: CXR today\n Fluids: kvo\n Consults: general/trauma surgery\n Billing Diagnosis: Other: megacolon\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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: Comments:\n Code status: Full code\n Disposition:\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367588, "text": "73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Atrial fibrillation (Afib)\n Assessment:\n Pt turned at the beginning of the shift and HR increased to 140-150 in\n afib, BP remained stable with BP from 100/64\n 140/68. settled\n slightly yet still HR remained from 120-130\n Action:\n Pt rebolused w/ 150mg of amiodarone a 8:45pm, lytes and abg sent.\n Response:\n Potassium came back at 3.7, repleted with total of 40meq\ns, abg wnl\n Pt converted back to sinus rhythm at 10pm and remains in sinus this\n AM. Amiodarone gtt decreased to 0.5mg/hr at midnight.\n Plan:\n Con\nt to monitor HR closely, con\nt amio gtt per team, not able to\n convert to PO\ns at this time secondary to still NPO . Follow lytes and\n replete as ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt w/ brisk u/o throughout the shift. Creat down to 1.7 this AM.\n Action:\n U/O monitored q one hour over night\n Response:\n Con\nt w/ brisk output , no lasix given over night.\n Plan:\n Con\nt to monitor closely, consider repeat lasix if u/o drops off.\n Problem\n C diff colitis\n Assessment:\n Abd soft distended s/p colectomy and ileostomy. Midline incision D+I,\n ileostomy red and edematous. Ileostomy draining green liquid stool,\n OGT w/ bilious output. Abd soft distended, bowel sounds present.\n Action:\n Monitor abd, pain med given as needed for c/o abd pain\n Response:\n Good relief noted with pain med\n Plan:\n Con\nt to monitor closely, pain med as ordered.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt on CPAP over night, PSV of 5 and 8 of PEEP, 50%, pt satting at\n 96-100% throughout shift. Breath sounds clear in upper lobes yet exp\n wheezes in bases intermittently. Suctioned for thick yellow/tan\n secretions, sputum spec sent. No resp distress over night.\n Action:\n Pulmonary toilet, risb this AM 31, ABG w/I nl limits.\n Response:\n Stable resp status over night\n Plan:\n Con\nt pulmonary hygiene as tolerates, con\nt to wean vent.\n Sepsis, Severe (with organ dysfunction)\n Assessment:\n T max 101.1, WBC increased slightly to 14.7\n Action:\n Pt pan cultured\n Response:\n Temp down on it\ns own, culture results pnd,\n Plan:\n Con\nt on antibiotics as ordered, follow culture results.\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Intensivist Note", "row_id": 367598, "text": "TSICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 15. Heparin 5000 UNIT\n SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n 24 Hour Events:\n PAN CULTURE - At 09:30 PM\n FEVER - 101.1\nF - 08:00 PM\n Post operative day:\n POD#3 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 03:13 PM\n Furosemide (Lasix) - 04:15 PM\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:20 AM\n Fentanyl - 05:49 AM\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: 38.4\nC (101.1\n T current: 37.6\nC (99.7\n HR: 102 (88 - 165) bpm\n BP: 170/80(111) {78/44(55) - 174/80(111)} mmHg\n RR: 23 (0 - 38) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84.1 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 12 (10 - 68) mmHg\n Total In:\n 2,226 mL\n 360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,226 mL\n 360 mL\n Blood products:\n Total out:\n 6,870 mL\n 1,200 mL\n Urine:\n 4,870 mL\n 950 mL\n NG:\n 850 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -4,644 mL\n -840 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 697 (633 - 719) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 12\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n SPO2: 97%\n ABG: 7.45/36/123/25/2\n Ve: 8.1 L/min\n PaO2 / FiO2: 246\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Distended, ileostomy\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 200 K/uL\n 10.1 g/dL\n 97 mg/dL\n 1.7 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 55 mg/dL\n 111 mEq/L\n 143 mEq/L\n 27.8 %\n 14.3 K/uL\n [image002.jpg]\n 10:50 AM\n 02:36 PM\n 05:21 PM\n 05:29 PM\n 01:59 AM\n 05:30 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n WBC\n 11.3\n 11.2\n 14.3\n Hct\n 29.0\n 26.9\n 27.8\n Plt\n 157\n 141\n 200\n Creatinine\n 3.2\n 2.9\n 2.1\n 1.7\n Troponin T\n 0.03\n TCO2\n 19\n 22\n 21\n 21\n 26\n Glucose\n 108\n 104\n 92\n 97\n Other labs: PT / PTT / INR:16.5/34.1/1.5, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, Ca:7.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: off sedation, AOE x 3, Ativan PRN. Start dilaudid, wean\n fentanyl.\n Cardiovascular: htn off pressors. On amio gtt for a fib with RVR. Cont\n amiodarone. Using monitor for titration\n Pulmonary: improved oxygenation down to CPAP/PSV 5/5. start Lasix drip\n goal neg 2.5L\n Gastrointestinal / Abdomen: NPO/IVF, abx. mature ostomy at bedside\n Nutrition: NPO. starting TF today per .\n Renal: ARF on CKD resolved, Currently Cr: 1.7, improved from\n yesterday. Overall negative 4 litres\n Hematology: Stable anemia.\n Endocrine: RISS\n Infectious Disease: vanc//Flagyl, f/u cx, sputum culture yeast\n consider coverage\n Lines / Tubes / Drains: L TLC, Aline, PIV, ETT, Foley, axillary fem\n line monitor\n Wounds:\n Imaging: CXR today\n Fluids: kvo\n Consults: general/trauma surgery\n Billing Diagnosis: Other: megacolon\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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: Comments:\n Code status: Full code\n Disposition: icu\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Intensivist Note", "row_id": 367600, "text": "TSICU\n HPI:\n 73M with C.diff colitis, sepsis, resp failure, ARF, ?toxic megacolon,\n s/p ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 15. Heparin 5000 UNIT\n SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n 24 Hour Events:\n PAN CULTURE - At 09:30 PM\n FEVER - 101.1\nF - 08:00 PM\n Post operative day:\n POD#3 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Amiodarone - 0.5 mg/min\n Other ICU medications:\n Metoprolol - 03:13 PM\n Furosemide (Lasix) - 04:15 PM\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Lorazepam (Ativan) - 01:20 AM\n Fentanyl - 05:49 AM\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: 38.4\nC (101.1\n T current: 37.6\nC (99.7\n HR: 102 (88 - 165) bpm\n BP: 170/80(111) {78/44(55) - 174/80(111)} mmHg\n RR: 23 (0 - 38) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 84.1 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 12 (10 - 68) mmHg\n Total In:\n 2,226 mL\n 360 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,226 mL\n 360 mL\n Blood products:\n Total out:\n 6,870 mL\n 1,200 mL\n Urine:\n 4,870 mL\n 950 mL\n NG:\n 850 mL\n 50 mL\n Stool:\n Drains:\n Balance:\n -4,644 mL\n -840 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 697 (633 - 719) mL\n PS : 5 cmH2O\n RR (Set): 20\n RR (Spontaneous): 12\n PEEP: 8 cmH2O\n FiO2: 50%\n RSBI: 31\n PIP: 14 cmH2O\n Plateau: 20 cmH2O\n SPO2: 97%\n ABG: 7.45/36/123/25/2\n Ve: 8.1 L/min\n PaO2 / FiO2: 246\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Irregular)\n Respiratory / Chest: (Breath Sounds: Crackles : )\n Abdominal: Distended, ileostomy\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 200 K/uL\n 10.1 g/dL\n 97 mg/dL\n 1.7 mg/dL\n 25 mEq/L\n 4.2 mEq/L\n 55 mg/dL\n 111 mEq/L\n 143 mEq/L\n 27.8 %\n 14.3 K/uL\n [image002.jpg]\n 10:50 AM\n 02:36 PM\n 05:21 PM\n 05:29 PM\n 01:59 AM\n 05:30 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n WBC\n 11.3\n 11.2\n 14.3\n Hct\n 29.0\n 26.9\n 27.8\n Plt\n 157\n 141\n 200\n Creatinine\n 3.2\n 2.9\n 2.1\n 1.7\n Troponin T\n 0.03\n TCO2\n 19\n 22\n 21\n 21\n 26\n Glucose\n 108\n 104\n 92\n 97\n Other labs: PT / PTT / INR:16.5/34.1/1.5, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:2.4 g/dL, Ca:7.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis, sepsis, resp failure,\n ARF, ?toxic megacolon, s/p ex lap, total abd colectomy, end ileostomy\n .\n Neurologic: off sedation, AOE x 3, Ativan PRN. Start Dilaudid for\n better pain control and wean fentanyl.\n Cardiovascular: htn off pressors. On amio gtt for a fib with RVR.\n Please stop amiodarone today.\n Pulmonary: improved oxygenation down to CPAP/PSV 5/5. start Lasix drip\n goal neg 2-3 L and extubated today if passes SBT.\n Gastrointestinal / Abdomen: NPO/IVF, abx. mature ostomy at bedside\n Nutrition: NPO. starting TF today per .\n Renal: ARF on CKD resolving, Currently Cr: 1.7, improved from\n yesterday and trending down. Keep negative 2-3 L today\n Hematology: Stable anemia\n monitor.\n Endocrine: RISS with adequate glucose control. Keep < 150\n Infectious Disease: vanc//Flagyl, f/u cx.\n Lines / Tubes / Drains: L TLC, Aline, PIV, ETT, Foley, axillary fem\n line monitor\n Wounds:\n Imaging: CXR today\n Fluids: kvo\n Consults: general/trauma surgery\n Billing Diagnosis: Other: megacolon\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Multi Lumen - 08:45 PM\n Arterial Line - 12:25 PM\n 20 Gauge - 12:00 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: Comments:\n Code status: Full code\n Disposition: icu\n Total time spent: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367713, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Atrial fibrillation (Afib)\n Assessment:\n Pt in SR w/ rate in the 80-90\ns at the beginning of the shift.. Had\n received first PO dose of amiodarone 400mg at 5pm, IV gtt of amio at\n 0.5mg/min turned off at 9:30pm Pt hypotensive at that time with BP as\n low as 75/45.\n Action:\n Amio gtt off, Pt given 500cc bolus of LR\n Response:\n BP back up to 90\ns/55-65, pt remains in SR over the night.\n Plan:\n Con\nt to monitor HR closely, pt now getting PO amiodarone and PO\n lopressor as ordered. Check lytes and replete as ordered.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt off lasix gtt over night as he was 3 liters negative for the day and\n transiently hypotensive as above. Creat stable this am at 1.1, NA and\n chloride slightly elevated. U/O remained greater than 60cc\ns/hour\n throughout shift.\n Action:\n Pt bolused w/ fluid as above, uvolemic this am.\n Response:\n Pt\ns weight down 5kg this AM, edema decreasing\n Plan:\n Con\nt to monitor closely, assess for need for further diuresis however\n may be dry according to lytes.\n Problem\n s/p colostomy/ileostomy\n Assessment:\n Pt tolerating clear liquids over night, ileostomy still edematous and\n red\n Action:\n Pt assisted w/ po intake\n Response:\n Pt denies any nausea/vomiting\n Plan:\n Con\nt to advance PO diet as tolerated.\n" }, { "category": "Physician ", "chartdate": "2131-02-26 00:00:00.000", "description": "Intensivist Note", "row_id": 367726, "text": "SICU\n HPI:\n 73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff colitis/toxic megacolon, sepsis, resp failure, ARF\n PMHx:\n PMH: HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 15. HYDROmorphone\n (Dilaudid) 0.25 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0\n mg(s)/hour 1-hr Max Limit: 2.5 mg(s) Order date: @ 1215\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Heparin 5000 UNIT SC TID Order date:\n @ 1053\n 3. 1000 mL LR Bolus 500 ml Over 10 mins Order date: @ 2126 17.\n Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 4. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 18.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 5. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 19.\n Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1505\n 6. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 20. Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 8. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Order date: @ 1505\n 22. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 9. Albumin 5% (25g / 500mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 2126 23. Meropenem 500 mg IV Q12H Order date: @ 1053\n 10. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 24. Metoprolol Tartrate 12.5 mg PO TID\n hold for SBP<100, HR<55 Order date: @ 1604\n 11. Amiodarone 400 mg PO BID Order date: @ 1604 25. Pantoprazole\n 40 mg IV Q24H Order date: @ 0826\n 12. Calcium Gluconate IV Sliding Scale Order date: @ 1053 26.\n Potassium Chloride IV Sliding Scale Order date: @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: @\n 1053\n 14. Furosemide 1-5 mg/hr IV DRIP INFUSION\n titrate to 2.5L neg/24h Order date: @ 0816 28. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1053\n 24 Hour Events:\n EXTUBATION - At 11:17 AM\n INVASIVE VENTILATION - STOP 11:18 AM\n ARTERIAL LINE - STOP 01:02 PM\n for \n started sips\n started PO amio & Lopressor, d/c'd amio gtt\n Lasix gtt, neg ~2.8L\n overdiuresed -> hypotensive -> bolused 500 cc LR\n Dilaudid PCA\n Post operative day:\n POD#4 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:11 AM\n Hydromorphone (Dilaudid) - 12:02 PM\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:55 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: 37.6\nC (99.6\n HR: 105 (87 - 117) bpm\n BP: 143/60(84) {73/37(50) - 184/80(111)} mmHg\n RR: 21 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 79.5 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 6 (4 - 17) mmHg\n Total In:\n 1,609 mL\n 447 mL\n PO:\n 180 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,429 mL\n 267 mL\n Blood products:\n Total out:\n 4,370 mL\n 550 mL\n Urine:\n 3,770 mL\n 550 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -2,761 mL\n -103 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 655 (655 - 655) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 31\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.46/36/138/30/2\n Ve: 11 L/min\n PaO2 / FiO2: 345\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), slightly tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n appropriately, inferior incisional erythema, ostomy pink with bilious\n material & gas in bag\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: dressing c/d/i. Erythema around colostomy and distal incision\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 232 K/uL\n 9.7 g/dL\n 126 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 41 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.6 %\n 12.1 K/uL\n [image002.jpg]\n 01:59 AM\n 05:30 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n 05:52 PM\n 06:02 PM\n 02:01 AM\n WBC\n 11.2\n 14.3\n 12.1\n Hct\n 26.9\n 27.8\n 26.6\n Plt\n 141\n 200\n 232\n Creatinine\n 2.9\n 2.1\n 1.7\n 1.2\n 1.1\n TCO2\n 21\n 21\n 26\n 26\n 26\n Glucose\n 104\n 92\n 97\n 88\n 101\n 94\n 126\n Other labs: PT / PTT / INR:18.4/36.8/1.7, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:1.9 g/dL, Ca:7.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.9 mg/dL\n Imaging: CXR: L pleural effusion/consolidation\n Microbiology: MRSA: neg\n urine: neg\n bld x2: P\n urine: P\n bld x2: P\n sputum: 3+ yeast\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis/toxic metacolon, sepsis,\n resp failure, ARF, s/p ex lap, total abd colectomy, end ileostomy .\n Neurologic: Pain controlled, Dilaudid PCA.\n Cardiovascular: F/u Cards consult for AF Amio 400\" x 2 wks -> amio\n 400' x 2 wks -> 200'. Metoprolol 12.5'''\n increase to 25 tid.\n Continue Lasix.\n Pulmonary: IS, Aggressive pulm toilet. Continue diuresis.\n Gastrointestinal / Abdomen: Ostomy functioning. Wound erythematous.\n Tolerating sips. ? Clears if o.k. with primary team.\n Nutrition: Clear liquids, Tolerating sips. ?clears\n Renal: Foley, Adequate UO, Continue diuresis. ARF normalized, Cr\n normal 1.1. Lytes stable. Keep negative 1-2 L negative today as still\n over dry weight.\n Hematology: Stable anemia. If o.k. with primary team would\n anticoagulate per cards, if not, will hold off for now.\n Endocrine: RISS with adequate glucose control, Goal FS<150.\n Infectious Disease: Check cultures, WBC decreasing. Continue Flagyl, ?\n d/c meropenum. F/u cx.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Comments: On sips, ?adv to clears.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: PPI\n switch to 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: 20 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367708, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nutrition", "chartdate": "2131-02-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 367734, "text": "Subjective\n \" i am starving\" pt reports having jello and juice without any N/V\n had good appetite and po intake PTA no wt loss\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 78 kg\n 79.5 kg ( 04:00 AM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n Pertinent medications: RISS, heparin. IV abx, heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 126 mg/dL\n 02:01 AM\n Glucose Finger Stick\n 103\n 08:00 PM\n BUN\n 41 mg/dL\n 02:01 AM\n Creatinine\n 1.1 mg/dL\n 02:01 AM\n Sodium\n 147 mEq/L\n 02:01 AM\n Potassium\n 4.1 mEq/L\n 02:01 AM\n Chloride\n 113 mEq/L\n 02:01 AM\n TCO2\n 30 mEq/L\n 02:01 AM\n PO2 (arterial)\n 138 mm Hg\n 06:02 PM\n PCO2 (arterial)\n 36 mm Hg\n 06:02 PM\n pH (arterial)\n 7.46 units\n 06:02 PM\n pH (urine)\n 5.0 units\n 11:37 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 06:02 PM\n Albumin\n 1.9 g/dL\n 02:01 AM\n Calcium non-ionized\n 7.5 mg/dL\n 02:01 AM\n Phosphorus\n 3.9 mg/dL\n 02:01 AM\n Ionized Calcium\n 1.09 mmol/L\n 10:33 AM\n Magnesium\n 1.9 mg/dL\n 02:01 AM\n ALT\n 30 IU/L\n 02:03 AM\n Alkaline Phosphate\n 75 IU/L\n 02:03 AM\n AST\n 37 IU/L\n 02:03 AM\n Total Bilirubin\n 0.6 mg/dL\n 02:03 AM\n WBC\n 12.1 K/uL\n 02:01 AM\n Hgb\n 9.7 g/dL\n 02:01 AM\n Hematocrit\n 26.6 %\n 02:01 AM\n Current diet order / nutrition support: clear liquids\n GI: soft, +BS\n Assessment of Nutritional Status\n Specifics: Pt was extubated, TF was ordered on but never started\n d/t extubation and TF ordered d/c\nd. Pt tolerating clear liquid diet\n with plans to advance diet. Renal function is improved.\n Medical Nutrition Therapy Plan - Recommend the Following\n Advance diet as tolerated\n Encourage pos\n Multivitamin / Mineral supplement: via po\n Will follow POC page with questions\n" }, { "category": "Physician ", "chartdate": "2131-02-27 00:00:00.000", "description": "Intensivist Note", "row_id": 367816, "text": "SICU\n HPI:\n 73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff colitis/toxic metacolon, sepsis, resp failure, ARF\n PMHx:\n HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A fib,\n COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Albuterol-Ipratropium 5. Albuterol\n Inhaler 6. Albuterol 0.083% Neb Soln\n 7. Albumin 5% (12.5g / 250mL) 8. Amiodarone 9. Aspirin EC 10. Calcium\n Gluconate 11. Ciprofloxacin HCl\n 12. Famotidine 13. Fentanyl Citrate 14. HYDROmorphone (Dilaudid) 15.\n Heparin 16. Influenza Virus Vaccine\n 17. Insulin 18. Ipratropium Bromide Neb 19. Lorazepam 20. Magnesium\n Sulfate 21. MetRONIDAZOLE (FLagyl)\n 22. Metoprolol Tartrate 23. Metoprolol Tartrate 24. Nystatin Oral\n Suspension 25. Potassium Chloride\n 26. Qvar 27. Simvastatin 28. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n Started on nystatin swish and swallow for po thrush. Meropenem d/c,\n Cipro started for ?wound infection.\n Post operative day:\n POD#5 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:24 PM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Lorazepam (Ativan) - 05:30 PM\n Metoprolol - 10:45 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:41 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: 37.2\nC (98.9\n HR: 92 (84 - 112) bpm\n BP: 134/59(86) {70/38(35) - 202/79(117)} mmHg\n RR: 18 (12 - 26) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 79.5 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 4 (1 - 14) mmHg\n Total In:\n 1,710 mL\n 455 mL\n PO:\n 960 mL\n 300 mL\n Tube feeding:\n IV Fluid:\n 750 mL\n 155 mL\n Blood products:\n Total out:\n 2,715 mL\n 1,300 mL\n Urine:\n 1,745 mL\n 600 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,005 mL\n -845 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///31/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Distant heart sounds: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n appropriately, Erythema inferior to incision\n Left Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Pulse - Dorsalis pedis: Present),\n (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 262 K/uL\n 10.0 g/dL\n 113 mg/dL\n 0.9 mg/dL\n 31 mEq/L\n 4.2 mEq/L\n 29 mg/dL\n 112 mEq/L\n 147 mEq/L\n 28.2 %\n 14.0 K/uL\n [image002.jpg]\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n 05:52 PM\n 06:02 PM\n 02:01 AM\n 02:00 PM\n 01:57 AM\n WBC\n 14.3\n 12.1\n 14.0\n Hct\n 27.8\n 26.6\n 28.2\n Plt\n 200\n 232\n 262\n Creatinine\n 2.1\n 1.7\n 1.2\n 1.1\n 0.9\n TCO2\n 21\n 26\n 26\n 26\n Glucose\n 92\n 97\n 88\n 101\n 94\n 126\n 173\n 113\n Other labs: PT / PTT / INR:20.1/51.8/1.9, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:1.9 g/dL, Ca:7.6 mg/dL,\n Mg:1.7 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis/toxic metacolon, sepsis,\n resp failure, ARF, s/p ex lap, total abd colectomy, end ileostomy .\n Neurologic: Pain controlled, Continue Diluadid PCA\n Cardiovascular: Aspirin, Beta-blocker, Statins, Patient currently in\n sinus Rhythm. Hemodynamically stable. ASA and Statin started yesterday.\n Continue po Amio, titrate up po Lopressor as tolerated. (advance to 50\n mg po tid today). Get 2d echo.\n Pulmonary: IS, agressive pulm toliet.\n Gastrointestinal / Abdomen: Clears, will advance diet as tolerated as\n per primary team\n Nutrition: will advance diet as tolerated as per primary team\n Renal: Foley, Adequate UO, Patient auto-diuresing.patient approaching\n dry weight.\n Hematology: Stable Anemia\n Endocrine: RISS, FS fairly well controlled. Goal FS <150\n Infectious Disease: Check cultures, Started on Cipro for wound\n infection . Meropenem d/c. Continue Flagyl for C.diff\n Lines / Tubes / Drains: Foley\n Wounds: Wet / Dry dressings\n Imaging:\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n" }, { "category": "Respiratory ", "chartdate": "2131-02-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367573, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 5\n Ideal body weight: 69.9\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Outside hospital\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 6 mL / Air\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 / Small\n Ventilation Assessment\n Level of breathing assistance: PSV5/8/.5\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n" }, { "category": "Respiratory ", "chartdate": "2131-02-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 367527, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 69.9 None\n Ideal tidal volume: 279.6 / 419.4 / 559.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 26 cmH2O\n Cuff volume: 6 mL / Air\n Airway problems:\n Comments:\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 / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt placed on PSV settings this afternoon; tolerating well at\n this time. Peep wean throughout shift & tolerating well.\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: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2131-02-26 00:00:00.000", "description": "Intensivist Note", "row_id": 367697, "text": "SICU\n HPI:\n 73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Chief complaint:\n C.diff colitis/toxic megacolon, sepsis, resp failure, ARF\n PMHx:\n PMH: HTN, perforated diverticulitis c/b sepsis, resp failure ARF; A\n fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA), SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n Current medications:\n 1. IV access: Temporary central access (ICU) Location: Left Subclavian,\n Date inserted: Order date: @ 1053 15. HYDROmorphone\n (Dilaudid) 0.25 mg IVPCA Lockout Interval: 6 minutes Basal Rate: 0\n mg(s)/hour 1-hr Max Limit: 2.5 mg(s) Order date: @ 1215\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Heparin 5000 UNIT SC TID Order date:\n @ 1053\n 3. 1000 mL LR Bolus 500 ml Over 10 mins Order date: @ 2126 17.\n Influenza Virus Vaccine 0.5 mL IM ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 4. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 18.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 5. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 19.\n Ipratropium Bromide Neb 1 NEB IH Q6H Order date: @ 1505\n 6. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 20. Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 7. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 21.\n Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 8. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Order date: @ 1505\n 22. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 9. Albumin 5% (25g / 500mL) 25 g IV 1X Duration: 1 Doses Order date:\n @ 2126 23. Meropenem 500 mg IV Q12H Order date: @ 1053\n 10. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 24. Metoprolol Tartrate 12.5 mg PO TID\n hold for SBP<100, HR<55 Order date: @ 1604\n 11. Amiodarone 400 mg PO BID Order date: @ 1604 25. Pantoprazole\n 40 mg IV Q24H Order date: @ 0826\n 12. Calcium Gluconate IV Sliding Scale Order date: @ 1053 26.\n Potassium Chloride IV Sliding Scale Order date: @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: @\n 1053\n 14. Furosemide 1-5 mg/hr IV DRIP INFUSION\n titrate to 2.5L neg/24h Order date: @ 0816 28. Sodium Chloride\n 0.9% Flush 10 mL IV PRN line flush\n Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and\n PRN. Order date: @ 1053\n 24 Hour Events:\n EXTUBATION - At 11:17 AM\n INVASIVE VENTILATION - STOP 11:18 AM\n ARTERIAL LINE - STOP 01:02 PM\n for \n started sips\n started PO amio & Lopressor, d/c'd amio gtt\n Lasix gtt, neg ~2.8L\n overdiuresed -> hypotensive -> bolused 500 cc LR\n Dilaudid PCA\n Post operative day:\n POD#4 - s/p colectomy and ileostomy\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Last dose of Antibiotics:\n Meropenem - 12:00 AM\n Metronidazole - 12:00 AM\n Infusions:\n Other ICU medications:\n Fentanyl - 08:11 AM\n Hydromorphone (Dilaudid) - 12:02 PM\n Pantoprazole (Protonix) - 12:00 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 05:55 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: 37.6\nC (99.6\n HR: 105 (87 - 117) bpm\n BP: 143/60(84) {73/37(50) - 184/80(111)} mmHg\n RR: 21 (9 - 25) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 79.5 kg (admission): 78 kg\n Height: 68 Inch\n CVP: 6 (4 - 17) mmHg\n Total In:\n 1,609 mL\n 447 mL\n PO:\n 180 mL\n 180 mL\n Tube feeding:\n IV Fluid:\n 1,429 mL\n 267 mL\n Blood products:\n Total out:\n 4,370 mL\n 550 mL\n Urine:\n 3,770 mL\n 550 mL\n NG:\n 150 mL\n Stool:\n Drains:\n Balance:\n -2,761 mL\n -103 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: PSV/SBT\n Vt (Spontaneous): 655 (655 - 655) mL\n PS : 5 cmH2O\n RR (Spontaneous): 17\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 31\n PIP: 11 cmH2O\n SPO2: 96%\n ABG: 7.46/36/138/30/2\n Ve: 11 L/min\n PaO2 / FiO2: 345\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), slightly tachy\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Bowel sounds present, Distended, Tender:\n appropriately, inferior incisional erythema, ostomy pink with bilious\n material & gas in bag\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Skin: dressing c/d/i\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 232 K/uL\n 9.7 g/dL\n 126 mg/dL\n 1.1 mg/dL\n 30 mEq/L\n 4.1 mEq/L\n 41 mg/dL\n 113 mEq/L\n 147 mEq/L\n 26.6 %\n 12.1 K/uL\n [image002.jpg]\n 01:59 AM\n 05:30 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n 05:52 PM\n 06:02 PM\n 02:01 AM\n WBC\n 11.2\n 14.3\n 12.1\n Hct\n 26.9\n 27.8\n 26.6\n Plt\n 141\n 200\n 232\n Creatinine\n 2.9\n 2.1\n 1.7\n 1.2\n 1.1\n TCO2\n 21\n 21\n 26\n 26\n 26\n Glucose\n 104\n 92\n 97\n 88\n 101\n 94\n 126\n Other labs: PT / PTT / INR:18.4/36.8/1.7, CK / CK-MB / Troponin\n T:265/5/0.03, ALT / AST:30/37, Alk-Phos / T bili:75/0.6,\n Differential-Neuts:51.0 %, Band:25.0 %, Lymph:5.0 %, Mono:17.0 %,\n Eos:0.0 %, Lactic Acid:0.8 mmol/L, Albumin:1.9 g/dL, Ca:7.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.9 mg/dL\n Imaging: CXR: L pleural effusion/consolidation\n Microbiology: MRSA: neg\n urine: neg\n bld x2: P\n urine: P\n bld x2: P\n sputum: 3+ yeast\n Assessment and Plan\n ATRIAL FIBRILLATION (AFIB), ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS,\n ACUTE LUNG INJURY, ), SUPRAVENTRICULAR TACHYCARDIA (SVT), IMPAIRED\n SKIN INTEGRITY, SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION), RENAL FAILURE,\n ACUTE (ACUTE RENAL FAILURE, ARF), PROBLEM - ENTER DESCRIPTION IN\n COMMENTS\n CDiff Colitis\n Assessment and Plan: 73M with C.diff colitis/toxic metacolon, sepsis,\n resp failure, ARF, s/p ex lap, total abd colectomy, end ileostomy .\n Neurologic: Pain controlled, Dilaudid PCA.\n Cardiovascular: F/u Cards consult. Amio 400\" x 2 wks -> amio 400' x 2\n wks -> 200'. Metoprolol 12.5'''. ?Continue Lasix gtt.\n Pulmonary: IS, Aggressive pulm toilet. Continue diuresis, ?gtt.\n Gastrointestinal / Abdomen: Ostomy functioning. Wound erythematous.\n Tolerating sips. ?Clears\n Nutrition: Clear liquids, Tolerating sips. ?clears\n Renal: Foley, Adequate UO, Continue diuresis, ?gtt. Cr normal 1.1.\n Lytes stable.\n Hematology: Stable. ?anticoagulation\n Endocrine: RISS, Goal FS<150.\n Infectious Disease: Check cultures, WBC decreasing. Continue\n /Flagyl. F/u cx.\n Lines / Tubes / Drains: Foley\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: General surgery, Cardiology\n Billing Diagnosis: (Respiratory distress: Failure), (Shock: Septic),\n Acute renal failure\n ICU Care\n Nutrition:\n Comments: On sips, ?adv to clears.\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 08:32 PM\n Multi Lumen - 08:45 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: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 367893, "text": "73 yom with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF,\n s/p ex lap, total abd colectomy & end ileostomy .\n EVENTS: Minimal sleep overnight, now resting/sleeping comfortably this\n afternoon.\n PCA used minimally. DC\nd and change to PRN percocet.\n Tolerating clear/full liquids well- advance diet as\n tolerated.\n Bedside ECHO\n * SpO2 94-96% on 2L NC, LS clear & diminished with occasional exp\n wheezing. Atrovent nebs Q6H ATC & albuterol nebs prn. Encouraged to\n CDB, using IS at 1 liter.\n Atrial fibrillation (Afib)\n Assessment:\n h/o Afib, however currently in SR. HR 70-90s.\n Action:\n Receiving 400mg amiodarone & 50mg lopressor for afib.\n Response:\n Has been in SR for past 48 hrs with no runs of Afib or SVT.\n Plan:\n Cont to CV status, cont to give amiodarone & lopressor as ordered.\n Will require tele on flr.\n Total colectomy w/ end ileostomy\n Assessment:\n Abd softly distended & tender to palpation. Midline incision stapled &\n OTA, erythema noted along distal portion of incision. Lower portion of\n incision open, wet to dry dsg changed everyday by surgical team and/or\n prn. Ileostomy red & patent, draining small to moderate amts of green\n liquid stool.\n Action:\n Dilaudid PCA discontinued & pt started on PO percocet prn with adequate\n relief of abd discomfort secondary to incision. Wet to dry dsg changed\n this am by surgical team. Tolerating POs well, denies nausea,\n encouraged to eat solids. Receiving flagyl & cipro for anbx coverage.\n Physical therapy by this am to work with pt.\n Response:\n Pain tolerable. Pt tolerating movement & turning well, able to assist\n with turns & ambulate- although requires 2 person assist when\n ambulating.\n Plan:\n Cont to GI status, encourage PO intake, cont wet to dry dsg\n changes prn, cont to administer anbx as ordered, prn percocet for\n relief of pain.\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n ACUTE RENAL FAILURE\n Code status:\n Full code\n Height:\n 68 Inch\n Admission weight:\n 78 kg\n Daily weight:\n 79.5 kg\n Allergies/Reactions:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Precautions: Contact\n PMH: Asthma, COPD\n CV-PMH: Arrhythmias, CVA, Hypertension\n Additional history: perforated diverticulitis with sepsis, resp,\n renal failure and afib\n colectomy followed by multiple abcesses\n diverticulitis , SBO \n exp lab for sbo and loa\n L hernia repair\n prostate cancer\n Surgery / Procedure and date: exlap colectomy with ileostomy\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:101\n D:52\n Temperature:\n 97\n Arterial BP:\n S:156\n D:67\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 81 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 70% %\n 24h total in:\n 1,787 mL\n 24h total out:\n 1,975 mL\n Pertinent Lab Results:\n Sodium:\n 147 mEq/L\n 01:57 AM\n Potassium:\n 4.2 mEq/L\n 01:57 AM\n Chloride:\n 112 mEq/L\n 01:57 AM\n CO2:\n 31 mEq/L\n 01:57 AM\n BUN:\n 29 mg/dL\n 01:57 AM\n Creatinine:\n 0.9 mg/dL\n 01:57 AM\n Glucose:\n 113 mg/dL\n 01:57 AM\n Hematocrit:\n 28.2 %\n 01:57 AM\n Finger Stick Glucose:\n 216\n 02:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Transferred from: \n Transferred to: CC614\n Date & time of Transfer: at 1730\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 367880, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n EVENTS: Minimal sleep overnight.\n PCA used minimally. DC\nd and change to PRN percocet.\n Tolerated clear/full liquids well- advance diet as\n tolerated.\n Bedside ECHO\n * SpO2 94-96% on 2L NC, LS clear & diminished with occasional exp\n wheezes. Albuterol & atrovent nebs administered prn. Encouraged to CDB,\n using IS at 1 liter.\n Atrial fibrillation (Afib)\n Assessment:\n h/o Afib, however currently in SR. HR 70-90s.\n Action:\n Receiving 400mg amiodarone & 50mg lopressor for afib.\n Response:\n Has been in SR for past 48 hrs with no runs of Afib or SVT.\n Plan:\n Cont to CV status, cont to give amiodarone & lopressor as ordered.\n Will require tele on flr.\n Total colectomy w/ end ileostomy\n Assessment:\n Abd softly distended & tender to palpation. Midline incision stapled &\n OTA, erythema noted along distal portion of incision. Lower portion of\n incision open, wet to dry dsg changed everyday by surgical team and/or\n prn. Ileostomy red & patent, draining small to moderate amts of green\n liquid stool.\n Action:\n Dilaudid PCA discontinued & pt started on PO percocet prn with adequate\n relief of abd discomfort secondary to incision. Wet to dry dsg changed\n this am by surgical team. Tolerating POs well, denies nausea,\n encouraged to eat solids. Receiving flagyl & cipro for anbx coverage.\n Physical therapy by this am to work with pt.\n Response:\n Pain tolerable. Pt tolerating movement & turning well, able to assist\n with turns & ambulate- although requires 2 person assist when\n ambulating.\n Plan:\n Cont to GI status, encourage PO intake, cont wet to dry dsg\n changes prn, cont to administer anbx as ordered, prn percocet for\n relief of pain.\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 367888, "text": "73 yom with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF,\n s/p ex lap, total abd colectomy & end ileostomy .\n EVENTS: Minimal sleep overnight, now resting/sleeping comfortably this\n afternoon.\n PCA used minimally. DC\nd and change to PRN percocet.\n Tolerating clear/full liquids well- advance diet as\n tolerated.\n Bedside ECHO\n * SpO2 94-96% on 2L NC, LS clear & diminished with occasional exp\n wheezing. Atrovent nebs Q6H ATC & albuterol nebs prn. Encouraged to\n CDB, using IS at 1 liter.\n Atrial fibrillation (Afib)\n Assessment:\n h/o Afib, however currently in SR. HR 70-90s.\n Action:\n Receiving 400mg amiodarone & 50mg lopressor for afib.\n Response:\n Has been in SR for past 48 hrs with no runs of Afib or SVT.\n Plan:\n Cont to CV status, cont to give amiodarone & lopressor as ordered.\n Will require tele on flr.\n Total colectomy w/ end ileostomy\n Assessment:\n Abd softly distended & tender to palpation. Midline incision stapled &\n OTA, erythema noted along distal portion of incision. Lower portion of\n incision open, wet to dry dsg changed everyday by surgical team and/or\n prn. Ileostomy red & patent, draining small to moderate amts of green\n liquid stool.\n Action:\n Dilaudid PCA discontinued & pt started on PO percocet prn with adequate\n relief of abd discomfort secondary to incision. Wet to dry dsg changed\n this am by surgical team. Tolerating POs well, denies nausea,\n encouraged to eat solids. Receiving flagyl & cipro for anbx coverage.\n Physical therapy by this am to work with pt.\n Response:\n Pain tolerable. Pt tolerating movement & turning well, able to assist\n with turns & ambulate- although requires 2 person assist when\n ambulating.\n Plan:\n Cont to GI status, encourage PO intake, cont wet to dry dsg\n changes prn, cont to administer anbx as ordered, prn percocet for\n relief of pain.\n" }, { "category": "Nursing", "chartdate": "2131-02-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367549, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt was in NSR until run of rapid Afib into 170s at 1500. SBP was 170s\n and dropped to 110-120s. Resident was at the bedside when episode\n occurred and lopressor 10 mg IVP given. Pt back into SR in 90s with\n frequent PACs. At 1600 pt back in afib with rate 100-120s and mod\n depression of SBP into 120s- MAP remains >60. Self limiting runs of\n rapid rate 130-160s.\n Action:\n Amiodarone bolus of 150mg given and gtt started at 1mg/min at 1810.\n Response:\n Currently in SR with HR in110s and BP 120s/60s. Pt now febrile 101.1\n which may account for st.\n Plan:\n Continue amio gtt and decrease rate to 0.5mg/min at midnight.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt remains vented. Lungs clear with crackles in bases.\n Action:\n Ventilator settings weaned to PS 5 and PEEP 8.\n Response:\n Adeq TV, RR and sats. Pt denies any SOB.\n Plan:\n Continue to wean as tolerated.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Pt with good UO averaging 200cc/h. Creatinine down to 2.1 on afternoon\n labs.\n Action:\n Lasix given for SVV 16, CVP 17, CO and HTN.\n Response:\n Brisk response to lasix and >2L neg currently.\n Plan:\n Monitor I&Os closely. Reevaluate fluid goals in rounds tomorrow.\n Problem - Description In Comments\n Assessment:\n Iileostomy, though immature, appears red, protruding and small amts\n serosang drainage.\n Action:\n Dr and Dr opened and sutured ilieosomy at bedside.\n Suctioned approximately 200cc green liquid stool at time of procedure.\n New appliance placed.\n Response:\n Several hours later 400cc emptied from ostomy bag.\n Plan:\n Continue to assess ostomy appearance and output frequently.\n" }, { "category": "Nursing", "chartdate": "2131-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367781, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Todays events:\n Atrial fibrillation (Afib)\n Assessment:\n Sinus rhythm rate increased to 120 at 1700 after staff assisted\n standing transfer from chair to bed. BP increased to 200/90.\n Action:\n Metoprolol scheduled doses increased to 3 x daily, Metoprolol 5 mg IVP\n given after no relief from ativan IVP.\n Response:\n HR 90s SR, BP 110-130 sys. Pt. resting comfortabley.\n Plan:\n Continue to monitor for increased BP and HR, medicate as needed.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Nasal canula 4 L O2. Rhonchi throughout, diminished in bases, guarded\n cough productive at times.\n Action:\n Encouraged cough and deep breathing excercises, incentive spirometry,\n OOB to chair with stand and pivot assisted by staff, chest PT and back\n rubs. Encouraged patient participation in self care.\n Response:\n Sats 93-97% on 4 L O2NC. Able to use yankauer to assist with removal of\n secretions.\n Plan:\n Continue to encourage aggressive pulmonary hygiene and increase\n activity as tolerated.\n Impaired Skin Integrity\n Assessment:\n Complains of tongue\nburning\n and lips\nchapped\n, hx of thrush with\n last intubation. Ostomy bag leaking green liquid stool.\n Action:\n Started on nystatin swish and swallow, Vaseline to lips, ostomy bag\n changed and secured.\n Response:\n Reports increased comfort, resting comfortabley.\n Plan:\n Continue to assess skin, abdominal wound not assessed by this nurse,\n dressing changed in the morning.\n" }, { "category": "Rehab Services", "chartdate": "2131-02-27 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 367870, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: sepsis / 038.9\n Reason of referral: Eval & treat\n History of Present Illness / Subjective Complaint: 73 yo M admitted to\n OSH on with weakness and lower abdominal pain, CT showing colitis\n with +c.diff, developed ARF with acute abdominal distrension and\n respiratory distress requiring intubation and pressors, transferred to\n with toxic megacolon, underwent ex. lap, total abdominal\n colectomy, and end ileostomy on . Extubated on .\n Past Medical / Surgical History: HTN, perforated diverticulitis \n c/b sepsis, s/p colectomy/Hartmanns c/b intra-abdominal abscess,\n colostomy takedown/Hartmann's reversal , SBO , ex.lap/small\n bowel rexection/LOA , s/p L inguinal hernia repair, prostate ca,\n COPD, recurrent pna, h/o CVA\n Medications: heparin, flagyl, albuterol, lorazepam, tylenol,\n amiodarone, ciprofloxacin, metoprolol, percocet\n Radiology: CXR - possible effusion and consolidation within the left\n lung base\n Labs:\n 28.2\n 10.0\n 262\n 14.0\n [image002.jpg]\n Other labs:\n INR 1.9\n PTT 51.8\n Activity Orders: Activity as tolerated\n Social / Occupational History: lives with his wife, has 10 kids, 8 live\n nearby and are very supportive.\n Living Environment: lives in multi-level home with flight of stairs to\n bedroom. has stayed on with hospital bed previously.\n Prior Functional Status / Activity Level: I pta, has RW which he was\n not using pta.\n Objective Test\n Arousal / Attention / Cognition / Communication: alert, oriented to\n self and place, for date- but easily reoriented. Follows all\n 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 84\n 102/50\n 94% on 2L\n Sit\n /\n Activity\n 94\n 97/57\n 90% on 2L\n Stand\n /\n Recovery\n /\n Total distance walked: 0\n Minutes:\n Pulmonary Status: diminished lung sounds B, reported increased WOB with\n mobility. No cough noted.\n Integumentary / Vascular: 2+ peripheral edema, L central line, tele, O2\n via NC\n Sensory Integrity: grossly intact to light touch, denies parasthesias\n Pain / Limiting Symptoms: denies pain, although asking RN for morphine\n discomfort\n Posture: mildly kyphotic posture in standing, rounded shoulders\n Range of Motion\n Muscle Performance\n B LE's grossly WNL\n B LE's grossly t/o\n shoulder flexion B\n elbow flexion/extension B\n strong grip\n Motor Function: no abnormal movement patterns, coordination slowed.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: able to take several steps in place with min A but\n declining transfer to chair fatigue. Mildly retropulsive in\n standing.\n Rolling:\n\n T\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n T\n\n\n Transfer:\n\n\n T\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: S/CG sitting. Min A static/dynamic standing activities.\n slight LOB backward initially.\n Education / Communication: Reviewed safety and d/c planning with\n patient and his wife, encouraged increased OOB time. Communicated with\n nsg re: status.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Decreased strength\n Clinical impression / Prognosis: 73 yo M with sepsis p/w above\n impairments a/w soft tissue surgery. He is most limited by general\n weakness associated with prolonged hospital stay and intubation and is\n well below his baseline level. Given his level of support at home, and\n because he has previously been able to d/c home following a similar\n admission, would anticipate that he will be able to d/c home following\n more PT tx to progress strength and endurance as able, as well as\n home PT to ensure safety and continue strengthening in home setting.\n Goals\n Time frame: 1 week\n 1.\n Independent with bed mobility, transfers, ambulation; S on stairs\n 2.\n No LOB with transfers/ambulation\n 3.\n Ambulate >/= 200' with stable HDR\n 4.\n Tolerate daily strengthening\n 5.\n 6.\n Anticipated Discharge: Home with Home PT\n Treatment :\n Frequency / Duration: daily\n bed mobility, transfers, ambulation, balance, stairs, endurance,\n strengthening, d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Physician ", "chartdate": "2131-02-25 00:00:00.000", "description": "Cardiology Comprehensive Physician Note", "row_id": 367654, "text": "TITLE:\n Date of service: \n Initial consultation: Inpatient\n Presenting complaint: Arrhythmia\n History of present illness: 73 year old male with h/o HTN, CVA and\n C.diff colitis with toxic megacolon, septic shock was transferred to\n from OSH where he presented with weakness and lower abdominal\n pain. He received a total colectomy with endileostomy on . Since\n then he developed acute renal failure and narrow complex tachycardia.\n We were consulted to help with the management of this supraventricular\n tachycardia. The SVT started on . Amiodarone iv was started\n which helped control the heart rate and eventually converted him to\n sinus. When amiodarone was stopped today he reverted to his SVT.\n Past medical history: HTN, perforated diverticulitis c/b sepsis, resp\n failure ARF; A fib, COPD, CVA, prostate ca, recent PNA (2 weeks PTA),\n SBO\n PSH: sigmoid colectomy/Hartmanns (), colostomy reversal (), ex\n lap/SBR/LOA (), LIHR\n CAD Risk Factors\n CAD Risk Factors Present\n Dyslipidemia, Hypertension\n CAD Risk Factors Absent\n Diabetes mellitus, Family Hx of CAD, Family Hx of sudden cardiac death\n (Tobacco: Yes), (Quit: Yes), (Discontinue tobacco: 40 years ago)\n Cardiovascular Procedural History\n There is no history of:\n PCI\n CABG\n Pacemaker / ICD\n Allergies:\n Zosyn (Intraven.) (Piperacillin Sodium/Tazobactam)\n Rash;\n Current medications: 1. IV access: Temporary central access (ICU)\n Location: Left Subclavian, Date inserted: Order date: @\n 1053 15. Heparin 5000 UNIT SC TID Order date: @ 1053\n 2. 1000 mL LR\n Continuous at 10 ml/hr\n kvo Order date: @ 0737 16. Influenza Virus Vaccine 0.5 mL IM\n ASDIR\n Follow Influenza Protocol Document administration in POE Order date:\n @ 1844\n 3. Acetaminophen 325-650 mg PR Q4H:PRN Order date: @ 17.\n Insulin SC (per Insulin Flowsheet)\n Sliding Scale Order date: @ 1053\n 4. Acetaminophen 325-650 mg PO Q4H:PRN Order date: @ 2359 18.\n Lorazepam 1-2 mg IV Q2H:PRN Order date: @ 1459\n 5. Albuterol-Ipratropium PUFF IH Q6H:PRN Order date: @ 1053\n 19. Magnesium Sulfate IV Sliding Scale Order date: @ 1053\n 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN Order date: @ 1053 20.\n MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Order date: @ 1053\n 7. Amiodarone 0.5 mg/min IV INFUSION after 1mg/min x 6h Order date:\n @ 2359 21. Meropenem 500 mg IV Q12H Order date: @ 1053\n 8. Amiodarone 150 mg IV BOLUS ONCE Duration: 1 Doses Order date: \n @ 1715 22. Norepinephrine 0.03-0.5 mcg/kg/min IV DRIP TITRATE TO MAP >\n 60 Order date: @ 1111\n 9. Amiodarone 0.5 mg/min IV DRIP INFUSION Duration: 18 Hours Start:\n After completion of 1 mg/min infused dose. Order date: @ 1715 23.\n Pantoprazole 40 mg IV Q24H Order date: @ 0826\n 10. Amiodarone 150 mg IV ONCE Duration: 1 Doses Order date: @\n 24. Potassium Chloride IV Sliding Scale Order date: @ 1053\n 11. Calcium Gluconate IV Sliding Scale Order date: @ 1053 25.\n Propofol 5-20 mcg/kg/min IV DRIP TITRATE TO sedation Order date: \n @ 1900\n 12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL \n Use only if patient is on mechanical ventilation. Order date: @\n 1053 26. Qvar *NF* 80 mcg/Actuation Inhalation B ID Order date: \n @ 1053\n 13. Fentanyl Citrate 25-100 mcg IV Q2H:PRN Order date: @ 1053\n 27. 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: @ 1053\n 14. Furosemide 20 mg IV ONCE Duration: 1 Doses Order date: @ 1459\n 28. Vasopressin 2.4 UNIT/HR IV DRIP TITRATE TO MAP > 60 or SBP > 95\n Order date: @ 1053\n Cardiovascular ROS\n Cardiovascular ROS Signs and Symptoms Present\n Syncope\n Cardiovascular ROS Signs and Symptoms Absent\n Murmur, Rheumatic fever, Chest pain, SOB, DOE, PND, Orthopnea, Edema,\n Palpitations, Presyncope, Lightheadedness, TIA / CVA, Pulmonary\n embolism, DVT, Claudication, Exertional buttock pain, Exertional calf\n pain\n Review of Systems\n Organ system ROS abnormal\n Constitutional, Respiratory, Gastrointestinal, Allergy / Immune\n Signs and symptoms present\n Recent fevers, Cough\n Organ system ROS normal\n Eyes, ENT, Endocrine, Hematology / Lymphatic, Genitourinary,\n Musculoskeletal, Integumentary, Neurological, Psychiatric\n Signs and symptoms absent\n Chills, Rigors, Hemoptysis, Black / red stool, Bleeding during surgery\n Social History\n Marital status: lives with wife in RI\n (Alcohol: No), (Recreational drug use: No)\n Family history: emphysema in his father and brain cancer in his mother\n Physical Exam\n : 68 Inch, 173 cm\n Weight: 84.1 kg\n Eyes: (Conjunctiva and lids: WNL)\n Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and\n palette: WNL)\n Neck: (Right carotid artery: No bruit), (Left carotid artery: No\n bruit), (Jugular veins: Not visible), (Thyroid: WNL)\n Back / Musculoskeletal: (Chest wall structure: WNL)\n Respiratory: (Effort: WNL), (Auscultation: Abnormal, crackles b/l)\n Cardiac: (Rhythm: Regular, tachycardic), (Palpation / PMI: WNL),\n (Auscultation: S1: WNL, S3: Absent, S4: Absent)\n Abdominal / Gastrointestinal: (Bowel sounds: Abnormal, hyperactive),\n (Bruits: No), (Pulsatile mass: No), (Hepatosplenomegaly: No), (Other\n abnormalities: jejunostomy)\n Genitourinary: (WNL)\n Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery:\n No bruit)\n Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and\n station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery:\n Right: +, Left: +), (Posterior tibial artery: Right: +, Left: +),\n (Edema: Right: 0, Left: 0)\n Skin: ( WNL)\n Labs\n 200\n 10.1\n 88\n 1.7\n 25\n 4.2\n 55\n 111\n 143\n 27.8\n 14.3\n [image002.jpg]\n 02:07 AM\n 08:03 AM\n 02:36 PM\n 05:21 PM\n 01:59 AM\n 03:07 PM\n 03:20 PM\n 08:34 PM\n 01:22 AM\n 10:33 AM\n WBC\n 10.0\n 11.3\n 11.2\n 14.3\n Hgb\n 9.6\n 10.2\n 9.6\n 10.1\n Hct (Serum)\n 27.2\n 29.0\n 26.9\n 27.8\n Plt\n 151\n 157\n 141\n 200\n INR\n 1.4\n 1.4\n 1.5\n PTT\n 34.4\n 33.7\n 34.1\n Na+\n 133\n 134\n 136\n 139\n 143\n K + (Serum)\n 4.5\n 4.5\n 4.4\n 4.0\n 4.2\n K + (Whole blood)\n 3.7\n Cl\n 106\n 107\n 106\n 108\n 111\n HCO3\n 18\n 17\n 20\n 21\n 25\n BUN\n 63\n 60\n 63\n 57\n 55\n Creatinine\n 3.8\n 3.2\n 2.9\n 2.1\n 1.7\n Glucose\n 124\n 108\n 104\n 92\n 97\n 88\n CK\n 329\n 265\n CK-MB\n 7\n 5\n Troponin T\n 0.03\n 0.03\n O2 sat (arterial)\n 98\n ABG: 7.36 / 44 / 106 / / 0 Values as of 10:33 AM\n Tests\n ECG: : NSR with APCs LAE\n : narrow complex tachycardia likely long RP tachycardia possibly\n atrial tachycardia\n Telemetry: Several episodes of atrial tachycardia with variable block\n and one episode of atrial flutter otherwise sinus tachycardia\n Echocardiogram: (Date: ), The views are quite limited. The\n left atrium is normal in size. Left ventricular wall thicknesses are\n normal. The left ventricular cavity size is normal. Overall left\n ventricular systolic function is probably normal (LVEF>55%). Given the\n limited views, it is difficult to be sure but it appears that there are\n no wall motion abnormalities. Right ventricular chamber size and free\n wall motion are normal. The aortic root is mildly dilated. The aortic\n valve leaflets (3) appear structurally normal with good leaflet\n excursion and no aortic regurgitation. The mitral valve leaflets are\n mildly thickened. No mitral regurgitation is seen. There is no\n pericardial effusion.\n Assessment and Plan\n Mr is a 73 year old man with h/o severe C.diff colitis s/p total\n colectomy with jejunostomie now with atrial tachycardia responsive to\n amiodarone.\n Atrial tachycardia: start lopressor 25 QID PO and uptitrate if\n patient\ns BP tolerates the beta blocker, continue amiodarone 400 \n for now, no anticoagulation needed for now since atrial tachycardia not\n Afib, if patient develops Afib consider coumadin since CHADS score 2,\n would check another Echo to assess for structural abnormalities.\n Sinus tachycardia: continue pain medication and rehydration with\n crystalline solutions\n For his wheezing likely due to history of recent intubation please\n avoid beta2 agonist and use ipatropium inhalers\n Cardiovascular risk profile: consider starting ASA 81 mg and check\n lipids to assess need for statin therapy\n" }, { "category": "Nursing", "chartdate": "2131-02-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367659, "text": "Atrial fibrillation (Afib)\n Assessment:\n Pt throughout the day. Amiodarone gtt at 0.5mg/min.\n Action:\n PO amiodarone and lopressor given at 1700 after Dr spoke with\n cardiology. Amio gtt 24h dose complete at 1800 however since po not\n given til 1700 will run for few more hours.\n Response:\n Transient hypotension 30 minutes after dose given.\n Plan:\n Continue with current POC.\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Pt was placed on SBT and tolerated well. RSBI in 30s. Small amts\n secretions and lungs CTA. On Lasix gtt for goal 2.5l neg as pt has\n large + fluid balance. Strong cough with thick yellow sputum\n expectorated frequently.\n Action:\n Extubated to 50% Face tent. Lungs coarse with insp/exp wheezes despite\n several doses albuterol and atrovent. Sats dropping to 89-91% and 6LNC\n added as pt breathes through nose often and FT decreased to 40%.\n Response:\n Wheezes persist. O2 sats >95%. PaO2>130s.\n Plan:\n Cont to given frequent nebs. Frequent repositioning and C&DB. Monitor\n I&Os.\n Renal failure, acute (Acute renal failure, ARF)\n Assessment:\n Foley patent and autodiuresing well.\n Action:\n Lasix gtt started at 2mg/h for goal of 2.5l negative. Chem 7 pending.\n Response:\n Lasix stopped at 1500 as pt is 2+L negative.\n Plan:\n Monitor I&Os closely and restart Lasix if needed.\n" }, { "category": "Nursing", "chartdate": "2131-02-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 367773, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n Todays events:\n Atrial fibrillation (Afib)\n Assessment:\n Action:\n Response:\n Plan:\n Acute Respiratory Distress Syndrome (ARDS, Acute Lung Injury, )\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Skin Integrity\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2131-02-27 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 367865, "text": "73M with C.diff colitis/toxic metacolon, sepsis, resp failure, ARF, s/p\n ex lap, total abd colectomy, end ileostomy .\n EVENTS: Minimal sleep overnight.\n PCA used minimally. DC\nd and change to PRN percocet.\n Tolerated clear liquids well- advance diet as\n tolerated.\n Bedside ECHO\n Atrial fibrillation (Afib)\n Assessment:\n h/o Afib, however currently in SR. HR 70-90s.\n Action:\n Receiving 400mg amiodarone & 50mg lopressor for afib.\n Response:\n Has been in SR for past 48 hrs with no runs of Afib or SVT.\n Plan:\n Cont to CV status, cont to give amiodarone & lopressor as ordered.\n Will require tele bed on flr.\n Total colectomy w/ end ileostomy\n Assessment:\n Abd softly distended & tender to palpation. Midline incision stapled &\n OTA, erythema noted along distal portion of incision. Lower portion of\n incision open, wet to dry dsg changed every day by surgical team.\n Ileostomy red & patent, draining small to moderate amts of green liquid\n stool.\n Action:\n Response:\n Plan:\n" }, { "category": "Echo", "chartdate": "2131-02-27 00:00:00.000", "description": "Report", "row_id": 75840, "text": "PATIENT/TEST INFORMATION:\nIndication: Atrial fibrillation. Endocarditis.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 111/57\nHR (bpm): 86\nStatus: Inpatient\nDate/Time: at 11:22\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nLEFT VENTRICLE: Mild (non-obstructive) focal hypertrophy of the basal septum.\nNormal LV cavity size. Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. Overall normal LVEF (>55%). No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal\nmotion consistent with conduction abnormality/ventricular pacing.\n\nAORTA: Mildly dilated aortic sinus.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No MR. LV inflow\npattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS. No PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild (non-obstructive) focal\nhypertrophy of the basal septum. The left ventricular cavity size is normal.\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.\nThe aortic root is mildly dilated at the sinus level. The aortic valve\nleaflets (3) are mildly thickened but aortic stenosis is not present. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nThere is no mitral valve prolapse. No mitral regurgitation is seen. The left\nventricular inflow pattern suggests impaired relaxation. There is mild\npulmonary artery systolic hypertension. There is a trivial/physiologic\npericardial effusion.\n\nIMPRESSION: Mild non-obstructive septal hypertrophy with preserved global\nsystolic function. Preserved right ventricular function. No signficant\nstructural valve disease.\n\nCompared with the prior study (images unavailable for review) of , no\nmajor change.\n\n\n" }, { "category": "ECG", "chartdate": "2131-03-07 00:00:00.000", "description": "Report", "row_id": 181362, "text": "Sinus rhythm\nNonspecific low amplitude T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-06 00:00:00.000", "description": "Report", "row_id": 181363, "text": "Baseline artifact. Sinus rhythm. Since the previous tracing of \nprobably no significant change.\n\n" }, { "category": "ECG", "chartdate": "2131-03-05 00:00:00.000", "description": "Report", "row_id": 181364, "text": "Sinus rhythm\nConsider left atrial abnormality although is nondiagnostic\nLow lateral T wave amplitude is nonspecific and may be within normal limits\nSince previous tracing of , lateral T wave amplitude lower but may be no\nsignificant change\n\n" }, { "category": "ECG", "chartdate": "2131-03-02 00:00:00.000", "description": "Report", "row_id": 181365, "text": "Sinus rhythm\nConsider left atrial abnormality although is nondiagnostic and tracing may be\nwithin normal limits\nSince previous tracing of _\n\n" }, { "category": "ECG", "chartdate": "2131-03-04 00:00:00.000", "description": "Report", "row_id": 181366, "text": "Sinus rhythm. Compared to the previous tracing of no diagnostic\ninterim change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2131-03-03 00:00:00.000", "description": "Report", "row_id": 181367, "text": "Sinus rhythm. Early precordial R wave transition. Compared to the previous\ntracing of sinus rhythm has appeared. The rate has slowed and\nthere is a generalized increase in voltage. Clinical correlation is suggested.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2131-02-22 00:00:00.000", "description": "Report", "row_id": 181368, "text": "Supraventricular tachycardia, most likely representing atrio-ventricular\nnodal re-entrant tachycardia but cannot exclude atrio-ventricular reciprocating\ntachycardia. Compared to the previous tracing of cardiac rhythm\nis now supraventricular tachycardia.\n\n" }, { "category": "ECG", "chartdate": "2131-02-21 00:00:00.000", "description": "Report", "row_id": 181369, "text": "Sinus rhythm with borderline sinus tachycardia and atrial premature beats.\nConsider left atrial abnormality. Low amplitude lateral T waves are\nnon-specific and may be within normal limits. Since the previous tracing\nof rate is faster and atrial ectopy is present.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-21 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 1064820, "text": " 10:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evalute colon\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 38.4\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with known c diff, now abdominal distension, ARF, and\n hypotension\n REASON FOR THIS EXAMINATION:\n evalute colon\n CONTRAINDICATIONS for IV CONTRAST:\n ARF;ARF\n ______________________________________________________________________________\n WET READ: 12:58 AM\n DIFFUSE LARGE AND SMALL BOWEL ILEUS WITH LOSS OF NML COLONIC HAUSTRA LIKELY\n RELATED TO KNOWN COLITIS (PORTION OF DESCENDING AND SIGMOID COLON ARE SPARED).\n CECUM MEASURES APPROX 10CM, WITH SMALL BOWEL MEASURING UP TO 5CM. SMALL LEFT\n EFFUSION WITH B/L LOWER LOBE ATELECTASIS.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with C. diff colitis presenting with abdominal\n distention.\n\n COMPARISON: Multiple prior exams, the most recent dated .\n\n CT ABDOMEN: Left effusion is minimal. There is mild bibasilar atelectasis\n without evidence of consolidation. Heart size is normal there is no\n pericardial effusion. A nasogastric tube courses through the esophagus to\n terminate with its side port and tip in the stomach. 5 mm right lower lung\n ground- glass opacity (2:7) is stable since and does not require\n followup.\n\n On this non-contrast enhanced examination, the liver, gallbladder, spleen,\n adrenals, pancreas, and kidneys are unremarkable. There is dilation of small\n bowel loops (up to 5 cm in the jejunum) and large bowel loops (up to 10 cm in\n the cecum) with transition point at a 5 cm stricture at the descending\n colon/sigmoid junction. There is no pneumatosis, free fluid or free air.\n\n CT PELVIS: The rectum and sigmoid are unremarkable and contain stool and air.\n The bladder is catheterized and contains air. The prostate is unremarkable.\n Ovoid fluid density focus (2 ) in the right inguinal canal is noted.\n\n Bone windows demonstrate no evidence of lesion that is suspicious for\n metastatic or infectious focus.\n\n IMPRESSION:\n 1. High-grade bowel obstruction with transition point at the descending\n colon/sigmoid junction secondary to stricture at site of prior inflammation.\n\n 2. Right lower lung ground-glass opacity is stable since and does not\n require followup.\n\n (Over)\n\n 10:19 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: evalute colon\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Field of view: 38.4\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Findings were discussd with by phone Dr. at 11:30 AM on , who\n confirmed the patient had already undergone a colectomy.\n\n" }, { "category": "Radiology", "chartdate": "2131-03-02 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1066385, "text": " 10:01 AM\n PIC CHECK/REPO Clip # \n Reason: Please place PICC.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man needing TPN. Failed bedside PICC placement, curls into axilla.\n REASON FOR THIS EXAMINATION:\n Please place PICC.\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n INDICATION: IV access needed for TPN.\n\n The procedure was explained to the patient. A timeout was performed.\n\n RADIOLOGIST: Dr. and Dr. performed the procedure. Dr. ,\n the Attending Radiologist, was present and supervised the entire procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A peel-away sheath was then placed over a\n guidewire and a double-lumen PICC line measuring 40 cm in length was then\n placed through the peel-away sheath with its tip positioned in the SVC under\n fluoroscopic guidance. Position of the catheter was confirmed by a\n fluoroscopic spot film of the chest.\n\n The peel-away sheath and guidwire were then removed. The catheter was secured\n to the skin, flushed, and a sterile dressing applied.\n\n The patient tolerated the procedure well. There were no immediate\n complications.\n\n IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided 5-French\n double-lumen PICC line placement via the right basilic venous approach. Final\n internal length is 40 cm, with the tip positioned in SVC. The line is ready to\n use.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1064808, "text": " 8:57 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: check new left subcl tlc placement.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with resp failure.\n REASON FOR THIS EXAMINATION:\n check new left subcl tlc placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Line placement.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, an endotracheal tube has\n been placed. The tip of the tube projects 5 cm above the carina. There is a\n newly placed right-sided central venous access line over the internal jugular\n vein and a left-sided central venous access line over the subclavian vein.\n The tips of both lines project over the mid SVC. There is no evidence of\n complications, notably no pneumothorax. Otherwise, there is unchanged\n elevation of the left hemidiaphragm with subsequent basal atelectasis. The\n newly occurred atelectasis at the right medial lung bases. Otherwise, no\n focal parenchymal opacities. Unchanged size of the cardiac silhouette, no\n signs of overhydration.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1064857, "text": " 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with megacolon\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:06 AM\n PFI: Limited study due to respiratory motion with unchanged left basal\n atelectasis. No pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Megacolon.\n\n Comparison is made to prior study .\n\n This study is very limited due to respiratory motion. Bilateral atelectasis\n greater on the left side are stable. There are low lung volumes and elevation\n of the left hemidiaphragm. ET tube is in standard position. Left subclavian\n catheter tip is in the SVC. There are no enlarging pleural effusions or\n definitive pneumothorax. NG tube tip is not clearly visualized. On prior exam\n was in the stomach.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2131-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1064858, "text": ", F. TSICU 5:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with megacolon\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n PFI REPORT\n PFI: Limited study due to respiratory motion with unchanged left basal\n atelectasis. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065340, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with sepsis, total abdominal colectomy\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Status post colectomy, followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position, except for the nasogastric tube that has\n been slightly pulled back and could be advanced by several centimeters. The\n extent of the pre-existing left-sided pleural effusion is unchanged. Also\n unchanged is the left retrocardiac atelectasis. On the right, the\n pre-existing small pleural effusion has cleared, a small discoid atelectasis\n persists at the right lung base. There is no evidence of focal parenchymal\n opacities suggestive of pneumonia, no evidence of overhydration.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1064923, "text": ", F. TSICU 11:28 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for worsening pulm edema.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with sepsis, acute desat, acidosis.\n REASON FOR THIS EXAMINATION:\n eval for worsening pulm edema.\n ______________________________________________________________________________\n PFI REPORT\n No pulmonary edema. Bibasilar atelectasis and moderate left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1064922, "text": " 11:28 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for worsening pulm edema.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with sepsis, acute desat, acidosis.\n REASON FOR THIS EXAMINATION:\n eval for worsening pulm edema.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:29 PM\n No pulmonary edema. Bibasilar atelectasis and moderate left pleural effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with sepsis and acute desaturation.\n\n Comparison is made to the prior study of .\n\n Findings: The NG tube, left subclavian line and endotracheal tube are\n unchanged in position. The latter is projecting approximately 6 cm above the\n carina. No pulmonary vascular congestion is noted. Moderate bibasilar\n atelectasis, left greater than right. Increasing moderate left pleural\n effusion. No pneumothorax.\n\n IMPRESSION: No pulmonary edema. Bibasilar atelectasis and moderate left\n pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065559, "text": " 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess L consolidation v. effusion\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p extubation yesterday\n REASON FOR THIS EXAMINATION:\n assess L consolidation v. effusion\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MON 11:49 AM\n The cardiomediastinal silhouette and hilar contours are normal, the lungs are\n clear. The elevated left hemidiaphragm is unchanged since . Previously\n mentioned possible effusion and consolidation within the left lung base is\n most likely related to the elevated left hemidiaphragm. There has been\n interval removal of endotracheal tube, NG tube. The left subclavian central\n line is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with extubation.\n\n Comparison is made to the prior study of .\n\n Findings: The cardiomediastinal silhouette and hilar contours are normal, the\n lungs are clear. The elevated left hemidiaphragm is unchanged since .\n Previously mentioned possible effusion and consolidation within the left lung\n base are related to the elevated left hemidiaphragm. There has been interval\n removal of endotracheal tube, NG tube. The left subclavian central line is\n unchanged.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065442, "text": " 5:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p total abdominal colectomy, intubated\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluation for opacities.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the monitoring and support\n devices are in unchanged position. The pre-existing linear right basal\n atelectasis has completely resolved. The extent of the left-sided pleural\n effusion, combined with the pre-existing left basal and retrocardiac opacity\n have slightly increased. Otherwise, no relevant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1066058, "text": " 8:19 PM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for infiltrate, etc\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with decreased O2 sat\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate, etc\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Decreased oxygen saturation, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is again striking\n elevation of the left hemidiaphragmatic contour, which is unchanged since at\n least 20/03. Some atelectatic changes and probable pleural fluid are seen at\n the left base. The right lung is clear.\n\n The left subclavian catheter has been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065560, "text": ", F. TSICU 5:14 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess L consolidation v. effusion\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p extubation yesterday\n REASON FOR THIS EXAMINATION:\n assess L consolidation v. effusion\n ______________________________________________________________________________\n PFI REPORT\n The cardiomediastinal silhouette and hilar contours are normal, the lungs are\n clear. The elevated left hemidiaphragm is unchanged since . Previously\n mentioned possible effusion and consolidation within the left lung base is\n most likely related to the elevated left hemidiaphragm. There has been\n interval removal of endotracheal tube, NG tube. The left subclavian central\n line is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065104, "text": " 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement, infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p colectomy, intubated\n REASON FOR THIS EXAMINATION:\n eval for tube placement, infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:31 AM\n There has been interval increase in moderate right and moderate left pleural\n effusion. Cardiac size is top normal. ETT is in standard position and the tip\n ___.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: Intubated patient s/p colectomy.\n\n ETT tip is 4.6 cm above the carina. NG tube tip is in the stomach. Left\n subclavian catheter tip is in SVC. There is no pneumothorax. There has been\n interval increase in mild to moderate right and moderate left pleural effusion\n and adjacent atelectasis. Cardiac size is normal.\n\n jr\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2131-02-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1065105, "text": ", F. TSICU 5:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for tube placement, infiltrate\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man s/p colectomy, intubated\n REASON FOR THIS EXAMINATION:\n eval for tube placement, infiltrate\n ______________________________________________________________________________\n PFI REPORT\n There has been interval increase in moderate right and moderate left pleural\n effusion. Cardiac size is top normal. ETT is in standard position and the tip\n ___.\n\n" }, { "category": "Radiology", "chartdate": "2131-03-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1066190, "text": " 12:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 45cm\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 45cm\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 4:14 PM\n Right PICC catheter coursing towards the lung and then curving around to and\n is directed again laterally terminating in the right axilla. This is\n discussed with at 1:30 p.m. on . Elevation of the left\n hemidiaphragm with left basilar atelectasis and gaseous distention of the\n stomach, unchanged in comparison one day prior. The right lung is clear.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old male with PICC catheter.\n\n COMPARISON: Prior chest radiographs, most recently one day prior () dating back to .\n\n CHEST, PORTABLE UPRIGHT FRONTAL VIEW: The right PICC line courses into the\n axilla, curves, and is directed laterally, terminating within the axilla. The\n right lung is clear. Elevation of left hemidiaphragm with left basilar\n atelectasis and gaseous distention of the stomach are unchanged in comparison\n to one day prior. Cardiac silhouette and mediastinal contours are unchanged.\n\n PICC placement was discussed by Dr. with at 130pm on\n .\n\n" }, { "category": "Radiology", "chartdate": "2131-03-01 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1066191, "text": ", F. CC6A 12:05 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: r dl picc 45cm\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl picc 45cm\n ______________________________________________________________________________\n PFI REPORT\n Right PICC catheter coursing towards the lung and then curving around to and\n is directed again laterally terminating in the right axilla. This is\n discussed with at 1:30 p.m. on . Elevation of the left\n hemidiaphragm with left basilar atelectasis and gaseous distention of the\n stomach, unchanged in comparison one day prior. The right lung is clear.\n\n" }, { "category": "Radiology", "chartdate": "2131-02-21 00:00:00.000", "description": "P ABDOMEN (LAT DECUB ONLY) PORT", "row_id": 1064811, "text": " 9:23 PM\n ABDOMEN (LAT DECUB ONLY) PORT Clip # \n Reason: ?free air\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with c diff colitis\n REASON FOR THIS EXAMINATION:\n ?free air\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old man with C. diff colitis. Question free air.\n\n COMPARISON: Abdominal radiograph of .\n\n TECHNIQUE: Left lateral decubitus view of the abdomen.\n\n FINDINGS: No free intra-abdominal air is seen. There is moderate distention\n of the colon. No definitive air-fluid levels are seen.\n\n IMPRESSION: Nonspecific bowel gas pattern. No free intra-abdominal air.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-28 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1066056, "text": " 8:18 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Please assess for dilated bowel, etc\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with distended abdomen\n REASON FOR THIS EXAMINATION:\n Please assess for dilated bowel, etc\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:50 AM\n 1. Multiple loops of dilated small bowels with step-ladder air-fluid levels,\n concerning for early small bowel obstruction.\n\n 2. No free air seen underneath the diaphgram.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 73-year-old man with complicated C. diff colitis, now status post\n total colectomy and end ileostomy. Assess for evidence of small-bowel\n obstruction.\n\n COMPARISON: CT abdomen and pelvis on .\n\n FINDINGS: Abdominal radiograph, supine and upright views. There are dilated\n loops of small bowel with \"stepladder\" air-fluid levels. There is no free air\n seen below the diaphragm. An ileostomy is seen in the right lower quadrant.\n The underlying osseous structures are within normal limits. The asymmetric\n elevation of left hemidiaphragm, not previously seen, is possibly secondary to\n the underlying gastric distention. The left costophrenic angle is blunted,\n compatible with a left pleural effusion. There is a line of surgical staples\n projected in the midline of the abdomen. The overlying soft tissues are\n otherwise unremarkable.\n\n IMPRESSION:\n\n Dilated loops of small bowels with \"stepladder\" air-fluid levels, consistent\n with early small-bowel obstruction. No evidence of free air.\n\n\n" }, { "category": "Radiology", "chartdate": "2131-02-28 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 1066057, "text": ", F. CC6A 8:18 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Please assess for dilated bowel, etc\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with distended abdomen\n REASON FOR THIS EXAMINATION:\n Please assess for dilated bowel, etc\n ______________________________________________________________________________\n PFI REPORT\n 1. Multiple loops of dilated small bowels with step-ladder air-fluid levels,\n concerning for early small bowel obstruction.\n\n 2. No free air seen underneath the diaphgram.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "T-SPINE", "row_id": 784840, "text": " 9:19 PM\n T-SPINE; L-SPINE (AP & LAT) Clip # \n Reason: fall from 2nd story\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n fall from 2nd story\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall from second storey.\n\n COMPARISON: No prior radiographs available for comparison.\n\n THORACIC SPINE, AP AND LATERAL VIEWS: There is a mild concave left scoliosis,\n which may be positional. The vertebral bodies are otherwise normal in height\n and alignment. No fractures. There is increased density at the lung base\n which limits bone detail in the lower thoracic spine.\n\n LUMBAR SPINE, AP AND LATERAL: The vertebral bodies are normal in height and\n alignment. No significant degenerative change is present. No fracture or\n osseous destruction. The hip and sacroiliac joints are unremarkable.\n\n IMPRESSION: No fracture. Repeat chest radiographs may be performed to\n evaluate the left lung base, if clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784839, "text": " 8:43 PM\n CHEST (PORTABLE AP) Clip # \n Reason: S/P POST INTUBATION\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post intubation.\n\n AP CHEST: In the interval since the prior study approximately one half hour\n prior, an endotracheal tube has been positioned with the tip just beyond the\n thoracic inlet approximately 7 cm above the carina. A nasogastric tube has\n also been positioned with the tip in the gastric cardia.\n\n" }, { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 784835, "text": " 8:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P FALL - ? BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n fall\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SMLe MON 9:10 PM\n no bleed\n Possible fb in R occiput\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n HISTORY: 20 year old man status post fall.\n\n TECHNIQUE: Multiple axial images of the head were obtained without\n intravenous contrast.\n\n FINDINGS: There is no intra- or extraaxial hemorrhage. There is no mass\n effect or shift of normally midline structures. The ventricles, cisterns and\n sulci are unremarkable. The -white matter differentiation is within\n normal limits. There are multiple calcifications in the central region of the\n inferior cerebellum, (vermis and adjacent white matter), seen best on series\n 2, images 7 through 9. Etiology and clinical significance of these is unknown.\n\n The visualized paranasal sinuses are unremarkable. The osseous structures\n demonstrate no fractures on bone windows. However, at the right vertex there\n is a calcific, linear foreign body extending through the soft tissues to the\n skull. Please correlate clinically. This is seen on sequence 3, images 30\n and 31, and sequence 2, image 31.\n\n IMPRESSION: No acute hemorrhage, mass effect or shift of midline structures.\n Cerebellar calcification of unknown etiology, clinical correlation is\n recommended. Foreign body in the right scalp, as described above.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 784836, "text": " 8:27 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: fall from 2nd story balcony\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n fall from 2nd story balcony\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EEZ MON 9:17 PM\n no solid organ injury. no free fluid. no free air.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: S/P fall from 2nd storey balcony.\n\n COMPARISON: No prior abdominal CT available for comparison.\n\n TECHNIQUE: Axial images of the abdomen and pelvis were acquired helically from\n the lung bases through the pubic symphysis, with 150 cc of Optiray contrast.\n There are no adverse reactions to contrast administration.\n\n FINDINGS:\n\n CT ABDOMEN WITH IV CONTRAST: There is atelectasis/consolidation in the left\n lung base, with a patchy area of atelectasis in the right lung base as well.\n No hepatic lacerations are present. There is distention of the IVC and\n bands of periportal decreased attenuation, consistent with aggressive fluid\n resuscitation. No splenic lacerations are present. The pancreas and duodenum\n are unremarkable. No renal lacerations are present. The kidneys enhance\n symmetrically without evidence of obstruction. The gallbladder, adrenal\n glands, stomach, and intraabdominal loops of small and large bowel are\n unremarkable. There is no free intraabdominal fluid and no pathologically\n enlarged mesenteric or retroperitoneal lymph nodes.\n\n CT PELVIS WITH IV CONTRAST: There is no free fluid in the pelvis. The sigmoid\n colon, rectum, and cecum are unremarkable. The distal ureters and bladder are\n within normal limits. No pathologically enlarged inguinal or pelvic lymph\n nodes are seen.\n\n Osseous structures are unremarkable. No fractures are seen.\n\n IMPRESSION: No solid organ injury. No free fluid and no free intraperitoneal\n air. No fractures.\n\n These results were discussed with the trauma team at the time of\n interpretation.\n\n (Over)\n\n 8:27 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: fall from 2nd story balcony\n Field of view: 33 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 784837, "text": " 8:28 PM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: fall from 2nd story\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n fall from 2nd story\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: EEZ MON 9:41 PM\n no fracture\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall from 2nd storey.\n\n COMPARISON: No prior CT scan available for comparison.\n\n TECHNIQUE: Axial images of the neck acquired helically without IV contrast.\n Coronal and sagittal reformations were made.\n\n NONCONTRAST CERVICAL SPINE CT: The vertebral bodies are normal in alignment.\n No fractures are seen. No prevertebral soft tissue swelling is present. The\n dens is unremarkable. The facets and pedicles are normal. The lateral masses\n are aligned normally about the odontoid process. The visualized portions of\n the lung apices are within normal limits.\n\n IMPRESSION: No fracture or malalignment.\n\n Findings were discussed with the Emergency Department House Staff.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-03-22 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 784834, "text": " 8:22 PM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: S/P MVA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post motor vehicle accident.\n\n AP TRAUMA CHEST: The cardiomediastinal and hilar contours are normal. The\n lungs are clear. There are no osseous abnormalities.\n\n AP PELVIS: There is no evidence of fracture, dislocation, or other osseous\n abnormality.\n\n IMPRESSION: No evidence of acute trauma to the chest or pelvis.\n\n\n" }, { "category": "Radiology", "chartdate": "2128-03-24 00:00:00.000", "description": "R SCAPULA RIGHT", "row_id": 784993, "text": " 10:55 AM\n SCAPULA RIGHT Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 20 year old man with\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Scapular pain after fall.\n\n RIGHT SCAPULA, TWO VIEWS.\n\n No scapular fracture is identified. Morphology and mineralization of the\n right scapula are within normal limits. The extreme corner of the junction\n between the acromion and spine are only partially imaged on one view, but are\n unremarkable on the AP view.\n\n" }, { "category": "Nursing/other", "chartdate": "2128-03-23 00:00:00.000", "description": "Report", "row_id": 1327926, "text": "Resp Care Note:\n\nPt cont sedated intub placed on mech vent upon arrival to TSICU as per Carevue. Lung sounds ess clear and equal. ABGs stable and pt in NARD on mech vent at present. Cont mech vent wean and extub when awake.\n" }, { "category": "Nursing/other", "chartdate": "2128-03-23 00:00:00.000", "description": "Report", "row_id": 1327927, "text": "T-SICU NSG NOTE:\n PT IS A 20YO MALE WHO FELL 2 STORIES ONTO SIDE OF HEAD. HE SUSTAINED +LOC THEN BECAME COMBATIVE AND VERBALY ABUSIVE REQ INTUBATION AND SEDATION IN ED.\n\nPMH-BIPOLAR DZ PER PARENTS, PT DOESN'T TAKE DEPAKOTE FAITHFULLY AS HE SHOULD, WHEN HE CONSUMES ALCOHOL HE BECOMES VERY HYPER AND TRYS TO GET AWAY IF MANY PEOPLE AROUND AS HE DID PRIOR TO THIS ADMISSION WHEN HE STEPPED OFF THE BALCONY. PT ALSO HAS A CEREBELLAR CALCIUM DEPOSIT WHICH GIVES HIM A TREMMOR. EX SMOKER.\n\nROS:\n\nNEURO- NOT OPENING EYES, TURNS S->S IN BED WHITH ARMS RESTRAINED, NOT FOLLOWING COMMANDS, PROPOFOL TITRATED UP TO 75MCG/KG/MIN FOR AIRWAY PROTECTION. MAE'S WITH GREAT STRENGTH.\n\nRESP- SUX FOR SM AMTS THICK OLD BLD TINGED SECRETIONS.BS CTA REMAINS FULLY VENTED TONIGHT\n\nCVS- SBP 82-130'S VARIES W/ LEVEL OF ALERTNESS. HR 70'S->90'S NSR,IVF OF RL @100CC/HR. AFEB, LABS PND\n\nGI- ABD SOFT, FLAT, +BS\n\nGU- FOLEY PATENT FOR CLEAR->CLOUDY YELLOW URINE IN ADEQ AMTS.\n\nSKIN- NO ISSUES, SM ABRASION REPORTED ON L CHEEK.\n\nSOCIAL- LIVES W/ PARENTS AND SIBLINGS. PT IS 2ND OLDEST OF 5.\n\nA: STABLE NVS, CVS\n\nP: MONITOR VS PER ROUTINE, WEAN PROPOFOL AND VENT THIS AM.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2102-03-11 00:00:00.000", "description": "Report", "row_id": 1337100, "text": "Nursing progress note\nS: \" I NEED TO GO TO THE BATHROOM\"\n\nO: PT. IS 50 Y/O MALE ADMITTED FROM 2 FOR RESP DISTRESS. PMH INCLUDES TRACHEOBRONCHIAL MALASIA W/ Y STENT PLACEMENT, SCHIZOPHRENIA, MITRAL VALVE PROLAPSE, PNEUMONIA. ALLERGIC TO SULFA. HE WAS ADMITTED TO ON FOR RIGID BRONCH WITH STENT REMOVAL. POST OP ADMITTED TO 2. ON HE DEVELOPED SIGNIFICANT STRIDOR, LOW O2 SATS AND POOR ABG. ADMITTED TO CCU (SICU BORDER) FOR MASK VENT TRIAL. AWAITING SURGERY NEXT WEEK FOR TRACHEAL RECONSTRUCTION.\n\nNEURO: PT. LETHARGIC ON ARRIVAL TO UNIT. AROUSABLE TO PAINFUL AND VERBAL STIMULI. ANSWERING QUESTIONS APPROPRIATELY. MOVING ALL EXTREMITES. FOUND OOB STANDING AT SIDE OF BED WANTING TO GO TO THE BATHROOM. NOTICEABLE TREMORS. ORIENTED X1 TO NAME ONLY.\n\nCV: HR 95 SR NO VEA NOTED. HR INCREASED TO 130'S WHEN FOUND OUT OF BED. BP STABLE. DENIES C/O CP.\n\nRESP: SIGNIFICANT STRIDOR ON ARRIVAL TO UNIT, PLACED ON R-EPI INHALER WITH SOME RELIEF. COARSE BREATH SOUNDS IN ALL LUNG FIELDS. NON-PRODUCTIVE COUGH. ATTEMPTED TO PLACE MASK VENT ON PT. BUT PT. REFUSING TO WEAR MASK, THROWING MASK AT MD. PLACED ON 6L NC WITH 50% FM. O2 SAT 96%. POOR ABG 7.35/52/68/30 93%. FIO2 INCREASED TO 100% REPEAT ABG 7.36/53/242/31 98%. WILL REMOVE 6L NC AND RECHECK ABG.\n\nGU: FOLEY DRAINING SMALL AMT OF CLEAR YELLOW URINE.\n\nGI: ABD SOFT, + BOWEL SOUNDS. NPO FOR NOW.\n\nSKIN: INTACT, NO BROKEN AREAS NOTED.\n\nA/P: TRACHEAL MALASIA, S/P STENT REMOVAL. FOR TRACHEAL RECONSTRUCTION EARLY NEXT WEEK. FOLLOW ABG'S, ADJUST O2 REQUIREMENT AS NEEDED. UPDATE PT. AND FAMILY ON PLAN OF CARE PER TSICU TEAM.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-22 00:00:00.000", "description": "Report", "row_id": 1337113, "text": "Respiratory Care\nPt s/p removal of Y-stent in OR today. PMH: severe tracheo-broncheo malasia requireing stent placement/pnuemonia/frequent bronchoscpoies. Received from OR with #8.0ETT/22cm at the lip. BS: coarse bilaterally L>R. Suctioned for scant amounts of white thick secretions. Pt having resp alkalosis on A/C 600/12/5/1.0--Resp rate decreased to 8/fio2 decreased to .40. Plan to keep sedated with Propofol until Friday when tracheoplasty planned in OR. Will continue to closely monitor at this time.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-22 00:00:00.000", "description": "Report", "row_id": 1337114, "text": "Neuro: did wake patient and did mae to command, back on prop gtt, pupils are equal and reative to light.\n\nCardiac: nsr with no ectopy, sbps wnls on and off nitro, palpible pedial pulses, skin warm dry and intact, afebrile, +1 edema in extremities.\n\nResp: lungs rhonchi, sxned but no secretions gained, remains vented and weaning down setting, abgs are good.\n\nSkin: intact with no skin incision wnds or no breakdown noted.\n\nGi/Gu: npo og tube to lwsxn draing small amount of clear, lots of oral secretions doing mouth care q 2 hrs, abd soft round and no bowel sounds yet, on csru riss blood sugars are wnls, renal u/s today for climbing creat, making 30 or >/hy of u/o.\n\nPlan: ? bronch in am per pulmonary team, ? remain intubated and sedated until friday for tracheoplasty, wean prop as needed, wean nitro on and off.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-14 00:00:00.000", "description": "Report", "row_id": 1337109, "text": "3p-7p\nSee carevue for details of assessment. Generalized rash all over body, PA aware, ? drug reaction no new orders. +MRSA in sputum ID following. OOB to chair x 2 hours. Tolerated well. Tremors at times, PA aware, pt taking a lot of psych meds.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-23 00:00:00.000", "description": "Report", "row_id": 1337115, "text": "CSRU A NPN:\nNEURO: Sedated on propofol 50mcg/kg/min - weaned propofol to 40mcg due to hypotension issues and pt.opening eyes, moving all extremities, following commands and denying pain. PERL 3mm and brisk.\nCV: Afeb. HR 50s-60s SB, no ectopy noted. Repleted with 20meq peripheral KCL for K 3.8 this am. Hypotensive overnight- received 3 500cc NS boluses with little effect. Neo started and currently at 0.5mcg/kg/min to maintain MAP >60. D51/2NS continues at 75cc/hr. Second peripheral IV placed last pm. Brachial a-line to R intact. Palpable pedal pulses. Trace edema.\nRESP: Continues on SIMV 550 x8 FIO2 40% with O2 Sat >96%. LS coarse throughout. Sx'd for thick pale yellow secretions in moderate amts. Intermittent large amts thick clear oral secretions. Brochospastic with turning and nursing care.\nGI/GU: Abd. soft with absent bowel sounds. OGT to continuous LWS with small amts clear drainage. No insulin needed with glucose checks. Foley draining clear yellow urine 25-30cc/hr.\nSKIN: Intact. L scab healing to L elbow.\nOTHER: Pt. placed on contact precautions due to history of MRSA in sputum.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-15 00:00:00.000", "description": "Report", "row_id": 1337110, "text": "FULL CODE Contact Precautions: MRSA sputum\nAllergy: Sulfa\n\n\nNeuro: lethargic, but arousable. - cooperative, follows commands, assists to turn self.\n\nCV: HR=90-100s, SR/ST, no ectopy. BP=90-110s/50s - while sleeping; up to 120s/ when awake. +periph pulses, extrems warm, +edema. CVP=.\n\nResp: 50% shovel mask w/ 02sat 97-100%. Lungs coarse bilat in all fields; strong, productive cough, but not expectorating sputum out. RR=18-25. ABG ok.\n\nGI/GU: abd softly distended, +BS, no BM. NGT. TF FS promote w/ fiber started at 10cc/hr, to be increased by 10cc q4hr to goal of 30cc. On PPI. Foley cath w/ clear, yellow urine - 150-500cc/hr.\n\nPain: denies discomfort\n\nAccess: R subcl TLC, L rad a-line, which can be positional at times; PIVx1.\n\nSkin: flushed all over body - ? rash r/t Zosyn - d/c'd. Otherwise, skin intact\n\nID: afebrile - remains on Vanco\n\nlabs: Lytes repleted. FS covered w/ RISS\n\nSocial: No phone calls from family memebers overnight.\n\nPlan: Awaiting surgery - debridement and y-stent placement. Monitor resp/neuro/cardiac status.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-15 00:00:00.000", "description": "Report", "row_id": 1337111, "text": "nursing note: (7a-7p)\n\ns/p \"Y\" stenting, awaiting tracheal resection, c/b pneumonia\n\nneuro: A&Ox2 (at times), answers most questions appropriately, MAE's, OOB x 1 to chair, slept almost entire day, seen by pyschiatry meds reduced/dc'd, oversedated, pulled out NG tube restraints back on, afebrile\n\n\nresp: non-productive cough, on FM .40 10L, sats >98%, rr 18-27, lungs coarse throughout\n\ncv: hemodynamically stable hr 90-100's, nbp 80-110's, palpable pulse\n\ngu/gi: past swallowing test today can eat solids & liquids, meds to be given PO now, t-feeds off when ng removed, foley w/good UO, abd. soft and distended team aware ?? last bowel movement, + BS\n\nendo: ssri no coverage needed\n\nsocial: sister called\n\nplan: ? transfer to step down unit, ?remove triple lumen , con't monitor for s/s of infection, con't pulm. toilet\n" }, { "category": "Nursing/other", "chartdate": "2102-03-16 00:00:00.000", "description": "Report", "row_id": 1337112, "text": "FULL CODE Contact Precautions MRSA in sputum\nAllergy: Sulfa, Bactrim\n\n\nNeuro: More awake earlier this evening. He was sitting in the chair. Taking po/meds well. Stood and pivoted, taking a few steps to get BTB - sl unsteady on his feet.\n\nCV: HR=90s, NSR, no ectopy. BP=100-110/50s. +periph pulses, extrrems warm, sl edema. CVP=.\n\nResp: 40% Face tent w/ 02sat99%. 02sat down to 93 when on r/a. When awak, coughs freq, non-productive. Lungs coarse bilat - diminished in bases bilat. RR=15-22.\n\nGI/GU: abd firm, distended, +BS. Colace started and milk of mag given - no results at this time. On PPI. taking meds/thickened fluids ok. Foley cath w/ great u/o of 100 to 300cc/hr.\n\nAssess: RSubcl TLC - intact. PIV d/c'd as routine change.\n\nSkin: intact\n\nID: afebrile - vanco.\n\nLabs: Mg and K repleted. RISS - no coverage required.\n\nSocial: no family called during the night.\n\nPlan: ?tx to floor today. Continues to await tracheoplasty surgery. Monitor cardiac/resp/neuro status.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-14 00:00:00.000", "description": "Report", "row_id": 1337107, "text": "Events: Pt had uneventful night. Slept throughout shift. Levophed weaned off this am, tolerating well.\n\nNeuro: Pt slept throughout shift. Easily arousable to verbal stimuli, follows commands consistently, MAE, A+Ox2, pt frequently asking if he can stay the night, and asking what is going to happen next. Pt reassured and reminded of by RN. No c/o pain\n\nResp: Remains on 70% humidified O2 via face tent and tolerating well. O2 sats high 90's -100%. Lung sounds remain quite coarse/rhonchorous throughout. Pt continues with occasional coughing fits which resolve with out intervention. No c/o difficulty breathing.\n\nCardiac: ST on monitor throughout shift HR 98-117. Largely in low 100's. No ectopy noted. SBP 80-110. Levophed weaned off at 0430 and tolerating well. ABP giving dampened waveform at times. NBP in use and consistently points higher than aline.\n\nGI: Abd softly distended. NGT contiues at LWS for total of 300cc's bilious stomach contents this shift. NGT with positive placement. No BM this shift. Remains NPO. D51/2 continues at 50cc/hr.\n\nGU: Voiding 100-240cc/hr yellow urine via foley. TFB for yesterday +1226cc. Currently -950 for today. BUN 6 Cr 0.6\n\nDerm: TLC with small amt old blood under dsg, otherwise benign. Aline with dampened waveform at times, dsg intact, PIV x1 in R forearm patent. Skin otherwise intact.\n\nID: Tmax 99.7ax continues on Zosyn and vancomycin. AM WBC 8.1 down from 9.2. No growth from bld cx taken on as of yet.\n\nPlan: Continue to monitor resp and mental status closely, follow culture data, to OR for tracheoplasty late this week or early next week.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-13 00:00:00.000", "description": "Report", "row_id": 1337105, "text": "Nursing Progress Note\nNeuro: Lethargic, waking slowly. Unable to open eyes on own due to swelling, pupils 3 brisk adn equal. tracks, gag intact, +corneals and strong cough. Purposeful move lowers and uppers, bue restraints for safety of ngt. Follows simple commands, responds to yes/no questions. Psych meds all given via ngt.\n\nCVS: HR sinus to sinus tachy no ectopy, MAp kept >60 on levophed weaned down to .05 at this time. Skin pink warm and flushed, afebrile. Pulses palp x 4 ext. CSL to BLEs thigh high. SC Heparin held for high pt/ptt/inr, will follow up with team in am. L rad a line, sharp waveform with visible notch. Rsc 3 lumen CVL, ports patent, dressing with old dried blood unerneath, but intact from . PIV x 2 LLarm and RL arm 20 G patent, flushed not in use at this time. Crit 26.4, team aware no transfusion at this time.\n\nResp: Ls to dim bilat. CPT when awake. Good cough effort, productive with thick tan to white sputum. Face tent at 70%, sats >93 nebs given q 6 hours. Voice is hoarse, but able to communicate. Guiatuss with codeine x 1 via ngt, morphine for pain x 1 and ativan for relaxation and decrease bronchospasm.\n\nGI: abd round soft, bs hypo. NGT 16 fr placed in right nare with minimal difficulty. Placement checked with air bolus, gastic contents when initially hooked to LWS. Clamped and used for med admin without incident.\n\nGU: Foley cath draining clear yellow urine in increased amounts as levophed dose decreased.\n\nLytes: potassium repleted per orders.\n\nSurgery for trachealplasty currently on hold, no contact from family. See carevue flow sheet for further details and values.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2102-03-14 00:00:00.000", "description": "Report", "row_id": 1337108, "text": "NPN: Review of Systems\nNeuro: Pt is lethargic. More so after bronchoscopy during which he received a total of 1mg versed and 25mcg fentanyl. Pt opens eyes to voice. Is slow to answer questions. Speech garbled. Follows commands. Purposeful movement. Soft wrist restraints on d/t lines. Intermittent shaking which mother and sister say is baseline.\n\nResp: BS are coarse bilaterally. Strong cough. Sao2 after bronchoscopy =92%, but has since increased to 97-99% on 70% shovel mask. Breathing unlabored w/ RR in the 20s.\n\nCV: SR. No ectopy. 80s to low 100s. Skin warm/ flushed. Rectal temp=99.0. Discussed this w/ PA . ? drug rash. Vancomycin had infused over 1hr. Next dose will be given over 2hours. DP/PT pulses palpable bilaterally.\n\nGI: NGT to LIS. Abdomen soft. (+) bowel sounds. ? start tubefeeds once abdominal x-ray read.\n\nGU: Brisk uo via foley. UO=1570cc from 8am-1300. Total UO =3000 since midnight.\n\nID: Continues on Zosyn and vancomycin. WBC down from .\n\nSkin: Intact. No pressure wounds present.\n\nSocial: Mother and sister in to visit. Will not be able to come back till next week. Feels like it took awhile to talk to MD, but feel like they are well informed now.\n\nA: Hemodynamics and pulmonary status stable at this time.\n\nP: Monitor as ordered. PA to look at skin. ? tubefeedings. Awaiting surgery.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-13 00:00:00.000", "description": "Report", "row_id": 1337106, "text": "nursing note (7a-7p):\n\nadm: tracheal malasia w/y stenting on , awaiting tracheal resection in OR late this week/early next week, being treated for sepsis, receiving vanco & zosyn, increasing temps late afternoon tylenol given (high 100.7)\n\nneuro: schizophrenic w/some mental slowness, a&ox2, MAE's, opens eyes to speech, answer questions appropriately, however, garbled speech, slept pretty much entire day even when family visited, refused oral hygiene, no c/o pain\n\nresp: lungs coarse throughout UL & LL, crackles/rhonci in RL. \"Y\" stent placed on 3/36. on trach mask .70 & 10L, tackypnic 22-28, sats> 98%, excessive coughing & decrease sats when rolled and recovers on own, inhalers given by respiratory\n\ncv: weaning levophed currently on 0.02 mcg w/sbp in 90's, MAP goal >60, hr 80-100 most of day since 1500 increasing hr upto 120's currently 117 (team aware), a-line in left wrist, pa cath in RIJ, fluids decreased per thorasic team\n\ngi/gu: foley w/good UO, no BM, + hypo BS, abdomen soft & distended new ng tube placed clamped w/meds otherwise on LCS, placement confirmed by cxr, currently NPO tube feeds to be restarted ? \n\nendo: csru sliding scale no coverage needed this shift\n\nskin: intact, no apparent breakdown of skin\n\ngoal: monitor respiratory status, ? restart tube feeds, infection control, wean down levophed\n" }, { "category": "Nursing/other", "chartdate": "2102-03-11 00:00:00.000", "description": "Report", "row_id": 1337101, "text": "Resp Care\nPt seen in the floors. Bs course throughtout and loud audible stridor. Md wanted on niv. Pt required be in unit. Went to ccu, gave one race. epi neb with mod improvent. Attempted niv and pt became combative and unwilling th have on. Placed on hiflow. Abgs showed no improvement and fio2 increased. Following gases acceptable. will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-11 00:00:00.000", "description": "Report", "row_id": 1337102, "text": "Pt presents with stridor and extremely congested non-productive cough due to severe tracheobronchial malacia. Tried briefly on BiPAP but resisted. HeliOx on SB. Bronched by IP with copious amounts of thick creamy mucus sx'd and lavaged from area distal to stenosis. BS improved with greater pt comfort. Able to wean pt to nasal cannula with adequate O2 sats. OR Monday for stent placement.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-11 00:00:00.000", "description": "Report", "row_id": 1337103, "text": "Nursing Note 7a-7p\nS:\"I feel alright\".\nO: Pt remains lethargic and difficult rouse. When awake he's confused to place/time, sometimes asking inappropriate questions. ? verbal hallucinations. Calm and cooperative with care, no attempts to climb oob. Received 1.5mg versed/50mcg fentanyl for a bronch.\nResp- LS rhonchorus throughout, currently 02 sats 93-100% on 3L nc. This AM pt was having bouts of stridorous coughing d/t his severe tracheal malasia. Sats 88-93% on 6L nc/70% FM, RR 35-45. Thoracic team observed, Racepinephrine neb x1 ordered with good effect. Pulmonary consulted and a Bronch Lavage was done @ 1100. Noted thick copious secretions R>L, sample sent. No ABGs obtained.\nCV- Tele SR/ST no vea. HR 78-114, NBPs 98-130s, no c/o c-pain.\nID- Tmax 102.3 ax, BC x2 UC, sputum cx sent. Sputum grew gram+ cocci, started on Vanco/zosyn.\nGI/GU- NPO, +bs no stool. Foley intact voiding qs cyu.\nSkin- No issues.\nA/P: 50yo male s/p ridged bronch with trach stent removal. Hx Tracheal Malasia, pending trach reconstructive monday. Cont plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2102-03-12 00:00:00.000", "description": "Report", "row_id": 1337104, "text": "NUSING PROGESS NOTE\nS\nO:PT SPIKE TEMP TO 102.6,ENTIRE BODY FLUSHED RED BUT BLANCHING, HOT AND DIAPHORETIC TO TOUCH. BCX2 SENT, TYLENOL GIVEN. DR. NOTIFIED. PT CURRENTLY ON ZOSYN AND VANCO. WBC THIS AM 11.4.\nPT BECAME HYPOTENSIVE REQUIRING LEVOPHED AND A TOTAL OF 3LITERS OF NS. DR. AND ATTENDING PRESENT TO INSERT CENTRAL LINE AND ALINE IN URGENTLY. CL PLACEMENT CONFIRMED BY CXR. AS MD. CXR SHOWING COLLAPSE OF RML AND RLL. SAT 90S ON 98% HIGHFLOW AEROSOL O2 VIA SHOVEL MASK. PT MENTAL STATUS STUPOROUS W/ HIGH TEMP, PT VERY DIFFICULT TO ARROUSE, REQUIRNG NOXIOUS STIMULUS. PT DID BECOME WAKEFUL AFTER COUGHING FIT. ABG 7.39/41/82/26. PLAN FOR BRONCH TODAY AND POSSIBLE INTUBATION. DIFFICULT INTUBATION CART OUTSIDE OF ROOM. MDS UNABLE TO CONTACT FAMILY MEMBERS FOR CONSENT LAST NOT. SEE CARE VUE FOR VS, GTT TITRATION, AND I/OS.\n" }, { "category": "Echo", "chartdate": "2102-03-10 00:00:00.000", "description": "Report", "row_id": 80427, "text": "PATIENT/TEST INFORMATION:\nIndication: Preoperative assessment.\nHeight: (in) 67\nWeight (lb): 115\nBSA (m2): 1.60 m2\nBP (mm Hg): 130/100\nHR (bpm): 95\nStatus: Inpatient\nDate/Time: at 14:40\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\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.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. Left ventricular wall thickness, cavity size, and systolic function are\nnormal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded.\n2. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation\nis seen.\n3. The mitral valve appears structurally normal with trivial mitral\nregurgitation.\n\n\n" }, { "category": "ECG", "chartdate": "2102-03-16 00:00:00.000", "description": "Report", "row_id": 204661, "text": "Sinus rhythm\nDiffuse nonspecific ST-T wave changes\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2102-03-12 00:00:00.000", "description": "Report", "row_id": 204662, "text": "Sinus rhythm. Non-specific diffuse T wave flattening. Compared to the previous\ntracing of T wave flattening is new.\n\n" }, { "category": "ECG", "chartdate": "2102-03-08 00:00:00.000", "description": "Report", "row_id": 204883, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906462, "text": " 9:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess RML/RLL pneumonia\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w stet placement for tracheomalaciea\n REASON FOR THIS EXAMINATION:\n assess RML/RLL pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man status post rigid bronchoscopy with stent\n placement for tracheomalacia. Assess for right middle lobe/right lower lobe\n pneumonia.\n\n COMPARISON: .\n\n CHEST AP: Tracheal stent is unchanged in position. A right subclavian line is\n present with its tip in distal SVC. An NG tube is present with its tip in the\n distal stomach. There is some interval clearing of the right middle lobe\n opacity. There are persistent perihilar and basilar opacities with associated\n peripheral septal lines representing pulmonary edema.\n\n IMPRESSION: Slight interval clearing of the right middle lung zone opacity\n with persistent bilateral pulmonary edema, bibasilar consolidations and\n effusions.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906248, "text": " 4:24 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: Eval of RLL colapse\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal now s/p R SC TLC\n placement\n REASON FOR THIS EXAMINATION:\n Eval of RLL colapse\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: at 6:19 a.m.\n\n INDICATION: Evaluate right lower lobe collapse.\n\n There has been placement of a Y stent in the trachea and main bronchi. There\n has been some interval improved aeration within the right middle and lower\n lobes with residual opacities remaining. The left retrocardiac region also\n appears slightly better aerated. New in the interval is perihilar haziness\n and subtle interstitial opacities, likely due to pulmonary edema related to\n fluid overload.\n\n Finally, note is again made of distention of the thoracic esophagus resulting\n in widening of the right mediastinal contour.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-12 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 906190, "text": " 5:33 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: please eval line tip position and r/o PTX\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal now s/p R SC TLC\n placement\n REASON FOR THIS EXAMINATION:\n please eval line tip position and r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Line placement.\n\n There has been interval placement of a right internal jugular catheter,\n terminating in the lower superior vena cava. There is no pneumothorax. There\n is worsening atelectasis in the right middle and both lower lobes, and there\n are persistent small pleural effusions.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907647, "text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with new stent removed,\n intubated\n REASON FOR THIS EXAMINATION:\n ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male with tracheomalacia, pneumonia, and stent\n removed.\n\n COMPARISON: .\n\n AP SEMI-UPRIGHT CHEST RADIOGRAPH: An endotracheal tube and nasogastric tube\n are seen unchanged in standard positions. The heart size is normal. There is\n interval improvement of bibasilar atelectasis. No pleural effusions or\n pneumothoraces are identified.\n\n IMPRESSION: Interval improvement in bibasilar atelectasis. No pneumonia or\n CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 907058, "text": " 10:02 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for stroke/bleed\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n REASON FOR THIS EXAMINATION:\n eval for stroke/bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Altered mental status.\n\n NON-CONTRAST HEAD CT: No priors for comparison.\n\n The inferior portion of this exam is limited by patient motion. No\n hydrocephalus, shift of normally midline structures, intra- or extra-axial\n hemorrhage, or acute major vascular territorial infarct is identified.\n Hyperdensity in the left basal ganglia likely represents chronic microvascular\n infarction. Imaged sinuses are remarkable for scattered mastoid air cell\n opacification. No fractures.\n\n IMPRESSION: No intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908211, "text": " 7:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy s/p bronch\n\n REASON FOR THIS EXAMINATION:\n ? effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50-year-old male status post tracheobronchoplasty via right\n thoracotomy, now with question of pleural effusion.\n\n COMPARISON: .\n\n AP PORTABLE SEMI-UPRIGHT CHEST: The patient has been extubated and the\n nasogastric tube removed. A right internal jugular central catheter remains\n with tip in the mid SVC. The previously identified right pneumothorax is no\n longer appreciated. There remains atelectasis and likely postoperative\n contusion of the right middle lung. Left basilar atelectasis also persists.\n There is interval increase in density at the right base which partially\n obscures the right heart border and may represent developing consolidation.\n Subcutaneous emphysema of the right hemithorax is again demonstrated.\n\n IMPRESSION: After extubation increased opacity at the right base which may\n represent developing pneumonia. Persistent atelectasis at the left base as\n well as atelectasis and postoperative contusion of the right middle lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-04-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 908773, "text": " 3:08 PM\n CHEST (PA & LAT) Clip # \n Reason: eval prog of PNA\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with h/o MRSA PNA s/p tracheobronchoplasty for tracheomalacia\n REASON FOR THIS EXAMINATION:\n eval prog of PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Worsening pneumonia. Evaluate for progression.\n\n CHEST PA AND LATERAL: Compared to the study from . There is\n improved aeration of the right lung. Improvement is seen in the subcutaneous\n emphysema over the right neck. There is interval removal of the right IJ\n line. The heart size, mediastinal and hilar contours are unremarkable. A\n small right effusion is noted.\n\n IMPRESSION: Interval clearing of right lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-04-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 908934, "text": " 8:42 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for infiltrate, effusion, etc\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with h/o MRSA PNA s/p tracheobronchoplasty for tracheomalacia\n\n REASON FOR THIS EXAMINATION:\n Please assess for infiltrate, effusion, etc\n ______________________________________________________________________________\n FINAL REPORT\n PA and lateral upright chest radiograph was compared to the previous film from\n .\n\n REASON FOR EXAMINATION: Followup of patient with known pneumonia, status post\n tracheobronchoplasty for tracheomalacia.\n\n No new pulmonary infiltrates are seen in the lungs. No pneumothorax is\n present. Slightly increased right pleural effusion is observed. The\n subcutaneous emphysema in the right neck is unchanged.\n\n The heart size, mediastinal and hilar contours are unremarkable.\n\n IMPRESSION:\n 1. Slight worsening of the right pleural effusion.\n 2. No evidence of pneumothorax. Stable subcutaneous right neck emphysema.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907878, "text": " 2:19 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pneumo, effusion, etc\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy, new chest tube and RIJ CVL.\n\n REASON FOR THIS EXAMINATION:\n eval for PTX, consolidation\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST ON AT 14:18\n\n INDICATION: New chest tube and right CVL.\n\n COMPARISON: at 20:24.\n\n FINDINGS:\n\n Lines and tubes remain in place. There has been addition of an NGT with its\n tip in the region of the antrum. There are no new consolidations and there is\n some resolution of prior atelectatic changes. A small amount of left pleural\n fluid is again demonstrated. The left retrocardiac region is more dense.\n Atelectasis or pneumonia can produce those findings.\n\n IMPRESSION:\n\n Interval insertion of NGT; improving appearance of the right lung and\n increased opacity seen in the left retrocardiac region. The latter can be the\n result of atelectasis or pneumonia.\n\n No PTX.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907055, "text": " 9:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PNA\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n REASON FOR THIS EXAMINATION:\n r/o PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n Single portable radiograph of the chest demonstrates no change in the\n cardiomediastinal silhouette when compared to . Tracheal stent\n remains unchanged in position. Right subclavian central venous catheter is\n again noted with its tip in the SVC. Right basilar atelectasis is again\n noted. Previously described pulmonary edema has improved. No left-sided\n effusion. Probable small right-sided effusion persists.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907584, "text": "\n CHEST (PORTABLE AP) Clip # \n Reason: ett placment\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n\n REASON FOR THIS EXAMINATION:\n ett placment\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Fever. Endotracheal tube placement.\n\n There has been apparent removal of an airway stent, and interval placement of\n an endotracheal tube, with the tip terminating approximately 2 cm above the\n carina with the neck in a flexed position. Heart size is normal. There are\n bibasilar atelectatic changes. No pleural effusions are evident. The right\n costophrenic angle has been excluded from the study and cannot be assessed.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907225, "text": " 8:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for PNA, etc\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n\n REASON FOR THIS EXAMINATION:\n assess for PNA, etc\n ______________________________________________________________________________\n FINAL REPORT\n AP and lateral chest 8:30 A.M. :\n\n HISTORY: Tracheomalacia. New fever and lethargy.\n\n IMPRESSION: AP chest compared to and :\n\n Residual peribronchial opacification in the right lower lung is unchanged\n compared to having cleared appreciably since . Left lung\n remains entirely clear. The heart is normal size, rightward mediastinal shift\n is mild and stable and the tracheobronchial stent is unchanged in position.\n No pleural abnormality is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 907246, "text": " 9:44 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: L picc\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n\n REASON FOR THIS EXAMINATION:\n L picc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, , at 9:57 a.m.\n\n COMPARISON: Previous study of earlier the same date at 8:30 a.m.\n\n INDICATION: PICC line placement.\n\n A left PICC line has been placed and is malpositioned, seen from the left\n brachiocephalic vein superiorly into the right brachiocephalic vein with the\n tip terminating at the level of the medial right clavicle and directed\n cephalad. There is otherwise no significant change from the recent radiograph\n of less than 2 hours earlier. The location of the line has been discussed by\n telephone with the IV nurse caring for the patient .\n\n" }, { "category": "Radiology", "chartdate": "2102-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908022, "text": " 10:26 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for ptx s/p bronchoscopy\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy s/p bronch\n REASON FOR THIS EXAMINATION:\n eval for ptx s/p bronchoscopy\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 50 y/o male s/p right thoracotomy.\n\n COMPARISON: at 8:16 a.m.\n\n There has been interval removal of the right apical pleural drain. There\n remains a right internal jugular central catheter with tip within the mid SVC\n and an ETT with tip 6 cm above the carina. The NG tube side hole and tip are\n both above the diaphragm. The right hemidiaphragm is unusually sharp likely\n due to persistent small right sided pneumothorax and change in patient\n position. There has been improvement in left basilar opacity likely\n representing atelectasis.\n\n IMPRESSION: Persistent small right pneumothorax. NG tube terminates above the\n diaphragm. Improvement in left basilar atelectasis.\n\n Results of this were discussed with Dr. at time 11:30 a.m. .\n\n" }, { "category": "Radiology", "chartdate": "2102-03-20 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 907260, "text": " 10:31 AM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: left picc line repostioned -wires in\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with tracheomalacia, PNA, with renewed fever and lethargy\n\n REASON FOR THIS EXAMINATION:\n left picc line repostioned -wires in\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 11:10 A.M., .\n\n HISTORY: Tracheomalacia, new fever and lethargy. Left PICC line\n repositioned.\n\n IMPRESSION: AP chest compared to at 8:30 and 9:57 a.m.\n\n Left PIC catheter has been repositioned, tip projecting over the lower\n superior vena cava. No pneumothorax, pleural effusion, or mediastinal\n widening present. Tracheobronchial stent unchanged in position. Atelectasis\n in right middle and lower lung improving. Left lung clear. Heart size\n normal.\n\n Increasing subdiaphragmatic lucency in the midline is probably distended\n transverse colon or gastric antrum rather than pneumoperitoneum.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908001, "text": " 8:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? effusion ? ptx\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy\n REASON FOR THIS EXAMINATION:\n ? effusion ? ptx\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Status post tracheal surgery. Question pneumothorax.\n\n An endotracheal tube has been withdrawn slightly in the interval and now\n terminates just above the thoracic inlet level, approximately 6 cm above the\n carina. A nasogastric tube has also been withdrawn with the side port now\n well above the GE junction level and the tip terminating at the\n thoracoabdominal junction. Cardiac and mediastinal contours are within normal\n limits. Right-sided chest tube remains in place, with a tiny right apical\n pneumothorax present. Diffuse hazy opacity throughout the right hemithorax is\n likely due to a layering right effusion. Left lower lobe atelectasis and\n small left effusion are again demonstrated.\n\n Finally, there is a small amount of extraluminal air within the mediastinum,\n likely postoperative in this patient status post recent tracheoplasty surgery.\n\n IMPRESSION:\n\n 1. Proximal location of endotracheal tube and nasogastric tube, as\n communicated to the clinical house staff caring for the patient on .\n\n 2. New tiny right apical pneumothorax with chest tube in place.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906754, "text": " 8:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess RML/RLL consolidation\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w stet placement for tracheomalaciea\n\n REASON FOR THIS EXAMINATION:\n assess RML/RLL consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old male status post stent for tracheomalacia.\n\n COMPARISON: .\n\n FINDINGS: The tracheal stent is unchanged in position. A right subclavian\n venous catheter is present with its tip in the distal SVC. There has been\n removal of a nasogastric tube. Slight interval improvement of a right middle\n lobe opacity is noted. Small bibasilar pleural effusions have decreased in\n size over the interval. There is decreased prominence of the pulmonary\n vasculature reflecting improving pulmonary edema.\n\n IMPRESSION: Interval improvement in bilateral pulmonary edema and small\n basilar pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2102-04-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908540, "text": " 12:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess for pneumo, etc\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy POD#7\n\n REASON FOR THIS EXAMINATION:\n Please assess for pneumo, etc\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n INDICATION: Thoracotomy and tracheobronchoplasty.\n\n Heart is normal in size. A residual effusion in the right hemithorax is\n present. A faint opacity at the right base remains unchanged from .\n The left lung is clear. A right IJ line terminates in the mid-to-lower SVC.\n There is no pneumothorax. Subcutaneous emphysema at the base of the neck on\n the right and to a lesser extent along the right lateral chest wall is\n present.\n\n IMPRESSION: Improvement in the appearance of the chest since with\n clearing of the changes at the left base and improvement in the changes at the\n right base.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906121, "text": " 12:06 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? assess rexpansion of RML/RLL **please do at noon *\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal now s/p bronch for\n RML/RLL collapse * please do at noon *\n REASON FOR THIS EXAMINATION:\n ? assess rexpansion of RML/RLL **please do at noon *\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE UPRIGHT CHEST, \n\n COMPARISON: Previous study of earlier the same date.\n\n INDICATION: Status post bronchoscopy.\n\n There has been interval improved aeration in the right middle and lower lobes\n following bronchoscopy with residual patchy opacity predominantly in the right\n lower lobe. Left retrocardiac opacity is again demonstrated. Small right\n pleural effusion is noted.\n\n There is no evidence of pneumothorax.\n\n IMPRESSION: Improving aeration in right middle and lower lobe following\n bronchoscopy.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906056, "text": " 7:48 PM\n CHEST (PORTABLE AP) Clip # \n Reason: wet?\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal\n REASON FOR THIS EXAMINATION:\n wet?\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post stent removal.\n\n The lung volumes are low. Allowing for this factor, heart size and\n mediastinal contours are stable. There has been interval development of\n increased opacity in the right lower lobe, predominantly in the retrocardiac\n region. The remainder of the lungs are clear.\n\n IMPRESSION: New right basilar retrocardiac opacity which may relate to\n atelectasis or aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906097, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: expiratory stridor\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal\n\n REASON FOR THIS EXAMINATION:\n expiratory stridor\n ______________________________________________________________________________\n FINAL REPORT\n\n PORTABLE CHEST, .\n\n COMPARISON: .\n\n INDICATION: Stridor. Stent removal.\n\n There is combined atelectasis of the right middle and lower lobes. There is\n associated slight shift of the mediastinum towards the right. The left lung\n is clear except for minimal patchy opacity at the left base. There remains\n diffuse air-filled distention of the thoracic esophagus. Finally, a small\n right pleural effusion is unchanged.\n\n IMPRESSION: Collapse of the right middle and lower lobes, likely due to\n mucous plugging given rapidity of onset. Findings communicated by telephone\n to Dr. on the date of the study.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906331, "text": " 11:55 AM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? location of NGT (was in esophagus before)\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal now s/p R SC TLC\n placement now NGT advanced\n REASON FOR THIS EXAMINATION:\n ? location of NGT (was in esophagus before)\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Status post rigid bronchoscopy with stent removal. Now status\n post right subclavian central venous line placement. Evaluate for NG tube\n advancement.\n\n FINDINGS: AP single view of the chest obtained with patient in supine\n position is analyzed in direct comparison with a similar previous study\n obtained four hours earlier. The NG tube has now been advanced successfully\n and is seen to curl up in the fundus of the stomach. A right subclavian\n central venous line terminates overlying the SVC at the level 1-2 cm below the\n carina. There is no pneumothorax. As before, however, there is perivascular\n haze, most marked in the central lower portions of the lung consistent with\n edema. The lateral pleural sinuses, however. remain free. The position of the\n Y-shaped airway stent is unchanged.\n\n IMPRESSION: Successful advancement of NG tube.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 906293, "text": " 8:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o inf\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal now s/p R SC TLC\n placement\n REASON FOR THIS EXAMINATION:\n r/o inf\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Line placement.\n\n There is a new nasogastric tube present, coiling in the lower thoracic\n esophagus with the tip directed cephalad. Right subclavian vascular catheter\n and Y-shaped airway stent remain in place. Cardiac and mediastinal contours\n are stable. There are worsening opacities in the perihilar and basilar\n regions with some associated air bronchograms. There is also increasing right\n middle lobe opacity. Small pleural effusions are present, and there has also\n been development of peripheral septal lines.\n\n IMPRESSION:\n 1. Coiling of nasogastric tube in lower thoracic esophagus, as communicated\n by telephone to on .\n 2. Worsening perihilar and basilar opacities with associated peripheral\n septal lines, likely due to pulmonary edema from fluid overload.\n 3. Worsening right middle lobe atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 905647, "text": " 12:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with s/p rigid bronch w/ stent removal\n REASON FOR THIS EXAMINATION:\n ? pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 1:03 P.M., \n\n HISTORY: Status post rigid bronchoscopy with stent removal.\n\n IMPRESSION: AP chest read in conjunction with CT of the trachea on :\n\n There is no pneumomediastinum, pneumothorax, or pleural effusion. A\n triangular opacity filling the right cardiophrenic sulcus is either\n atelectasis or mediastinal fat, but there is no lobar atelectasis. As before,\n the entire esophagus is distended with air projecting over the trachea which\n is unremarkable in appearance. Upper lungs are clear. The heart is normal\n size and midline.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-14 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 906466, "text": " 9:38 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for ileus\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with distended tympanic abd /ngt w/ mod drainage\n REASON FOR THIS EXAMINATION:\n eval for ileus\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Distended, tympanic abdomen. Evaluate for ileus.\n\n COMPARISONS: None.\n\n FINDINGS: Nasogastric tube is seen with tip overlying the stomach.\n Nonspecific bowel gas pattern is seen. There is no evidence of abnormally\n dilated loops of small bowel. There is evidence of stool within the colon.\n Gas is seen in the rectum.\n\n IMPRESSION: No abnormally dilated loops of small bowel.\n\n" }, { "category": "Radiology", "chartdate": "2102-03-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 908481, "text": " 1:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy POD#7\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postoperative day seven from tracheobronchioplasty.\n\n AP bedside chest is markedly suboptimal due to overlying arms. No gross\n cardiac enlargement in the left lung is clear without consolidation or\n effusion. There is a probable right effusion layering in this prone exam.\n Tip of right IJ catheter in the proximal SVC and there is subcutaneous\n emphysema in the right supraclavicular area. Multiple tubes overlying the\n right upper thorax but none appear to be within the patient. Little overall\n change from more satisfactory examination 2 days ago ().\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907823, "text": " 8:11 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT position, CT position, RIJ CVL position. r/o PTX\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy, new chest tube and RIJ CVL.\n REASON FOR THIS EXAMINATION:\n eval ETT position, CT position, RIJ CVL position. r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: AP chest, .\n\n HISTORY: 50-year-old man status post tracheobronchoplasty via a right\n thoracotomy.\n\n FINDINGS: Comparison is made to previous study from .\n\n The patient is status post right thoracotomy and there has been partial\n resection of the right posterior fifth rib. There is an endotracheal tube\n with the distal tip 6 cm above the carina at the level of the clavicular\n heads. There is a right-sided central venous catheter with distal tip in the\n distal SVC. There is a right-sided chest tube with the distal tip in the\n right lung apex. There is gas in the soft tissues of the right axilla and\n right neck. Cardiac silhouette and mediastinum is within normal limits. There\n are streaky opacities in the right base which may be secondary to the recent\n surgery versus atelectasis. There is a small left-sided pleural effusion.\n There is hazy consolidation seen in the left retrocardiac region.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 907936, "text": " 11:21 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50yo M s/p tracheobronchoplasty via R thoracotomy, new chest tube and RIJ\n CVL.\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Thoracotomy.\n\n Single portable chest radiograph again demonstrates a left-sided effusion,\n unchanged from the chest radiograph obtained the previous day. Support lines\n are unchanged in position. Bilateral increased airspace opacities, worse on\n the right than the left, remain unchanged as well. There is no shift of the\n midline structures.\n\n IMPRESSION:\n\n Pulmonary edema and left-sided effusion, unchanged. No pneumothorax detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-22 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 907604, "text": " 4:54 PM\n RENAL U.S. PORT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n DUPLEX DOP ABD/PEL LIMITED\n Reason: ELEVATED CREATINE WITH DOPPLERS\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man admitted with tracheomalacia, PNA, to undergo elective\n intubation / bronchoscopy today in anticipation of tracheoplasty on .\n Developing rising creatinine during hospital stay.\n REASON FOR THIS EXAMINATION:\n r/o hydro, perform with Doppler. requested by renal consult.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 50-year-old man admitted with tracheomalacia and pneumonia to\n undergo elective intubation bronchoscopy today in anticipation of\n tracheoplasty on . Developing rising creatinine. Evaluate for\n hydronephrosis performed with Doppler.\n\n No comparison studies.\n\n TECHNIQUE: Renal ultrasound.\n\n FINDINGS: The right kidney measures 12.4 cm. The left kidney measures 12.2\n cm. There is no evidence of hydronephrosis. There are few punctate areas of\n increased attenuation bilaterally, which may represent milk of calcium. There\n is a small sliver of decreased echogenicity in pouch, which\n probably represents a small amount of fluid. Intralobar renal arteries\n demonstrate normal waveform and resistive indices.\n\n IMPRESSION:\n\n No evidence of hydronephrosis. Silver of fluid in pouch.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2102-03-30 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 908369, "text": " 12:31 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for etiology--acute pathologic process\n Admitting Diagnosis: TRACHEO-BRONCHEO MALACEA\\BRONCHOSCOPY RIGID;STENT REMOVAL\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 50 year old man with psych issues- schizophrenia- followed by psych, s/p\n trahcealplasty POD#5 w/ acute mental status changes post-op\n REASON FOR THIS EXAMINATION:\n eval for etiology--acute pathologic process\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE HEAD WITHOUT CONTRAST DATED \n\n HISTORY: 50-year-old male schizophrenic, now five days status post\n tracheoplasty with acute mental status changes.\n\n TECHNIQUE: Contiguous 5-mm axial tomographic sections were obtained from the\n skull base through the vertex and viewed in brain and bone window on the\n workstation.\n\n The study is compared with recent NECT dated ; the overall appearance is\n unchanged. Again, the evaluation of the inferior posterior cranial fossa and\n more caudal structures is somewhat limited by motion and streak artifact.\n There is no intra- or extra-axial hemorrhage or fluid collection and the\n midline structures are in the midline. The ventricles and cisterns are\n unchanged in size and configuration. There is prominence of, particularly,\n the bifrontal extra-axial CSF spaces, cortical sulci and fissures,\n representing atrophy. There is no cerebral edema, loss of grey-white matter\n differentiation or sulcal effacement to indicate acute territorial infarction.\n Noted is calcification of the intracranial carotid arteries.\n\n IMPRESSION:\n 1. No acute intracranial abnormality and no significant change since the\n study.\n 2. Moderate bifrontal atrophy.\n\n" } ]

[ { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597608, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt Intubated on 50%/500x16/5+. LSCTA throughout. Productive\n cough. Low grade temp of 99.5.\n Action:\n Pt extubated and now on RA. Given alb MDIs by RT.\n Response:\n O2 sats of 95%.\n Plan:\n Cont to monitor Resp status closely, encourage CDB.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, MAE, following commands. Pt c/o pain\n to head and lower back. Pt denies SI/HI, but does state that she is\n very depressed.\n Action:\n Given 15mg po morphine.\n Response:\n Pain .\n Plan:\n Cont to monitor MS, hold pain meds for RR <12.\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597623, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services. Pt initially\n placed on 1:1 sitter, but sitter is now d/c\nd per psychiatry.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt Intubated on 50%/500x16/5+. LSCTA throughout. Productive\n cough. Low grade temp of 99.5.\n Action:\n Pt extubated and now on RA. Given alb MDIs by RT.\n Response:\n O2 sats of 95%.\n Plan:\n Cont to monitor Resp status closely, encourage CDB.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, MAE, following commands. Pt denies SI/HI,\n but does state that she is very depressed.\n Action:\n Given 15mg po morphine.\n Response:\n Pain .\n Plan:\n Cont to monitor MS, hold pain meds for RR <12.\n H/O back pain\n Assessment:\n Received pt on 20mg propofol this am. Once extubated pt immediately\n asking for pain meds.. stating she has back/head pain at rest.\n Action:\n Given 15mg po morphine x 2 today\n.last dose given @ 1520.\n Response:\n Pain level following first dose, but pt able to fall asleep and\n slightly lethargic. Resp status stable.\n Plan:\n Cont w/ pain mgmt, repositioning, emotional support.\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597596, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597668, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airwayChief Complaint: Drug overdose\n HPI:\n 44 y.o. Female with h/o prescription drug abuse, bipolar disorder,\n recently admitted for multiple drug overdose. Per pt apparently took\n a mixture of 0.1mg Clonidine, Suboxone, Gabapentin. Pt was found in the\n homeless shelter with altered mental status and prescription of\n Suboxone. In the pt was intubated for apneic periods. Toxicology\n were consulted and recommended supportive care. Pt received an amp of\n bicarb given EKG showed prolonged QRS. Following amp of bicarb repeat\n EKG showed no change in QRS.\n .\n Of note pt was recently admitted to the ED after experiencing headaches\n and seizure. She was noted to have an elevated lactate as well as an\n anion gap which closed the following day. At that time she also talked\n to a resident requesting demerol for a headache, when told it was an\n inappropriate medication, she became unhappy and accused the medical\n team of not trusting her. She repeated this request to multiple\n providers. Per her PCP, has received various narcotics from\n different prescribers around the city. She was also tested positive for\n Methadone which she denied taking.\n .\n In the ED, initial vs were: T98.8, HR 94, BP 109/75, RR 14, Sat 100%.\n Per ED note pt's RR was depressed at 10bpm, slurred speech was noted.\n In the pt was noted to have no leukocytosis, U/A was negative,\n Lactate 1.4, +serum TCA level. Negative urine tox. Pt was noted to be\n altered on presentation and was given narcan. Given continued concern\n pt was intubated for airway protection for apnea. Tox consult was\n obtained and recommended supportive care. Pt had an EKG which showed a\n QRS of 108, he received an amp of bicarb and an EKG was repeated which\n showed no changed. CXR in the ED showed right mainstem intubation and\n the tube was pulled back. Pt was originally on Versed/Fentanyl for\n sedation protection. Tox screen positive for tricyclics. EKG done.\n Propofol gtt for sedation. Pt transferred to micu for further care,\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services. Pt initially\n placed on 1:1 sitter, but sitter is now d/c\nd per psychiatry.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n - EKG done this am\nno further QT interval changes. OTC\n 0.431.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt Intubated on 50%/500x16/5+. LSCTA throughout. Productive\n cough. Low grade temp of 99.5.\n Action:\n Pt extubated and now on RA. Given alb MDIs by RT.\n Response:\n O2 sats of 94% on 2L o2, desats to 89% on RA.\n Plan:\n Cont to monitor Resp status closely, encourage CDB.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, MAE, following commands. Pt denies SI/HI,\n but does state that she is very depressed.\n Action:\n Given 15mg po morphine.\n Response:\n Pain .\n Plan:\n Cont to monitor MS, hold pain meds for RR <12.\n H/O back pain\n Assessment:\n Received pt on 20mg propofol this am. Once extubated pt immediately\n asking for pain meds.. stating she has back/head pain at rest.\n Action:\n Given 15mg po morphine x 2 today\n.last dose given @ 1520.\n Response:\n Pain level following first dose, but pt able to fall asleep and\n slightly lethargic. Resp status stable.\n Plan:\n Cont w/ pain mgmt, repositioning, emotional support.\n Demographics\n Attending MD:\n \n Admit diagnosis:\n OVERDOSE\n Code status:\n Height:\n Admission weight:\n 73.4 kg\n Daily weight:\n 75.2 kg\n Allergies/Reactions:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n throat swelling\n Erythromycin (Oral) (Erythromycin Base)\n throat swelling\n Nsaids\n throat swelling\n Precautions:\n PMH:\n CV-PMH:\n Additional history: migraines, anoxic brain injury S/P MVA ,\n Bipolar, hypothyroidism, chronic LBP, DVT, PSA recent w/u for ?\n seizure\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:105\n D:56\n Temperature:\n 100.9\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 93 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 90% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 50% %\n 24h total in:\n 1,692 mL\n 24h total out:\n 1,535 mL\n Pertinent Lab Results:\n Sodium:\n 142 mEq/L\n 01:06 AM\n Potassium:\n 3.5 mEq/L\n 01:06 AM\n Chloride:\n 108 mEq/L\n 01:06 AM\n CO2:\n 26 mEq/L\n 01:06 AM\n BUN:\n 10 mg/dL\n 01:06 AM\n Creatinine:\n 0.6 mg/dL\n 01:06 AM\n Glucose:\n 101 mg/dL\n 01:06 AM\n Hematocrit:\n 34\n 01:18 AM\n Finger Stick Glucose:\n 98\n 11:00 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: valuables in CC2 security locker\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: 221\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Physician ", "chartdate": "2197-10-19 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 597477, "text": "Chief Complaint: Ingestion\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 presents with altered mental status, witnessed apneas and\n intubation required for airway protection.\n Patient lives in shelter and slurred speech noted today. Suboxone\n (combination buprenorphine/naloxone) found in room and patient brought\n to ED for further evaluation.\n In addition--Clonidine and Gabapentin available to patient.\n Upon presentation to the ED patient had worsening respiratory\n depression and worsening level of alertness and patient was intubated\n and toxicology consulted.\n ECG performed--QRS-108ms and no change seen with bicarbonate\n Urine Tox-negative\n Serum Tox--positive for Tricyclics\n HCO3-27\n and patient admitted to ICU with ingestion and respiratory failure\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n throat swelling\n Erythromycin (Oral) (Erythromycin Base)\n throat swelling\n Nsaids\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Past medical history:\n Family history:\n Social History:\n Substance Abuse\n Bipolar Disorder\n Hypothyroidism\n Migraine HA\n DVT\n Non-contributory\n Occupation: unemp\n Drugs: See above--polysubstance abuse, typically with prescription\n medications\n Tobacco: ppd\n Alcohol: None\n Other:\n Review of systems:\n Constitutional: Fatigue, No(t) Fever\n Nutritional Support: NPO\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 02:02 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 55 (55 - 73) bpm\n BP: 95/58(67) {95/58(67) - 141/90(102)} mmHg\n RR: 16 (15 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 12 mL\n 120 mL\n PO:\n TF:\n IVF:\n 12 mL\n 120 mL\n Blood products:\n Total out:\n 900 mL\n 320 mL\n Urine:\n 320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -888 mL\n -200 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.44/39/98.//1\n Ve: 8.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General Appearance: Thin\n Head, Ears, Nose, Throat: Endotracheal tube\n Cardiovascular: (S1: Normal), (S2: Distant)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : ),\n (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Patient unresponsive\n Labs / Radiology\n 34\n 0.8\n 12\n 27\n 105\n 3.6\n 140\n [image002.jpg]\n 01:18 AM\n Hct\n 34\n TC02\n 27\n Other labs: PT / PTT / INR://1.0\n Imaging: CXR-ETT at 6cm, no pulmonary infiltrates-\n ECG: Normal Intervals\n Assessment and Plan\n 47 yo female with history of substance abuse who now is found with\n altered mental status, polysubstance ingestion and with signfiicant\n respiratory depression patient now admitted to ICU intubated for\n further care. This may well be a combination of significant TCA\n overdose and respiratory suppression in the setting of narcotic\n agonists.\n 1)Ingestion-\n -Will continue to monitor for evolution of any signfiicant ECG changes\n or evolution of acidosis\n -Will consider TCA ingestion most threatening\n -Appreciate toxicology input\n -Will hold all medications\n -Will need 1:1 sitter and psych following extubation.\n 2)Respiratory Failure-\n -Move to PSV with return of signfiicant respiratory drive\n -VAP protocol\n 3)ALTERED MENTAL STATUS (NOT DELIRIUM)-\n -Will have to follow patient exam with intermittent decrease in\n sedation\n ICU Care\n Nutrition:\n NPO\n Glycemic Control:\n Lines / Intubation:\n 18 Gauge - 11:36 PM\n 20 Gauge - 11:37 PM\n Comments:\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP: HOB elevation, Mouth care, Daily wake up, RSBI\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597480, "text": "Patient presents with altered mental status, witnessed apneas and\n intubation required for airway protection.\n Patient lives in shelter and slurred speech noted today. Suboxone\n (combination buprenorphine/naloxone) found in room and patient brought\n to ED for further evaluation.\n In addition--Clonidine and Gabapentin available to patient.\n Upon presentation to the ED patient had worsening respiratory\n depression and worsening level of alertness and patient was intubated\n and toxicology consulted.\n ECG performed--QRS-108ms and no change seen with bicarbonate\n Urine Tox-negative\n Serum Tox--positive for Tricyclics\n HCO3-27\n and patient admitted to ICU with ingestion and respiratory failure\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n throat swelling\n Erythromycin (Oral) (Erythromycin Base)\n throat swelling\n Nsaids\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597487, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 16, +5, 50%. No overbreathing. Breath sounds\n rhonchorous on admission, now are clear, diminished at bases. Sats\n 100%. SB 50s, NBP 100s/60s.\n Action:\n ABG drawn\n7.44/39/98/27. Sat 97%. No vent changes made.\n Response:\n Tolerating current vent settings.\n Plan:\n Will lighten up sedation later today to assess rep drive, ? extubate if\n awake\n Altered mental status (not Delirium)\n Assessment:\n Sedated on propofol 20 mcg. On transfer pt attempting to sit up in bed,\n unable to redirect verbally. Soft wrist restraints for safety. PERL\n 6mm, brisk. No commands.\n Action:\n Titrated propofol to sedation, currently at 25mcg.\n Response:\n PERL 3mm, brisk.\n Plan:\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597489, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 16, +5, 50%. No overbreathing. Breath sounds\n rhonchorous on admission, now are clear, diminished at bases. Sats\n 100%. SB 50s, NBP 100s/60s.\n Action:\n ABG drawn\n7.44/39/98/27. Sat 97%. No vent changes made.\n Response:\n Tolerating current vent settings.\n Plan:\n Will lighten up sedation later today to assess rep drive, ? extubate if\n awake\n Altered mental status (not Delirium)\n Assessment:\n Sedated on propofol 20 mcg. On transfer pt attempting to sit up in bed,\n unable to redirect verbally. Soft wrist restraints for safety. PERL\n 6mm, brisk. No commands. No gag.\n Action:\n Titrated propofol to sedation, currently at 25mcg.\n Response:\n PERL 3mm, brisk. Withdraws to nailbed pressure very weakly. Grimaces\n with turns. No other response.\n Plan:\n Sedation with propofol, neuro checks. Will lighten sedation today to\n assess ability to extubate. Will need 1:1 sitter and psych eval when\n extubated for OD, ? SA.\n" }, { "category": "Physician ", "chartdate": "2197-10-19 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 597497, "text": "TITLE:\n Chief Complaint: Drug overdose\n HPI:\n 44 y.o. Female with h/o prescription drug abuse, bipolar disorder,\n recently admitted for multiple drug overdose. Per pt apparently took\n a mixture of 0.1mg Clonidine, Suboxone, Gabapentin. Pt was found in the\n homeless shelter with altered mental status and prescription of\n Suboxone. In the pt was intubated for apneic periods. Toxicology\n were consulted and recommended supportive care. Pt received an amp of\n bicarb given EKG showed prolonged QRS. Following amp of bicarb repeat\n EKG showed no change in QRS.\n .\n Of note pt was recently admitted to the ED after experiencing headaches\n and seizure. She was noted to have an elevated lactate as well as an\n anion gap which closed the following day. At that time she also talked\n to a resident requesting demerol for a headache, when told it was an\n inappropriate medication, she became unhappy and accused the medical\n team of not trusting her. She repeated this request to multiple\n providers. Per her PCP, has received various narcotics from\n different prescribers around the city. She was also tested positive for\n Methadone which she denied taking.\n .\n In the ED, initial vs were: T98.8, HR 94, BP 109/75, RR 14, Sat 100%.\n Per ED note pt's RR was depressed at 10bpm, slurred speech was noted.\n In the pt was noted to have no leukocytosis, U/A was negative,\n Lactate 1.4, +serum TCA level. Negative urine tox. Pt was noted to be\n altered on presentation and was given narcan. Given continued concern\n pt was intubated for airway protection for apnea. Tox consult was\n obtained and recommended supportive care. Pt had an EKG which showed a\n QRS of 108, he received an amp of bicarb and an EKG was repeated which\n showed no changed. CXR in the ED showed right mainstem intubation and\n the tube was pulled back. Pt was originally on Versed/Fentanyl for\n sedation.\n Allergies:\n Bactrim (Oral) (Sulfamethoxazole/Trimethoprim)\n throat swelling\n Erythromycin (Oral) (Erythromycin Base)\n throat swelling\n Nsaids\n throat swelling\n Last dose of Antibiotics:\n Infusions:\n Propofol - 25 mcg/Kg/min\n Other ICU medications:\n Home medications:\n Albuterol Sulfate 90 mcg 1-2 Puffs Inhalation Q4H PRN\n Amitriptyline 150 mg qHS\n Diphenhydramine HCl 50 mg PRN\n Gabapentin 900 mg TID\n Levothyroxine 100 mcg daily\n Omeprazole 40 mg Daily\n Quetiapine 50 mg \n Acetaminophen 650 mg Q6H PRN\n Prochlorperazine Maleate 10 mg q6h PRN\n Clonazepam 2 mg TID\n Nicotine 14 mg/24 hr Patch 24 hr daily\n Buprenorphine-Naloxone 8-2 mg Daily\n Buprenorphine-Naloxone 8-2 mg qDinner\n Clonidine 0.1 mg TID\n Past medical history:\n Family history:\n Social History:\n Recurrent bouts of bronchitis.\n Hypothyroidism.\n Bipolar disorder, well controlled on her current medications.\n Anxiety.\n History of appendectomy.\n Status post ectopic pregnancy.\n Status post four back surgeries in , , and\n . Per recent imaging, evidence of L5-S1 posterior fusion and\n anterior fusion with intravertebral discs\n s/p anoxic brain injury with damage to the basal ganglia s/p MVA .\n Migraine Headache\n Status post repair of rectocele at the in 02/.\n s/p cystocele repair.\n History of lower extremity DVT treated with 4 months of coumadin.\n Prescription drug abuse.\n Unable to obtain\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Unable to obtain\n Flowsheet Data as of 03:16 AM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 59 (54 - 73) bpm\n BP: 102/68(76) {92/58(66) - 141/90(102)} mmHg\n RR: 16 (15 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SB (Sinus Bradycardia)\n Total In:\n 12 mL\n 245 mL\n PO:\n TF:\n IVF:\n 12 mL\n 245 mL\n Blood products:\n Total out:\n 900 mL\n 360 mL\n Urine:\n 360 mL\n NG:\n Stool:\n Drains:\n Balance:\n -888 mL\n -115 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n SpO2: 100%\n ABG: 7.44/39/98./26/1\n Ve: 8.7 L/min\n PaO2 / FiO2: 196\n Physical Examination\n General: Alert, oriented, no acute distress\n HEENT: Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD\n Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 101 mg/dL\n 0.6 mg/dL\n 10 mg/dL\n 26 mEq/L\n 108 mEq/L\n 3.5 mEq/L\n 142 mEq/L\n 34\n [image002.jpg]\n \n 2:33 A10/1/ 01:06 AM\n \n 10:20 P10/1/ 01:18 AM\n \n 1:20 P\n \n 11:50 P\n \n 1:20 A\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n Hct\n 34\n Cr\n 0.6\n TC02\n 27\n Glucose\n 101\n Other labs: Albumin:3.3 g/dL, Ca++:8.1 mg/dL, Mg++:1.9 mg/dL, PO4:2.9\n mg/dL\n Assessment and Plan This is a 44 y.o. Female with h.o. BPD, Depression,\n hypothyroidism, prescription drug abuse p/w altered mental status\n suspected OD s/p intubation.\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n ICU Care\n ##. Overdose: Pt presented with overdose with +urine tox for TCAs.\n Suspected pt overdosed on 0.1mg Clonidine, Suboxone, Gabapentin. On\n admission pt was very lethargic with periods of apnea. Given pt is not\n hypotensive and Suboxone contains Narcan susoect her overdose may be\n from gabapentin and Amitriptyline causing CNS depression. Pt tested\n positive for TCAs at a potentially toxic level. Pt's QRS have remained\n borderline high and unchanged after amp of HCO3. Suspect that this may\n be a suicide attempt given the choice of medications versus\n reacreational.\n - check daily EKGs to monitor QRS and QTc\n - f/u toxicology recs\n - follow lytes daily to check for gap\n - consult psych in the AM\n - 1:1 sitter when extubated\n - addiction consult in the AM\n .\n ##. Respiratory Failure: Likely to central respiratory depression\n from overdose leading to CNS depression. Pt intubated in the ED \n apneic episodes. Currently on Propfol gtt on CMV vent settings, FiO2\n 50%.\n - will check ABG\n - as mentioned above will attempt to extubate in the AM\n .\n ##. Hypothyroidism: Will continue on home regimen of Levothyroxine.\n .\n ##. Bronchitis: Will continue on Albuterol INH.\n .\n ##. Depression/BPD: Will currently hold off on pt's Amitriptyline given\n concern for possible overdose as well as quietiapine. Psych consult in\n the AM for possible suicide attempt, will also ask regarding restarting\n psych medications.\n .\n ##. Smoking: Will continue on nicotine patch.\n .\n ##. FEN: No IVF, replete electrolytes, NPO for now\n .\n ##. Prophylaxis: Subcutaneous heparin, Lansoprazole \n .\n ##. Access: peripherals\n .\n ##. Code: presumed full\n .\n ##. Communication: Will touch base with PCP, ?psychiatrist\n .\n ##. Disposition: pending above\n ##. Lines:\n 18 Gauge - 11:36 PM\n 20 Gauge - 11:37 PM\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 597542, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airway protection. Tox screen positive for tricyclics.\n EKG done. Propofol gtt for sedation. Pt keys, clothing, and suboxone\n locked in Wednesday locker in EW. Tx MICU.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated, AC 500 x 16, +5, 50%. No overbreathing. Breath sounds\n rhonchorous on admission, now are clear, diminished at bases. Sats\n 100%. SB 50s, NBP 100s/60s.\n Action:\n ABG drawn\n7.44/39/98/27. Sat 97%. No vent changes made.\n Response:\n Tolerating current vent settings.\n Plan:\n Will lighten up sedation later today to assess rep drive, ? extubate if\n awake\n Altered mental status (not Delirium)\n Assessment:\n Sedated on propofol 20 mcg. On transfer pt attempting to sit up in bed,\n unable to redirect verbally. Soft wrist restraints for safety. PERL\n 6mm, brisk. No commands. No gag.\n Action:\n Titrated propofol to sedation, currently at 20mcg.\n Response:\n PERL 3mm, brisk. Withdraws to nailbed pressure very weakly. Grimaces\n with turns. No other response.\n Plan:\n Sedation with propofol, neuro checks. Will lighten sedation today to\n assess ability to extubate. Will need 1:1 sitter and psych eval when\n extubated for OD, ? SA.\n" }, { "category": "Physician ", "chartdate": "2197-10-19 00:00:00.000", "description": "MICU Attending Admission Note", "row_id": 597652, "text": "TITLE: MICU ATTENDING PROGRESS NOTE\n I saw and examined the patient, and was physically present with the ICU\n team for the key portions of the services provided. I would emphasize\n and add the following points: 44F substance abuse, psych disorder p/w\n altered mental status and likely OD (?clonidine, amytriptylline,\n gabapentin, suboxone) - intubated in ED, tox +TCA, HCO3 without change\n in QRS (108mS). On propofol overnight.\n Exam notable for Tm 97.6 BP 100/50 HR 66 RR 16 with sat 100 on VAC\n 500x16 5 0.5. Intubated, alert, follows commands. CTA B. RRR s1s2. Soft\n +BS. No edema. Labs notable for WBC 5K, HCT 30, K+ 3.5, Cr 0.6. CXR\n with clear lungs, EKG s QRS 102mS.\n Agree with plan to manage respiratory failure with SBT now on propofol,\n plan to extubate today. For overdose, suspect TCA / benadryl +/-\n gabapentin are major contributors, recheck EKG, HCO3 if QRS >110. Will\n need psych eval / 1:1 sitter once extubated, addiction services, SW\n eval. Will check iron studies and hemolysis labs for anemia. Will d/w\n PCP and family.\n Patient is critically ill\n Total time: 35 min\n" }, { "category": "Social Work", "chartdate": "2197-10-19 00:00:00.000", "description": "Social Work Admission Note", "row_id": 597616, "text": "Social Work Initial Note:\n Received referral from MICU team for EtOH/substance abuse assessment\n for this 44 y.o. woman admitted to on with dx of\n overdose. Reviewed chart and discussed with RN. SW met briefly with\n pt in MICU to begin assessment. She presents as alert and grossly\n oriented and states that she would rather not talk at this time.\n told my story so many times already today, I\nd rather not get into it\n again right now,\n she states. Pt c/o feeling tired and wanting to\n rest. She requests that SW return tomorrow for interview. She also\n requests phone number for , Inc. Shelter in where she\n wants to call to relay a message to her friend, , that she is in\n the hospital. SW provided her with the phone number so she can make\n the call. Agreed to return tomorrow for interview. Discussed with\n RN. Please page with any questions or concerns.\n , LICSW, #\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597626, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airwayChief Complaint: Drug overdose\n HPI:\n 44 y.o. Female with h/o prescription drug abuse, bipolar disorder,\n recently admitted for multiple drug overdose. Per pt apparently took\n a mixture of 0.1mg Clonidine, Suboxone, Gabapentin. Pt was found in the\n homeless shelter with altered mental status and prescription of\n Suboxone. In the pt was intubated for apneic periods. Toxicology\n were consulted and recommended supportive care. Pt received an amp of\n bicarb given EKG showed prolonged QRS. Following amp of bicarb repeat\n EKG showed no change in QRS.\n .\n Of note pt was recently admitted to the ED after experiencing headaches\n and seizure. She was noted to have an elevated lactate as well as an\n anion gap which closed the following day. At that time she also talked\n to a resident requesting demerol for a headache, when told it was an\n inappropriate medication, she became unhappy and accused the medical\n team of not trusting her. She repeated this request to multiple\n providers. Per her PCP, has received various narcotics from\n different prescribers around the city. She was also tested positive for\n Methadone which she denied taking.\n .\n In the ED, initial vs were: T98.8, HR 94, BP 109/75, RR 14, Sat 100%.\n Per ED note pt's RR was depressed at 10bpm, slurred speech was noted.\n In the pt was noted to have no leukocytosis, U/A was negative,\n Lactate 1.4, +serum TCA level. Negative urine tox. Pt was noted to be\n altered on presentation and was given narcan. Given continued concern\n pt was intubated for airway protection for apnea. Tox consult was\n obtained and recommended supportive care. Pt had an EKG which showed a\n QRS of 108, he received an amp of bicarb and an EKG was repeated which\n showed no changed. CXR in the ED showed right mainstem intubation and\n the tube was pulled back. Pt was originally on Versed/Fentanyl for\n sedation protection. Tox screen positive for tricyclics. EKG done.\n Propofol gtt for sedation. Pt transferred to micu for further care,\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services. Pt initially\n placed on 1:1 sitter, but sitter is now d/c\nd per psychiatry.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n - EKG done this am\nno further QT interval changes. OTC\n 0.431.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt Intubated on 50%/500x16/5+. LSCTA throughout. Productive\n cough. Low grade temp of 99.5.\n Action:\n Pt extubated and now on RA. Given alb MDIs by RT.\n Response:\n O2 sats of 95%. VSS.\n Plan:\n Cont to monitor Resp status closely, encourage CDB.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, MAE, following commands. Pt denies SI/HI,\n but does state that she is very depressed.\n Action:\n Given 15mg po morphine.\n Response:\n Pain .\n Plan:\n Cont to monitor MS, hold pain meds for RR <12.\n H/O back pain\n Assessment:\n Received pt on 20mg propofol this am. Once extubated pt immediately\n asking for pain meds.. stating she has back/head pain at rest.\n Action:\n Given 15mg po morphine x 2 today\n.last dose given @ 1520.\n Response:\n Pain level following first dose, but pt able to fall asleep and\n slightly lethargic. Resp status stable.\n Plan:\n Cont w/ pain mgmt, repositioning, emotional support.\n" }, { "category": "Respiratory ", "chartdate": "2197-10-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 597532, "text": "Demographics\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Cuff 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: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed\n Respiratory Care Shift Procedures\n Bedside Procedures: Patient remains on ventilatory support with no\n parameter changes made throughout the night. Latest abg results\n determined a very mild metabolic alkalemia with very good oxygenation.\n No RSBI measured due to lack of spontaneous respiration.\n" }, { "category": "Nursing", "chartdate": "2197-10-19 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 597634, "text": "Pt is 44 yo female who lives in shelter, found in her room\n with slurred speech and adm to EW. Pt took a handful of clonidin, 600\n gabapentin, suboxone. Pt denies SI/SA in ew, noted to be apneic,\n intubated for airwayChief Complaint: Drug overdose\n HPI:\n 44 y.o. Female with h/o prescription drug abuse, bipolar disorder,\n recently admitted for multiple drug overdose. Per pt apparently took\n a mixture of 0.1mg Clonidine, Suboxone, Gabapentin. Pt was found in the\n homeless shelter with altered mental status and prescription of\n Suboxone. In the pt was intubated for apneic periods. Toxicology\n were consulted and recommended supportive care. Pt received an amp of\n bicarb given EKG showed prolonged QRS. Following amp of bicarb repeat\n EKG showed no change in QRS.\n .\n Of note pt was recently admitted to the ED after experiencing headaches\n and seizure. She was noted to have an elevated lactate as well as an\n anion gap which closed the following day. At that time she also talked\n to a resident requesting demerol for a headache, when told it was an\n inappropriate medication, she became unhappy and accused the medical\n team of not trusting her. She repeated this request to multiple\n providers. Per her PCP, has received various narcotics from\n different prescribers around the city. She was also tested positive for\n Methadone which she denied taking.\n .\n In the ED, initial vs were: T98.8, HR 94, BP 109/75, RR 14, Sat 100%.\n Per ED note pt's RR was depressed at 10bpm, slurred speech was noted.\n In the pt was noted to have no leukocytosis, U/A was negative,\n Lactate 1.4, +serum TCA level. Negative urine tox. Pt was noted to be\n altered on presentation and was given narcan. Given continued concern\n pt was intubated for airway protection for apnea. Tox consult was\n obtained and recommended supportive care. Pt had an EKG which showed a\n QRS of 108, he received an amp of bicarb and an EKG was repeated which\n showed no changed. CXR in the ED showed right mainstem intubation and\n the tube was pulled back. Pt was originally on Versed/Fentanyl for\n sedation protection. Tox screen positive for tricyclics. EKG done.\n Propofol gtt for sedation. Pt transferred to micu for further care,\n EVENTS:\n - Pt successfully extubated at 1030am.\n - Pt seen by psych/SW and addiction services. Pt initially\n placed on 1:1 sitter, but sitter is now d/c\nd per psychiatry.\n - Belongings incuding subloxone prescription in the CC2\n security locker.\n - EKG done this am\nno further QT interval changes. OTC\n 0.431.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Assumed pt Intubated on 50%/500x16/5+. LSCTA throughout. Productive\n cough. Low grade temp of 99.5.\n Action:\n Pt extubated and now on RA. Given alb MDIs by RT.\n Response:\n O2 sats of 94% on 2L o2, desats to 89% on RA.\n Plan:\n Cont to monitor Resp status closely, encourage CDB.\n Altered mental status (not Delirium)\n Assessment:\n Pt alert and oriented x 3, MAE, following commands. Pt denies SI/HI,\n but does state that she is very depressed.\n Action:\n Given 15mg po morphine.\n Response:\n Pain .\n Plan:\n Cont to monitor MS, hold pain meds for RR <12.\n H/O back pain\n Assessment:\n Received pt on 20mg propofol this am. Once extubated pt immediately\n asking for pain meds.. stating she has back/head pain at rest.\n Action:\n Given 15mg po morphine x 2 today\n.last dose given @ 1520.\n Response:\n Pain level following first dose, but pt able to fall asleep and\n slightly lethargic. Resp status stable.\n Plan:\n Cont w/ pain mgmt, repositioning, emotional support.\n" }, { "category": "ECG", "chartdate": "2197-10-20 00:00:00.000", "description": "Report", "row_id": 233505, "text": "Sinus rhythm. Non-specific low amplitude T waves. Compared to the previous\ntracing of artifact is absent.\n\n" }, { "category": "ECG", "chartdate": "2197-10-19 00:00:00.000", "description": "Report", "row_id": 233506, "text": "Sinus rhythm. Baseline artifact. Probably normal tracing. Compared to\ntracing #3 there is no significant difference.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2197-10-18 00:00:00.000", "description": "Report", "row_id": 233507, "text": "Sinus rhythm. Normal tracing. Compared to tracing #2 the Q-T interval has\nmildly decreased.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2197-10-18 00:00:00.000", "description": "Report", "row_id": 233508, "text": "Borderline sinus bradycardia. Slightly prolonged Q-T interval. Compared to\ntracing #1 the rate has decreased markedly.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2197-10-18 00:00:00.000", "description": "Report", "row_id": 233509, "text": "Sinus tachycardia. Otherwise, normal tracing. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2197-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100671, "text": " 9:26 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? aspiration\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with fever, recently extubated\n REASON FOR THIS EXAMINATION:\n ? aspiration\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 9:38 P.M., \n\n HISTORY: Fever, recently extubated. Check aspiration.\n\n IMPRESSION: AP chest compared to , 3:20 a.m.:\n\n Heterogeneous left infrahilar opacification is actually improved since\n , following extubation. There is no strong evidence for\n pneumonia. Lungs are grossly clear. Heart size normal. No pleural effusion\n or evidence of central adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100508, "text": " 9:42 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with right mainstem intubation, tube pulled back\n REASON FOR THIS EXAMINATION:\n eval placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison made with a prior study from approximately 20 minutes earlier.\n\n CLINICAL HISTORY: Right main stem bronchus intubation, status post ET tube\n retraction. Evaluate position of ET tube.\n\n FINDINGS: Single portable supine view of the chest is obtained. The ET tube\n tip is now positioned 5.5 cm above the carina with both lungs appearing\n well-aerated. NG tube is unchanged.\n\n IMPRESSION: Interval placement of the ET tube now positioned 5.5 cm above the\n carina. NG tube unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-10-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100502, "text": " 9:14 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for cardiopulmonary process and tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with overdose, post intubation, post NG tube placement\n REASON FOR THIS EXAMINATION:\n eval for cardiopulmonary process and tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 44-year-old woman with an overdose after intubation and NG tube\n placement.\n\n COMPARISON: Chest x-ray .\n\n CHEST, PORTABLE FRONTAL VIEW: The endotracheal tube extends into the right\n main bronchus. Nasogastric tube terminates in the stomach, with the tip\n directed cephalad. Heart size is normal. The pulmonary vasculature is\n prominent, likely due to vascular congestion. Mediastinal and hilar\n prominence is likely due to portable supine technique. There is no\n pneumothorax or effusion or pulmonary consolidation.\n\n IMPRESSION:\n 1. ETT in right main bronchus. The patient has had a subsequent chest\n radiograph demonstrating retraction of the endotracheal tube.\n\n 2. Pulmonary vascular congestion.\n\n" }, { "category": "Radiology", "chartdate": "2197-10-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1100523, "text": " 2:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation\n Admitting Diagnosis: OVERDOSE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 44 year old woman with h.o. BPD, drug abuse p/w multiple drug overdose s/p\n intubation.\n REASON FOR THIS EXAMINATION:\n s/p intubation\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Drug abuse, multiple drug overdose, status post intubation.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the endotracheal tube and\n the nasogastric tube are in unchanged position. The lung parenchyma currently\n is unremarkable, there are no focal parenchymal opacity suggesting pneumonia.\n No pleural effusions, no pneumothorax. No overhydration. Normal size of the\n cardiac silhouette, normal hilar and mediastinal contours.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2164-11-27 00:00:00.000", "description": "Report", "row_id": 93478, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraoperative TEE for CABP on IABP\nStatus: Inpatient\nDate/Time: at 11:25\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement. Depressed LAA emptying velocity (<0.2m/s) No\nthrombus in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA\nand extending into the RV. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF\n(>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in aortic arch. Normal\ndescending aorta diameter. No thoracic aortic dissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PR.\n\nConclusions:\nPRE-CPB:\nThe left atrium is mildly dilated. The left atrial appendage emptying velocity\nis depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No\natrial septal defect is seen by 2D or color Doppler.\n\nThere is mild symmetric left ventricular hypertrophy. The left ventricular\ncavity size is normal. Overall left ventricular systolic function is normal\n(LVEF>55%). Right ventricular chamber size and free wall motion are normal.\n\nThere are simple atheroma in the aortic arch. No thoracic aortic dissection is\nseen.\n\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion. There is no aortic valve stenosis. Trace aortic regurgitation is\nseen.\n\nThe mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation\nis seen.\n\nPOST-CPB:\nLV EF remains normal with IABP. Vavlular function remains unchanged. There is\nno evidence of aortic dissection.\n\nDr was notified of results at time of study.\n\n\n" }, { "category": "Echo", "chartdate": "2164-11-26 00:00:00.000", "description": "Report", "row_id": 93479, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. Preoperative assessment.\nHeight: (in) 62\nWeight (lb): 209\nBSA (m2): 1.95 m2\nBP (mm Hg): 110/45\nHR (bpm): 75\nStatus: Inpatient\nDate/Time: at 17:13\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThe patient was on an IABP set at 1:1.\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and global systolic\nfunction (LVEF>55%). Suboptimal technical quality, a focal LV wall motion\nabnormality cannot be fully excluded. No resting LVOT gradient.\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.\nIndeterminate 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 echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - body habitus.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size, and global systolic function are normal\n(LVEF>55%; on IABP). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic stenosis or\naortic regurgitation. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. The pulmonary artery systolic pressure could not\nbe determined. There is an anterior space which most likely represents a\nprominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with\npreserved global biventricular systolic function. No valvular pathology or\npathologic 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": "ECG", "chartdate": "2164-11-27 00:00:00.000", "description": "Report", "row_id": 244101, "text": "Normal sinus rhythm, rate 76. Low voltage in the limb leads as well as the\nlateral leads. T wave inversion and ST segment depression in the anterior\nprecordium which is unchanged from prior tracings, particularly a tracing\nfrom , which may represent myocardial ischemia but clinical correlation\nis required.\n\n" }, { "category": "ECG", "chartdate": "2164-11-26 00:00:00.000", "description": "Report", "row_id": 244102, "text": "Sinus rhythm. Prolonged Q-T interval. Diffuse severe T wave abnormalities as\npreviously described remain unchanged with differential diagnosis as previously\ndescribed.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2164-11-25 00:00:00.000", "description": "Report", "row_id": 244103, "text": "Sinus rhythm. Deep T wave inversions throughout the tracing and upright T wave\nin lead aVR most consistent with multivessel or left main coronary ischemia and\nless likely due to Takotsubo syndrome or neurogenic myocardial ischemia.\nCompared to the previous tracing the aforementioned T wave abnormalities are\nmore profound.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2164-11-25 00:00:00.000", "description": "Report", "row_id": 244104, "text": "Sinus rhythm. Consider left atrial abnormality. Low voltage throughout.\nQ-T interval prolongation. Inferior and precordial T wave inversions. Since\nthe previous tracing the inferior T wave inversions are more prominent.\nQ-T interval prolongation is also more prominent. Clinical correlation is\nsuggested.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2164-11-24 00:00:00.000", "description": "Report", "row_id": 244105, "text": "Sinus rhythm. ST-T wave abnormalities with prominent precordial T wave\ninversions. Consider non-ST segment elevation myocardial infarction. Since the\nprevious tracing the precordial T wave abnormalities are more prominent and the\nQ-T interval is longer. Also consider metabolic derangements or Takotsubo\nsyndrome.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2164-11-23 00:00:00.000", "description": "Report", "row_id": 244106, "text": "Sinus tachycardia. Left axis deviation. Left anterior fascicular block. R wave\nreversal in leads V1-V2 possibly related to left anterior fascicular block.\nST-T wave abnormalities. Since the previous tracing of there is no\nsignificant change. Clinical correlation is suggested.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2164-11-23 00:00:00.000", "description": "Report", "row_id": 244107, "text": "Sinus tachycardia. Consider left atrial abnormality. Left axis deviation. Left\nanterior fascicular block. ST-T wave abnormalities. Late R wave progression.\nSince the previous tracing of the rate is faster. The axis is more\nleftward. ST-T wave abnormalities are more marked. Clinical correlation is\nsuggested.\nTRACING #1\n\n" } ]

[ { "category": "Physician ", "chartdate": "2159-02-18 00:00:00.000", "description": "Intensivist Note", "row_id": 362509, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant\n Chief complaint:\n PMHx:\n PMH:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 04:10 AM\n MULTI LUMEN - START 04:19 AM\n INTUBATION - At 04:20 AM\n INVASIVE VENTILATION - START 04:20 AM\n Post operative day:\n POD#0 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:57 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: 36.2\nC (97.1\n HR: 96 (91 - 98) bpm\n BP: 159/68(95) {159/68(95) - 195/81(117)} mmHg\n RR: 14 (14 - 15) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,217 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,497 mL\n Blood products:\n 721 mL\n Total out:\n 0 mL\n 850 mL\n Urine:\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,367 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.28/40/332/16/-7\n Ve: 6.6 L/min\n PaO2 / FiO2: 664\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), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 186 K/uL\n 10.0 g/dL\n 161 mg/dL\n 12.2 mg/dL\n 16 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 98 mEq/L\n 131 mEq/L\n 28.0 %\n 12.3 K/uL\n [image002.jpg]\n 12:50 AM\n 04:16 AM\n 04:25 AM\n WBC\n 12.3\n Hct\n 30\n 28.0\n Plt\n 186\n Creatinine\n 12.2\n TCO2\n 23\n 20\n Glucose\n 158\n 161\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n Assessment and Plan: 70M w/ ESRD due to glomerulonephritis s/p ECD\n renal transplant\n Neurologic: propofol gtt, fentanyl prn\n Cardiovascular: SBP goal 140-170, lopressor 5q6\n Pulmonary: keep intubated today\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, f/u u/o, D5 1/2NS at 50 ml/hr and replete\n u/o cc per cc.\n Hematology: f/u Hct, keep it 30 or above\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath\n Wounds: Dry dressings\n Imaging:\n Fluids: D5 1/2NS at 50 ml/hr\n Consults: Transplant\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2159-02-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 362599, "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: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Crackles\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:\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 weaned to CPAP without incident however will remain intubated\n overnight pending further correction of metabolic acidosis and pending\n reevaluation by Neuro.\n" }, { "category": "Nursing", "chartdate": "2159-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362765, "text": "Hypertension, benign\n Assessment:\n Pt\ns BP rising to 150\ns at times when moving or coughing, at rest,\n 120\ns-130\n Action:\n Dr. notified. Lopressor given as ordered, held for BP lower\n than 140 per order\n Response:\n Responding well to Lopressor. Dr. stating that 140\ns-150\ns does\n not need additional intervention.\n Plan:\n notify MD rising above 150\ns and sustained. Continue to\n give Lopressor as ordered and hold for <140\n" }, { "category": "Nursing", "chartdate": "2159-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362665, "text": "Ekg nsr, rate 70s to 80s, no ectopy. Sbp stable in 130-140s, occ drop\n to 110 after pain med, lopressor given without significant in bp or\n hr. cvp 6-10 after blood and ns bolus. Received total of 3 units of\n prbc for low gtt, post transfusion hct was 29. all maintenance and\n replacement fluid off during transfusions. Lasix 100 mg given after\n final prbc, with minimal response. Maintenamce and replacement fluids\n resumed at 0200. urine clearing overnight, still has visible red\n cells. Breath sounds rhonchorous to clear, on cpap all night, no vent\n changes, acceptable abgs. Abd soft, hypoactive bowel sounds present.\n Ogt to lws, bilious drainage. Initial or dressing intact and dry. Pd\n catheter dressing dry. Skin warm and dry, feet warm, pt and dp pulses\n palp bilat. Sedated with propofol at 30 mcg, arouses to voice,\n follows commands slowly. Med for pain x 4 with fentanyl 25 mcg.\n Plan: keep map > 75. replace uo as ordered, monitor electrolytes\n and glucose. Wean to extubation today. Assess and medicate for pain.\n Reassure and update pt and family.\n" }, { "category": "Respiratory ", "chartdate": "2159-02-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 362491, "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: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt from OR,S/P kidney tx. Will cont to monitor resp status.\n Wean per ABG.\n" }, { "category": "Nursing", "chartdate": "2159-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362581, "text": "Transplant, kidney (Renal transplant)\n Assessment:\n Neuro: On IV Propofol\nresponding to verbal stimuli, nodding head yes\n and no to questions. Mae, following commands\n Cardiac: Heart rate 90- without ectopy , S b/p low 80\n mean 60\n Resp: CS diminished in bases\n GI: Og in place, patent for bilious, large amt.\n GU: Foley in place, patent for thick bldy to now pink\n Endo: Glucose ^ 200\n Pain: Nods yes to pain in abdomen\n Family: wife in / daughter here from D.C.\n Action:\n Neuro: oriented\n Cardiac: Iv Dopamine added to keep map ^ 75, 500ml 5% albumin and unit\n cells given\n Resp: Suctioned for thick tan\n GI: IV protonix given\n Endo: Insulin given\n Pain: medicated with iv fentanyl\n Family: wife called early am, daughter in to visit as well as sister in\n law/brother.\n Response:\n Cardiac: Map ^ 75, weaning IV Dopamine\n Resp: Cpap 5/5-40%\n GU: urine output increased after volumn/Dopamine\n Pain: more comfortable after pain med\n Family: daughter spoke with her mother- explained events and plans.\n Plan:\n Neuro: reorient as needed.\n Cardiac: Titrate Iv Dopamine to keep map ^ 75\n Resp: No plan to extubate today- will reevaluate.\n GU: Monitor urine output.\n Endo: follow insulin protocol/sliding scale written\n Pain: Medicate as needed\n Family: answer all questions of daughter\n" }, { "category": "Nursing", "chartdate": "2159-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 362852, "text": "70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant. OR\n complication of hypotension prior to induction and then showed fix\n defect cardiac with St depression and Q waves. Pt was hypertensive and\n arrived to SICU for observation.\n Chief complaint:\n ESRD due to glomerulonephritis s/p ECD renal transplant\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Hypertension, benign\n Assessment:\n No HTN as of this time needing any intervention. SBP <140 with MAP\n 70-90. No lopressor given today.\n Action:\n No HTN, no intervention given.\n Response:\n SBP <140 today.\n Plan:\n Con\nt to monitor. Give lopressor if SBP >140 as ordered.\n Transplant, kidney (Renal transplant)\n Assessment:\n UO 60-120cc hr. Urine is yellow and after walking today became pinkish.\n UO is being replaced\n cc per cc with .45 NS. Pt also remains on D5.45\n @50cc hr maintenance fluid. Pt ambulated around unit x1 with assist of\n 2 persons. At baseline, pt uses a cane d/t spinal stenosis. Did well.\n This am, pt c/o incisional pain along with feeling full\nlike I need to\n move bowels.\n Pt states that he has BM qd and has not gone since Sat.\n This RN explained how his bowels are sleeping and are slowly waking so\n we must be gentle. He received 10 mg of po ducolax. Medicated with 10mg\n po oxycodone x2 then with 5mg po oxycodone. Pain is under control and\n discomfort of having to move bowels has subsided. Last CR down to 8\n from hi of 16. Pt on Cl liq and tolerating well.\n Action:\n .45NS replacing hourly uo\n cc per cc. Pain med given with good\n relief.\n Response:\n Team is aware of uo 60-100. Goal is to maintain uo >50 cc hr.\n Plan:\n Con\nt to assess for pain, medicate, assess relief. Con\n cc per cc\n with IVF of .45 NS. ADAT when bowels start to move. Transfer to floor\n on tele.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n KIDNEY TRANSPLANT\n Code status:\n Full code\n Height:\n Admission weight:\n 55 kg\n Daily weight:\n 59.3 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: HEMO or PD\n CV-PMH: Hypertension\n Additional history: renal failure secondary to glomerulonephritis,\n spinal stenosis, prostate CA, rib fractures\n PSH: prostatectomy in for prostate CA, bilateral hernia repair w/\n mesh\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:72\n Temperature:\n 98\n Arterial BP:\n S:151\n D:63\n Respiratory rate:\n 12 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 40% %\n 24h total in:\n 3,883 mL\n 24h total out:\n 1,655 mL\n Pertinent Lab Results:\n Sodium:\n 135 mEq/L\n 02:37 AM\n Potassium:\n 3.4 mEq/L, Dr. notified, no intervention\n 02:37 AM\n Chloride:\n 102 mEq/L\n 02:37 AM\n CO2:\n 21 mEq/L\n 02:37 AM\n BUN:\n 56 mg/dL\n 02:37 AM\n Creatinine:\n 8.5 mg/dL\n 02:37 AM\n Glucose:\n 142 mg/dL\n 02:37 AM\n Hematocrit:\n 27.0 %\n 02:37 AM\n Finger Stick Glucose:\n 248\n 04:00 PM\n Valuables / Signature\n Patient valuables: somewhere in hospital. Still attempting to locate\n them\n Other valuables:\n Clothes: Sent home with: looking for pt\ns cane\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: SICU B\n Transferred to: 10\n Date & time of Transfer: Monday 1815\n" }, { "category": "Nursing", "chartdate": "2159-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362636, "text": "Ekg nsr, rate 70s to 80s, no ectopy. Sbp stable in 130-140s, occ drop\n to 110 after pain med, lopressor given without significant in bp or\n hr. cvp 6-10 after blood and ns bolus. Received total of 3 units of\n prbc for low gtt, post transfusion hct was 29. all maintenance and\n replacement fluid off during transfusions. Lasix 100 mg given after\n final prbc, with minimal response. Maintenamce and replacement fluids\n resumed at 0200. urine clearing overnight, still has visible red\n cells. Breath sounds rhonchorous to clear, on cpap all night, no vent\n changes, acceptable abgs. Abd soft, hypoactive bowel sounds present.\n Ogt to lws, bilious drainage. Initial or dressing intact and dry. Pd\n catheter dressing dry. Skin warm and dry, feet warm, pt and dp pulses\n palp bilat. Sedated with propofol at 30 mcg, arouses to voice,\n follows commands slowly. Med for pain x 4 with fentanyl 25 mcg.\n Plan: keep map > 75. replace uo as ordered, monitor electrolytes\n and glucose. Wean to extubation today. Assess and medicate for pain.\n Reassure and update pt and family.\n" }, { "category": "Nursing", "chartdate": "2159-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362637, "text": "Ekg nsr, rate 70s to 80s, no ectopy. Sbp stable in 130-140s, occ drop\n to 110 after pain med, lopressor given without significant in bp or\n hr. cvp 6-10 after blood and ns bolus. Received total of 3 units of\n prbc for low gtt, post transfusion hct was 29. all maintenance and\n replacement fluid off during transfusions. Lasix 100 mg given after\n final prbc, with minimal response. Maintenamce and replacement fluids\n resumed at 0200. urine clearing overnight, still has visible red\n cells. Breath sounds rhonchorous to clear, on cpap all night, no vent\n changes, acceptable abgs. Abd soft, hypoactive bowel sounds present.\n Ogt to lws, bilious drainage. Initial or dressing intact and dry. Pd\n catheter dressing dry. Skin warm and dry, feet warm, pt and dp pulses\n palp bilat. Sedated with propofol at 30 mcg, arouses to voice,\n follows commands slowly. Med for pain x 4 with fentanyl 25 mcg.\n Plan: keep map > 75. replace uo as ordered, monitor electrolytes\n and glucose. Wean to extubation today. Assess and medicate for pain.\n Reassure and update pt and family.\n" }, { "category": "Physician ", "chartdate": "2159-02-19 00:00:00.000", "description": "Intensivist Note", "row_id": 362627, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant OR\n complication hypotension prior to induction and then showed fix defect\n cardiac with St depression and Q waves\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n Anti-Thymocyte Globulin (Rabbit), Chlorhexidine Gluconate 0.12% Oral\n Rinse, Fentanyl Citrate, Furosemide, Insulin, MethylPREDNISolone Sodium\n Succ, Metoprolol Tartrate, Mycophenolate Mofetil Suspension, Nystatin\n Oral Suspension, Pantoprazole, PredniSONE, Propofol,Sodium Bicarbonate,\n Sulfameth/Trimethoprim SS, ValGANCIclovir Suspension\n 24 Hour Events:\n ULTRASOUND - At 08:41 AM\n renal ultrasound\n EKG - At 09:22 AM\n Post operative day:\n POD#1 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Metoprolol - 08:35 PM\n Furosemide (Lasix) - 10:00 PM\n Fentanyl - 02:00 AM\n Flowsheet Data as of 04:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.2\nC (99\n HR: 74 (72 - 122) bpm\n BP: 149/65(86) {93/45(59) - 195/90(129)} mmHg\n RR: 10 (8 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (2 - 28) mmHg\n Total In:\n 10,422 mL\n 635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,168 mL\n 635 mL\n Blood products:\n 2,194 mL\n Total out:\n 2,964 mL\n 540 mL\n Urine:\n 2,524 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,458 mL\n 95 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 96 (96 - 540) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.37/42/130/23/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress, intubated and sedated\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: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 165 K/uL\n 10.6 g/dL\n 113 mg/dL\n 11.2 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 61 mg/dL\n 99 mEq/L\n 134 mEq/L\n 28.1 %\n 11.1 K/uL\n [image002.jpg]\n 04:25 AM\n 06:24 AM\n 09:11 AM\n 09:34 AM\n 02:08 PM\n 04:15 PM\n 09:29 PM\n 09:55 PM\n 03:12 AM\n 03:26 AM\n WBC\n 11.9\n 11.1\n Hct\n 25.3\n 23.7\n 29.5\n 28.1\n Plt\n 160\n 165\n Creatinine\n 11.7\n 11.4\n 11.2\n TCO2\n 20\n 15\n 18\n 24\n 25\n Glucose\n 124\n 109\n 113\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.3 mg/dL, Mg:1.6 mg/dL, PO4:6.5\n mg/dL\n Assessment and Plan\n TRANSPLANT, KIDNEY (RENAL TRANSPLANT)\n Assessment and Plan:\n Neurologic: propofol gtt, fentanyl prn,\n Cardiovascular: MAP>75, off dopamine after blood. receieved three\n units of PRBC\n Pulmonary: intubated, extubate in AM\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, stat US normal, f/u u/o, D5 1/2NS at 50\n ml/hr and replete u/o cc per cc\n Hematology: f/u Hct,rec'd three units PRBC total overnight and Lasix\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath, ulnar aline RIGHT\n Wounds: Dry dressings\n Imaging: ? renal US\n Fluids: D5 1/2NS at 50 ml/hr\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 AM\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2159-02-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 362629, "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: Yes\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details.RSBI done on 0 peep/ 5 ips 22. Temp 99.Suctioned for mod amts\n of thick secretions. Plan is to extubate pt today.Will cont to monitor\n resp status.\n" }, { "category": "Nursing", "chartdate": "2159-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362722, "text": "TITLE:\n Transplant, kidney (Renal transplant)\n Assessment:\n Pt alert and oriented x 3\n Verbalizing needs\n 2L nc\n Rsr\n No episodes of hypotension\n No ekg changes seen\n Npo\n Urine output 100-200/hr\n Incisional pain present\n Action:\n Extubated at 1200 with md present\n 1400 electroylytes sent\n Immunosuppressives given as ordered\n Replacing urine cc:cc with ivf\n Fentanyl x 1 for incisional pain\n Response:\n Pt oxygenating well on 2L\n Pt verbalizes relief of pain\n Pt expectorating secretions well\n Remains normotensive and without ekg changes\n Creatinine decreasing\n Electrolytes wnl\n Plan:\n Pulm toilet\n Follow labs\n Monitor hemodynamics\n Replace urine cc:cc\n Immunosuppressives as ordered\n Transfer to floor in am\n" }, { "category": "Physician ", "chartdate": "2159-02-18 00:00:00.000", "description": "Intensivist Note", "row_id": 362539, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant\n Chief complaint:\n PMHx:\n PMH:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n 24 Hour Events:\n OR RECEIVED - At 04:10 AM\n MULTI LUMEN - START 04:19 AM\n INTUBATION - At 04:20 AM\n INVASIVE VENTILATION - START 04:20 AM\n Post operative day:\n POD#0 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Propofol - 60 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:57 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: 36.2\nC (97.1\n HR: 96 (91 - 98) bpm\n BP: 159/68(95) {159/68(95) - 195/81(117)} mmHg\n RR: 14 (14 - 15) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,217 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,497 mL\n Blood products:\n 721 mL\n Total out:\n 0 mL\n 850 mL\n Urine:\n 410 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 5,367 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 500 (500 - 500) mL\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 19 cmH2O\n Plateau: 15 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 100%\n ABG: 7.28/40/332/16/-7\n Ve: 6.6 L/min\n PaO2 / FiO2: 664\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), (Pulse -\n Dorsalis pedis: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities, Sedated\n Labs / Radiology\n 186 K/uL\n 10.0 g/dL\n 161 mg/dL\n 12.2 mg/dL\n 16 mEq/L\n 3.7 mEq/L\n 56 mg/dL\n 98 mEq/L\n 131 mEq/L\n 28.0 %\n 12.3 K/uL\n [image002.jpg]\n 12:50 AM\n 04:16 AM\n 04:25 AM\n WBC\n 12.3\n Hct\n 30\n 28.0\n Plt\n 186\n Creatinine\n 12.2\n TCO2\n 23\n 20\n Glucose\n 158\n 161\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.2 mg/dL, Mg:1.6 mg/dL, PO4:4.8\n mg/dL\n Assessment and Plan\n Assessment and Plan: 70M w/ ESRD due to glomerulonephritis s/p ECD\n renal transplant\n Neurologic: propofol gtt, fentanyl prn\n Cardiovascular: SBP goal 140-170, lopressor 5q6\n Pulmonary: keep intubated today\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, f/u u/o, D5 1/2NS at 50 ml/hr and replete\n u/o cc per cc.\n Hematology: f/u Hct, keep it 30 or above\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath\n Wounds: Dry dressings\n Imaging: renal transplant US\n Fluids: D5 1/2NS at 50 ml/hr\n Consults: Transplant\n Billing Diagnosis: Post-op hypotension\n ICU Care\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2159-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362610, "text": "Transplant, kidney (Renal transplant)\n Assessment:\n Neuro: On IV Propofol\nresponding to verbal stimuli, nodding head yes\n and no to questions. Mae, following commands\n Cardiac: Heart rate 90- without ectopy , S b/p low 80\n mean 60\n Resp: CS diminished in bases\n GI: Og in place, patent for bilious, large amt.\n GU: Foley in place, patent for thick bldy to now pink\n Endo: Glucose ^ 200\n Pain: Nods yes to pain in abdomen\n Family: wife in / daughter here from D.C.\n Action:\n Neuro: oriented\n Cardiac: Iv Dopamine added to keep map ^ 75, 500ml 5% albumin and unit\n cells given\n Resp: Suctioned for thick tan\n GI: IV protonix given\n Endo: Insulin given\n Pain: medicated with iv fentanyl\n Family: wife called early am, daughter in to visit as well as sister in\n law/brother.\n Response:\n Cardiac: Map ^ 75, weaning IV Dopamine\n Resp: Cpap 5/5-40%\n GU: urine output increased after volumn/Dopamine\n Pain: more comfortable after pain med\n Family: daughter spoke with her mother- explained events and plans.\n Plan:\n Neuro: reorient as needed.\n Cardiac: Titrate Iv Dopamine to keep map ^ 75\n Resp: No plan to extubate today- will reevaluate.\n GU: Monitor urine output.\n Endo: follow insulin protocol/sliding scale written\n Pain: Medicate as needed\n Family: answer all questions of daughter\n" }, { "category": "Nursing", "chartdate": "2159-02-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362625, "text": "Ekg nsr, rate 70s to 80s, no ectopy. Sbp stable in 130-140s, occ drop\n to 110 after pain med, lopressor given without significant in bp or\n hr. cvp 6-10 after blood and ns bolus. Received total of 3 units of\n prbc for low gtt, post transfusion hct was 29. all maintenance and\n replacement fluid off during transfusions. Lasix 100 mg given after\n final prbc, with minimal response. Maintenamce and replacement fluids\n resumed at 0200. urine clearing overnight, still has visible red\n cells. Breath sounds rhonchorous to clear, on cpap all night, no vent\n changes, acceptable abgs. Abd soft, hypoactive bowel sounds present.\n Ogt to lws, bilious drainage. Initial or dressing intact and dry. Pd\n catheter dressing dry. Skin warm and dry, feet warm, pt and dp pulses\n palp bilat.\n" }, { "category": "Physician ", "chartdate": "2159-02-20 00:00:00.000", "description": "Intensivist Note", "row_id": 362800, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant OR\n complication hypotension prior to induction and then showed fix defect\n cardiac with St depression and Q waves\n Chief complaint:\n ESRD due to glomerulonephritis s/p ECD renal transplant\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n Acetaminophen (Liquid) 5. Anti-Thymocyte Globulin (Rabbit)\n 6. Anti-Thymocyte Globulin (Rabbit) 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. DOPamine 9. DiphenhydrAMINE\n 10. Fentanyl Citrate 11. Influenza Virus Vaccine 12. Insulin 13.\n MethylPREDNISolone Sodium Succ 14. Metoprolol Tartrate\n 15. Mycophenolate Mofetil Suspension 16. Nystatin Oral Suspension 17.\n Pantoprazole 18. Pneumococcal Vac Polyvalent\n 19. PredniSONE 20. PredniSONE 21. Propofol 22. Sodium Chloride 0.9%\n Flush 23. Sulfameth/Trimethoprim SS\n 24. Tacrolimus 25. ValGANCIclovir Suspension\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:28 PM\n EXTUBATION - At 12:35 PM\n Post operative day:\n POD#2 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 AM\n Fentanyl - 12:01 PM\n Other medications:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.3\nC (97.3\n HR: 86 (75 - 93) bpm\n BP: 137/60(87) {118/49(71) - 158/67(95)} mmHg\n RR: 20 (10 - 22) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.3 kg (admission): 55 kg\n CVP: 7 (1 - 15) mmHg\n Total In:\n 5,121 mL\n 1,209 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,001 mL\n 1,209 mL\n Blood products:\n Total out:\n 3,645 mL\n 890 mL\n Urine:\n 3,545 mL\n 890 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,476 mL\n 319 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 40%\n SPO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 153 K/uL\n 9.7 g/dL\n 142 mg/dL\n 8.5 mg/dL\n 21 mEq/L\n 3.4 mEq/L, Dr. notified, no intervention\n 56 mg/dL\n 102 mEq/L\n 135 mEq/L\n 27.0 %\n 9.5 K/uL\n [image002.jpg]\n 09:11 AM\n 09:34 AM\n 02:08 PM\n 04:15 PM\n 09:29 PM\n 09:55 PM\n 03:12 AM\n 03:26 AM\n 01:54 PM\n 02:37 AM\n WBC\n 11.9\n 11.1\n 9.5\n Hct\n 25.3\n 23.7\n 29.5\n 28.1\n 27.0\n Plt\n 160\n 165\n 153\n Creatinine\n 11.7\n 11.4\n 11.2\n 10.3\n 8.5\n TCO2\n 18\n 24\n 25\n Glucose\n 124\n 109\n 113\n 169\n 142\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.3 mg/dL, Mg:1.6 mg/dL, Dr.\n notified- no intervention, PO4:6.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, TRANSPLANT, KIDNEY (RENAL TRANSPLANT)\n Assessment and Plan:\n Neurologic: propofol gtt, fentanyl prn,\n Cardiovascular: stable, MAP>75. receieved three units of PRBC\n Pulmonary: extubated stable\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, stat US normal, f/u u/o, D5 1/2NS at 50\n ml/hr and replete u/o cc per cc\n Hematology: f/u Hct,\n Endocrine: RISS, ,\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath, ulnar aline RIGHT\n Wounds: c/d/i\n Imaging:\n Fluids:\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 AM\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\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: ICU\n Total time spent: 32 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2159-02-20 00:00:00.000", "description": "Intensivist Note", "row_id": 362812, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant OR\n complication hypotension prior to induction and then showed fix defect\n cardiac with St depression and Q waves\n Chief complaint:\n ESRD due to glomerulonephritis s/p ECD renal transplant\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n Acetaminophen (Liquid) 5. Anti-Thymocyte Globulin (Rabbit)\n 6. Anti-Thymocyte Globulin (Rabbit) 7. Chlorhexidine Gluconate 0.12%\n Oral Rinse 8. DOPamine 9. DiphenhydrAMINE\n 10. Fentanyl Citrate 11. Influenza Virus Vaccine 12. Insulin 13.\n MethylPREDNISolone Sodium Succ 14. Metoprolol Tartrate\n 15. Mycophenolate Mofetil Suspension 16. Nystatin Oral Suspension 17.\n Pantoprazole 18. Pneumococcal Vac Polyvalent\n 19. PredniSONE 20. PredniSONE 21. Propofol 22. Sodium Chloride 0.9%\n Flush 23. Sulfameth/Trimethoprim SS\n 24. Tacrolimus 25. ValGANCIclovir Suspension\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 12:28 PM\n EXTUBATION - At 12:35 PM\n Post operative day:\n POD#2 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 AM\n Fentanyl - 12:01 PM\n Other medications:\n Flowsheet Data as of 07:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.3\nC (97.3\n HR: 86 (75 - 93) bpm\n BP: 137/60(87) {118/49(71) - 158/67(95)} mmHg\n RR: 20 (10 - 22) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 59.3 kg (admission): 55 kg\n CVP: 7 (1 - 15) mmHg\n Total In:\n 5,121 mL\n 1,209 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,001 mL\n 1,209 mL\n Blood products:\n Total out:\n 3,645 mL\n 890 mL\n Urine:\n 3,545 mL\n 890 mL\n NG:\n 100 mL\n Stool:\n Drains:\n Balance:\n 1,476 mL\n 319 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n FiO2: 40%\n SPO2: 95%\n ABG: ///21/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 153 K/uL\n 9.7 g/dL\n 142 mg/dL\n 8.5 mg/dL\n 21 mEq/L\n 3.4 mEq/L, Dr. notified, no intervention\n 56 mg/dL\n 102 mEq/L\n 135 mEq/L\n 27.0 %\n 9.5 K/uL\n [image002.jpg]\n 09:11 AM\n 09:34 AM\n 02:08 PM\n 04:15 PM\n 09:29 PM\n 09:55 PM\n 03:12 AM\n 03:26 AM\n 01:54 PM\n 02:37 AM\n WBC\n 11.9\n 11.1\n 9.5\n Hct\n 25.3\n 23.7\n 29.5\n 28.1\n 27.0\n Plt\n 160\n 165\n 153\n Creatinine\n 11.7\n 11.4\n 11.2\n 10.3\n 8.5\n TCO2\n 18\n 24\n 25\n Glucose\n 124\n 109\n 113\n 169\n 142\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.3 mg/dL, Mg:1.6 mg/dL, Dr.\n notified- no intervention, PO4:6.0 mg/dL\n Assessment and Plan\n HYPERTENSION, BENIGN, TRANSPLANT, KIDNEY (RENAL TRANSPLANT)\n Assessment and Plan:\n Neurologic: propofol gtt, fentanyl prn,\n Cardiovascular: stable, MAP>75. receieved three units of PRBC\n Pulmonary: extubated stable\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, stat US normal, f/u u/o, D5 1/2NS at 50\n ml/hr and replete u/o now 1/2 cc per cc\n Hematology: f/u Hct,\n Endocrine: RISS, ,\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath, ulnar aline RIGHT\n Wounds: c/d/i\n Imaging:\n Fluids: above\n Consults: Transplant\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 AM\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\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: ICU\n Total time spent: Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2159-02-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362532, "text": "ESRF had been on PD. In for kidney transplant, upon induction became\n very hypotensive with + ST changes on EKG. Stable throughout OR but\n remained intubated and transferred to SICU for monitoring.\n Transplant, kidney (Renal transplant)\n Assessment:\n Arrived from OR at 0400\n Hemodynamically stable upon arrival\n U/o 100-200 cc/hrs initially, down to 30 cc at 0700\n Urine blood tinged initially, becoming increasingly bloody at 0700\n Remains intubated post op d/t difficult airway, adequate oxygenation on\n CMV bur in uncompensated metabolic\n acidosis.\n Post op HCT 28\n Action:\n u/o monitored q1 hr and cc/cc repletion per order\n transplant team notified of change in u/o and urine color\n remains sedated on cmv d/t acidosis\n transfusion for hct <30 initiated\n Response:\n resp status stable at this time\n +rigors, hypertension, tachyardic ~20 min into transfusion. Sicu and\n transplant team aware. Blood bank notified. Transfusion reaction\n protocol initiated.\n Plan:\n Awaiting transplant team to round. ? Wean to extubated depending on\n metabolic acidosis. Cont to monitor closely.\n" }, { "category": "Physician ", "chartdate": "2159-02-19 00:00:00.000", "description": "Intensivist Note", "row_id": 362684, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant OR\n complication hypotension prior to induction and then showed fix defect\n cardiac with St depression and Q waves\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Current medications:\n Anti-Thymocyte Globulin (Rabbit), Chlorhexidine Gluconate 0.12% Oral\n Rinse, Fentanyl Citrate, Furosemide, Insulin, MethylPREDNISolone Sodium\n Succ, Metoprolol Tartrate, Mycophenolate Mofetil Suspension, Nystatin\n Oral Suspension, Pantoprazole, PredniSONE, Propofol,Sodium Bicarbonate,\n Sulfameth/Trimethoprim SS, ValGANCIclovir Suspension\n 24 Hour Events:\n ULTRASOUND - At 08:41 AM\n renal ultrasound\n EKG - At 09:22 AM\n Post operative day:\n POD#1 - s/p kidney transplant\n Allergies:\n No Known Drug Allergies\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 10:00 AM\n Metoprolol - 08:35 PM\n Furosemide (Lasix) - 10:00 PM\n Fentanyl - 02:00 AM\n Flowsheet Data as of 04:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.2\nC (99\n HR: 74 (72 - 122) bpm\n BP: 149/65(86) {93/45(59) - 195/90(129)} mmHg\n RR: 10 (8 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n CVP: 15 (2 - 28) mmHg\n Total In:\n 10,422 mL\n 635 mL\n PO:\n Tube feeding:\n IV Fluid:\n 8,168 mL\n 635 mL\n Blood products:\n 2,194 mL\n Total out:\n 2,964 mL\n 540 mL\n Urine:\n 2,524 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 7,458 mL\n 95 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 96 (96 - 540) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: 7.37/42/130/23/0\n Ve: 7.4 L/min\n PaO2 / FiO2: 325\n Physical Examination\n General Appearance: No acute distress, intubated and sedated\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: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 165 K/uL\n 10.6 g/dL\n 113 mg/dL\n 11.2 mg/dL\n 23 mEq/L\n 3.9 mEq/L\n 61 mg/dL\n 99 mEq/L\n 134 mEq/L\n 28.1 %\n 11.1 K/uL\n [image002.jpg]\n 04:25 AM\n 06:24 AM\n 09:11 AM\n 09:34 AM\n 02:08 PM\n 04:15 PM\n 09:29 PM\n 09:55 PM\n 03:12 AM\n 03:26 AM\n WBC\n 11.9\n 11.1\n Hct\n 25.3\n 23.7\n 29.5\n 28.1\n Plt\n 160\n 165\n Creatinine\n 11.7\n 11.4\n 11.2\n TCO2\n 20\n 15\n 18\n 24\n 25\n Glucose\n 124\n 109\n 113\n Other labs: Lactic Acid:1.9 mmol/L, Ca:8.3 mg/dL, Mg:1.6 mg/dL, PO4:6.5\n mg/dL\n Assessment and Plan\n TRANSPLANT, KIDNEY (RENAL TRANSPLANT)\n Assessment and Plan:\n Neurologic: propofol gtt, fentanyl prn,\n Cardiovascular: MAP>75, off dopamine after blood. receieved three\n units of PRBC\n Pulmonary: intubated, extubate in AM. Difficult intubation. Will\n staff with anesthesiologist.\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: s/p renal transplant, stat US normal, f/u u/o, D5 1/2NS at 50\n ml/hr and replete u/o cc per cc\n Hematology: f/u Hct,rec'd three units PRBC total overnight and Lasix\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: rt IJ, foley, PD cath, ulnar aline RIGHT\n Wounds: Dry dressings\n Imaging: ? renal US\n Fluids: D5 1/2NS at 50 ml/hr\n Consults: Transplant\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 04:00 AM\n 18 Gauge - 04:18 AM\n Multi Lumen - 04:19 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2159-02-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 362766, "text": "SICU\n HPI:\n 70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant OR\n complication hypotension prior to induction and then showed fix defect\n cardiac with St depression and Q waves\n Hypertension, benign\n Assessment:\n Pt\ns BP rising to 150\ns at times when moving or coughing, at rest,\n 120\ns-130\n Action:\n Dr. notified. Lopressor given as ordered, held for BP lower\n than 140 per order\n Response:\n Responding well to Lopressor. Dr. stating that 140\ns-150\ns does\n not need additional intervention.\n Plan:\n notify MD rising above 150\ns and sustained. Continue to\n give Lopressor as ordered and hold for <140\n" }, { "category": "Nursing", "chartdate": "2159-02-20 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 362839, "text": "70M w/ ESRD due to glomerulonephritis s/p ECD renal transplant. OR\n complication of hypotension prior to induction and then showed fix\n defect cardiac with St depression and Q waves. Pt was hypertensive and\n arrived to SICU for observation.\n Chief complaint:\n ESRD due to glomerulonephritis s/p ECD renal transplant\n PMHx:\n prostatectomy in for prostate cancer\n bilateral hernia repairs w/mesh\n appendectomy in youth\n rib fracture\n glomerulonephritis\n spinal stenosis\n Hypertension, benign\n Assessment:\n No HTN as of this time needing any intervention. SBP <140 with MAP\n 70-90. No lopressor given today.\n Action:\n No HTN, no intervention given.\n Response:\n SBP <140 today.\n Plan:\n Con\nt to monitor. Give lopressor if SBP >140 as ordered.\n Transplant, kidney (Renal transplant)\n Assessment:\n UO 60-120cc hr. Urine is yellow and after walking today became pinkish.\n UO is being replaced\n cc per cc with .45 NS. Pt also remains on D5.45\n @50cc hr maintenance fluid. Pt ambulated around unit x1 with assist of\n 2 persons. At baseline, pt uses a cane d/t spinal stenosis. Did well.\n This am, pt c/o incisional pain along with feeling full\nlike I need to\n move bowels.\n Pt states that he has BM qd and has not gone since Sat.\n This RN explained how his bowels are sleeping and are slowly waking so\n we must be gentle. He received 10 mg of po ducolax. Medicated with 10mg\n po oxycodone x2 then with 5mg po oxycodone. Pain is under control and\n discomfort of having to move bowels has subsided. Last CR down to 8\n from hi of 16. Pt on Cl liq and tolerating well.\n Action:\n .45NS replacing hourly uo\n cc per cc. Pain med given with good\n relief.\n Response:\n Team is aware of uo 60-100. Goal is to maintain uo >50 cc hr.\n Plan:\n Con\nt to assess for pain, medicate, assess relief. Con\n cc per cc\n with IVF of .45 NS. ADAT when bowels start to move. Transfer to floor\n on tele.\n" }, { "category": "Echo", "chartdate": "2159-02-18 00:00:00.000", "description": "Report", "row_id": 77012, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Hypertension. Left ventricular function. Right ventricular function.\nStatus: Inpatient\nDate/Time: at 01:20\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n70 years old male with sudden decrease in arterial blood pressure to systolic\nof 40mm of mercury. Intraoperative TEE showed normal hyperdynamic heart with\nno abnormality.\nNormal diastolic function and LVDEP.\nNo valvular abnormalities seen.\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or color\nDoppler.\n\nLEFT VENTRICLE: Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal\nPCWP (<12mmHg). Transmitral Doppler and TVI c/w normal LV diastolic function.\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 systolic function.\n\nAORTA: Normal ascending aorta diameter. Simple atheroma in ascending aorta.\nNormal descending 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\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. No TEE related\ncomplications.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect is seen by 2D or\ncolor Doppler. Overall left ventricular systolic function is normal\n(LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling\npressure (PCWP<12mmHg). Transmitral Doppler and tissue velocity imaging are\nconsistent with normal LV diastolic function. with normal free wall\ncontractility. There are simple atheroma in the ascending aorta. There are\nsimple atheroma in the descending thoracic aorta. The aortic valve leaflets\n(3) appear structurally normal with good leaflet excursion and no aortic\nregurgitation. The mitral valve appears structurally normal with trivial\nmitral regurgitation.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1058734, "text": " 5:12 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Please assess for CVL position and for PTX\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p renal transplant\n REASON FOR THIS EXAMINATION:\n Please assess for CVL position and for PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:21 A.M. \n\n HISTORY: Renal transplant, check line positions and possible pneumothorax.\n\n IMPRESSION: AP chest compared to :\n\n ET tube, right internal jugular line are in standard placements and a\n nasogastric tube is looped in the stomach. No pneumothorax or pleural\n effusion. Heart size top normal. Thoracic aorta generally large and\n tortuous. No pneumothorax or pleural effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2159-02-18 00:00:00.000", "description": "Report", "row_id": 182686, "text": "Sinus rhythm\nPossible left atrial abnormality\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2159-02-17 00:00:00.000", "description": "Report", "row_id": 182452, "text": "Sinus rhythm. Possible left atrial abnormality. Compared to the previous\ntracing of there is no significant diagnostic change.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-17 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 1058718, "text": " 8:37 PM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: pre-op\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man admitted for kidney transplant\n REASON FOR THIS EXAMINATION:\n pre-op\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: A 70-year-old male admitted for renal transplant, pre-operative\n study.\n\n COMPARISON: Chest radiograph .\n\n TWO VIEWS OF THE CHEST: The cardiomediastinal contour is unchanged, with no\n evidence of cardiomegaly, but aortic tortuosity is again noted. The lungs are\n clear with no pleural effusion or focal consolidation. Degenerative changes\n in the thoracic spine are again seen, and there is no change in a compression\n deformity of a mid thoracic vertebral body. There is a mild pectus excavatum\n of the chest but osseous structures are otherwise unremarkable.\n\n IMPRESSION: No evidence of acute process.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-18 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 1058756, "text": ", J. SICU-B 8:31 AM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: SP RLQ KIDNEY TRANSPLANT EVAL ANY SIGNS OF CHANGE\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new renal transplant\n REASON FOR THIS EXAMINATION:\n any signs of change\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n 1. Normal waveform of main renal artery and intrarenal artery.\n\n 2. Normal flow in main renal vein.\n\n 3. No urinoma seen.\n\n 4. Echogenicity of transplant kidney within normal limits.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-22 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1059740, "text": " 5:48 PM\n PORTABLE ABDOMEN Clip # \n Reason: assess for gastric/bowel distension\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man pod 4 from renal transplant now with distended abdomen\n REASON FOR THIS EXAMINATION:\n assess for gastric/bowel distension\n ______________________________________________________________________________\n WET READ: 7:12 PM\n no definite evidence of obstruction. borderline distended loops of large and\n small bowel throughout could possibly represent ileus. ? peritoneal dialysis\n catheter in R lower abdomen.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Postop day 4 from renal transplant, now with distended abdomen.\n Assess for gastric or bowel distention.\n\n COMPARISON: CT abdomen from .\n\n SINGLE SUPINE PORTABLE ABDOMINAL RADIOGRAPH:\n\n FINDINGS: There are air-filled minimally distended loops of small and large\n bowel without evidence for obstruction. Air is seen in the rectum. There are\n degenerative changes of the lumbar spine along with S-shaped scoliosis.\n Multiple surgical staples project over the patient's right lower abdomen and\n there are surgical clips in the pelvis. A curvilinear radiopaque density\n projects over the patient's right mid-abdomen and may be related to the\n patient's renal transplantation. A peritoneal dialysis catheter projects over\n the patient's left pelvis. Minimal right basilar atelectasis is present.\n\n IMPRESSION: Minimal distention of small and large bowel loops without\n evidence for obstruction.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059745, "text": " 5:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for pulmonary edema\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man s/p renal transplant (postop day 4) now sob\n REASON FOR THIS EXAMINATION:\n assess for pulmonary edema\n ______________________________________________________________________________\n WET READ: 7:15 PM\n linear L mid lung opacity, likely atelectasis. no pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 70-year-old male after renal transplant with difficulty breathing\n and concern for edema.\n COMPARISON: .\n\n AP PORTABLE CHEST: The patient has been extubated in the interval. There are\n associated lower lung volumes and bibasilar atelectasis, plate-like at the\n right base. Heart size and mediastinal contours are normal. There is no\n pulmonary edema.\n\n IMPRESSION: After extubation, smaller lung volumes. No pulmonary edema.\n Bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-18 00:00:00.000", "description": "P RENAL TRANSPLANT U.S. PORT", "row_id": 1058755, "text": " 8:31 AM\n RENAL TRANSPLANT U.S. PORT Clip # \n Reason: SP RLQ KIDNEY TRANSPLANT EVAL ANY SIGNS OF CHANGE\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with new renal transplant\n REASON FOR THIS EXAMINATION:\n any signs of change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp 11:09 AM\n PFI:\n 1. Normal waveform of main renal artery and intrarenal artery.\n\n 2. Normal flow in main renal vein.\n\n 3. No urinoma seen.\n\n 4. Echogenicity of transplant kidney within normal limits.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: New renal transplant.\n\n COMPARISON: CT .\n\n Grayscale and color Doppler son images were obtained that demonstrate\n transplant kidney in the right lower quadrant to measure 9.8 cm pole to pole\n with normal echogenicity without evidence of proximal urinoma or hemorrhage.\n\n DOPPLER ULTRASOUND: Main renal artery and intrarenal arterial flow\n demonstrates a rapid upstroke and resistive indices ranging from 0.55 to 0.71.\n Main renal venous flow is normal in terms of direction and velocity. In some\n of the intrarenal arteries the upstoke is slightly broadened.\n\n IMPRESSION:\n\n 1. Normal arterial and venous waveforms to the transplant kidney; some\n intrarenal arteries suggest broadening of the upstoke - consider repeating\n study in 24h.\n\n 2 No proximal urinoma or hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2159-02-23 00:00:00.000", "description": "RENAL SCAN", "row_id": 1059936, "text": "RENAL SCAN Clip # \n Reason: 70 Y/O WITH CADAVERIC KIDNEY TRANSPLANT NOW WITH DECREASED URINE FLOW AND QUESTION OF URINE LEAK\n ______________________________________________________________________________\n FINAL REPORT\n\n RADIOPHARMACEUTICAL DATA:\n 5.5 mCi Tc-m MAG3 ();\n HISTORY: renal transplant with new fluid collection at the upper pole of the\n transplanted kidney. Decreased urine flow. Possible urine leak.\n\n INTERPRETATION:\n\n Flow and dynamic images were obtained after intravenous administration of\n tracer.\n\n Blood flow images show relatively normal flow to the transplanted kidney.\n\n Renogram images show normal uptake of tracer into the renal parenchyma, with\n appearance of excreted tracer in the bladder within 4 minutes.\n\n No tracer concentration is seen above the transplanted kidney on initial or\n delayed dynamic images.\n\n The hilum of the transplanted kidney is facing laterally.\n\n IMPRESSION: No evidence of urine leak on initial images. Normal perfusion and\n tracer concentration in the transplanted kidney. Excretion of the tracer into\n the bladder by 4 minutes. Dr. was notified of these findings by phone.\n She declined 18 hour delayed images.\n\n\n , M.D. Approved: TUE 3:14 PM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2159-02-22 00:00:00.000", "description": "R RENAL TRANSPLANT U.S. RIGHT", "row_id": 1059611, "text": " 10:04 AM\n RENAL TRANSPLANT U.S. RIGHT Clip # \n Reason: Please assess flows to transplant kidney, assess for hydro o\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with renal transplant 4 days ago now with decreased urine\n output and non-decreasing creatinine\n REASON FOR THIS EXAMINATION:\n Please assess flows to transplant kidney, assess for hydro or fluid collection\n around the transplant kidney\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 11:48 AM\n New peritransplant fluid collection, possibly a urinoma. Maintained arterial\n and venous flow to and from the transplant.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Renal transplant four days ago with decreased urine output and\n non-decreasing creatinine.\n\n COMPARISON: .\n\n RENAL TRANSPLANT ULTRASOUND: The renal transplant is again seen in the right\n lower quadrant, measuring 10.5 cm. There is new peritransplant fluid,\n anechoic. The fluid is seen in a triangular pocket superficial to the\n transplant kidney measuring roughly 3.2 x 2.6 x 1.2 cm. There is no\n hydronephrosis of the transplant, and normal renal echogenicity is maintained.\n\n Doppler evaluation reveals a patent main renal artery and vein to the\n transplant. There is brisk systolic upstroke in the main renal artery, and\n the resistive index in this vessel measures 0.85. Resistive indices in the\n upper, mid and lower pole renal artery branches range from 0.55-0.67, not\n significantly changed.\n\n IMPRESSION:\n 1. New moderate sized peritransplant fluid collection, possibly a urinoma\n given the history above.\n 2. Maintained arterial and venous flow to and from the transplant.\n\n Findings were discussed with on the morning of .\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2159-02-22 00:00:00.000", "description": "R RENAL TRANSPLANT U.S. RIGHT", "row_id": 1059612, "text": ", J. FA10 10:04 AM\n RENAL TRANSPLANT U.S. RIGHT Clip # \n Reason: Please assess flows to transplant kidney, assess for hydro o\n Admitting Diagnosis: KIDNEY TRANSPLANT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old man with renal transplant 4 days ago now with decreased urine\n output and non-decreasing creatinine\n REASON FOR THIS EXAMINATION:\n Please assess flows to transplant kidney, assess for hydro or fluid collection\n around the transplant kidney\n ______________________________________________________________________________\n PFI REPORT\n New peritransplant fluid collection, possibly a urinoma. Maintained arterial\n and venous flow to and from the transplant.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2161-10-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1155307, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with IPH, intubated, now with ? pneumonia\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n CLINICAL INFORMATION: IPH, intubated, pneumonia.\n\n FINDINGS:\n Comparison is made to the prior study from . The heart is enlarged.\n There is dense left lower lobe consolidation. Right subclavian catheter\n terminates in the superior vena cava. Endotracheal tube is positioned at the\n thoracic inlet. Nasogastric tube courses below the diaphragm but the tip is\n not seen. There is mild congestive failure and this has increased since the\n prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-20 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1154463, "text": ", M. NSURG TSICU 7:06 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please do bilateral lower US; pt with multiple embolic\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with multiple embolic strokes to the ; ? DVT please do\n bilateral US screen\n REASON FOR THIS EXAMINATION:\n Please do bilateral lower US; pt with multiple embolic strokes to the\n brain. thx\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of DVT seen in either lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-20 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 1154462, "text": " 7:06 AM\n BILAT LOWER EXT VEINS Clip # \n Reason: Please do bilateral lower US; pt with multiple embolic\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with multiple embolic strokes to the ; ? DVT please do\n bilateral US screen\n REASON FOR THIS EXAMINATION:\n Please do bilateral lower US; pt with multiple embolic strokes to the\n brain. thx\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE 1:38 PM\n PFI: No evidence of DVT seen in either lower extremity.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 30-year-old female with embolic stroke and intraparenchymal\n hemorrhage in the brain, here to assess bilateral lower extremities for\n evidence of DVT.\n\n COMPARISON: None available.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale, and color and pulse\n Doppler son examinations were performed over bilateral common femoral,\n superficial femoral and popliteal veins. The study shows normal\n compressibility, wall-to-wall color flow, normal venous waveforms with\n respiratory variation, and normal augmentation. No intraluminal thrombus is\n seen. Also, color flow can be seen extending into the posterior tibial veins\n of the calves bilaterally.\n\n IMPRESSIONS: No evidence of DVT seen in either lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154630, "text": " 1:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for cute changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p craniotomy ICH\n REASON FOR THIS EXAMINATION:\n Eval for cute changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw WED 4:17 AM\n 1. Stable to decreased hemorrhagic products within the right cerebral\n hemisphere and ventricular system.\n\n 2. Increased hypodensity in the right cerebral hemisphere compatible with\n encephalomalacia. Multifocal evolving left cerebral and brainstem infarcts.\n No new hemorrhage.\n\n 3. Stable ventricular catheter. Stable effacement of the ambient cisterns.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post craniotomy and intracranial hemorrhage. Evaluate for\n acute change.\n\n CT HEAD: Axial imaging was performed through the brain without IV contrast.\n\n COMPARISON: CT head . MRI brain .\n\n FINDINGS: Patient is status post right frontal and parietal craniectomy.\n Hyperdense material remains extra-axial at site of craniectomy. There is\n overall decreased blood products in the right cerebral hemisphere. There is\n diffuse hypoattenuation within the white matter of the right cerebral\n hemisphere compatible with developing encephalomalacia. There remains blood\n products within the lateral ventricles, third ventricle. There is stable\n appearance to a left frontal approach ventriculostomy catheter.\n\n There are multifocal regions of hypoattenuation in the left cerebral\n hemisphere compatible with evolving infarcts, seen on prior MRI. There are\n evolving hypodensities in the brainstem (2:9, 7). The ambient cisterns remain\n effaced. There are no new areas concerning for hemorrhage. There is trace\n pneumocephalus anterior to the right temporal lobe.\n\n The visualized paranasal sinuses are clear. Globes and orbits are intact.\n\n IMPRESSION:\n\n 1. Stable to decreased hemorrhagic products within the right cerebral\n hemisphere and ventricular system, with no new hemorrhage.\n\n 2. Increased hypodensity in the right cerebral hemisphere compatible with\n evolving encephalomalacia.\n\n (Over)\n\n 1:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for cute changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 3. Multifocal evolving left cerebral and brainstem infarcts.\n\n 4. Stable ventricular catheter. Stable effacement of the ambient cisterns.\n\n COMMENT: Findings were discussed with Dr. at 2:15AM .\n\n NOTE ADDED IN ATTENDING REVIEW: Again demonstrated is the small hemorrhagic\n focus in the paramedian ventral aspect of the upper pons; given this pattern,\n in the setting of persistent downward transtentorial herniation, this likely\n represents a Duret hemorrhage, associated with a poor prognosis.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1155007, "text": " 5:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: acute changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p ICH\n REASON FOR THIS EXAMINATION:\n acute changes\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Intracranial hemorrhage.\n\n FINDINGS: Comparison to prior radiographs dating back to and most\n recently .\n\n FINDINGS: There is now complete opacification of the left retrocardiac space\n with obliteration of the left medial hemidiaphragm indicating probable left\n lower lobe consolidation. Bilateral hilar prominence suggests probable\n concomitant pulmonary venous hypertension. Right lower lobe opacity is\n suggestive of evolving consolidation. Moderate cardiomegaly is unchanged\n since . A right subclavian central venous catheter, endotracheal tube\n and nasogastric tube are in satisfactory position.\n\n IMPRESSION:\n Progression of left lower lobe/retrocardiac opacity indicating left lower lobe\n consolidation, possible additional right lower lobe consolidation.\n\n Pulmonary vascular engorgement and moderate cardiomegaly.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-17 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1154137, "text": " 7:07 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? ICH\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with sudden onset , then L hemiparesis, then\n unresponsive\n REASON FOR THIS EXAMINATION:\n ? ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JXRl SAT 8:18 PM\n C- head: large right hemispheric parenchymal hemorrhage w/ intraventricular\n extension, blood fill and expands the third, fourth and right lateral\n venricles. 5mm leftward shift of midline structures. sulci are diffusely\n effaced. effacement of quadreminal cistern concerning for transtenorial\n herniation. basilar cisterns are obilterated. bilateral apical opacities\n concerning for aspiration. CTA: carotid, vetebral arteries are patent. no\n aneurysm identified. final read pending reformats.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CTA of the head and neck.\n\n CLINICAL INFORMATION: Patient with sudden onset mental status change.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Following this, using departmental protocol, CT angiography of the head and\n neck were acquired. 3D reformatted images were obtained.\n\n FINDINGS:\n\n CT HEAD:\n\n The CT head demonstrates a large intraparenchymal basal ganglia hemorrhage\n identified, which extends to the lateral ventricle. There is dilatation of\n the temporal horns indicating developing hydrocephalus. There is blood\n visualized in the third and the fourth ventricle. There is mass effect with\n central herniation and compression of the brainstem as well as likely foramen\n magnum herniation. There is decrease size of the quadrigeminal cistern\n identified. There is diffuse loss of cerebral sulci seen.\n\n CT ANGIOGRAPHY NECK:\n\n The CT angiography of the neck demonstrate normal appearance of the carotid\n and vertebral arteries without stenosis or occlusion. There is bilateral\n diffuse airspace disease at the lung apices, right greater than left side\n which indicates a pneumonic infiltrate likely due to aspiration pneumonia.\n Correlation with chest radiographs recommended. An endotracheal tube is\n identified in position.\n\n CT ANGIOGRAPHY HEAD:\n\n (Over)\n\n 7:07 PM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: ? ICH\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The CT angiography of the head demonstrates vascular displacement in the right\n middle cerebral region secondary to the intracerebral hematoma. No evidence\n of vascular occlusion or stenosis seen. A tiny 2 mm aneurysm is noted at the\n anterior communicating artery at junction with the left A2 segment. There are\n no other aneurysms identified.\n\n IMPRESSION:\n 1. Right-sided basal ganglia hemorrhage extending to the ventricles with\n signs of central transtentorial and foramen magnum herniations. Developing\n hydrocephalus is also seen.\n 2. CT angiography of the neck demonstrate no vascular abnormalities.\n Bilateral upper lung airspace disease could be secondary to aspiration\n pneumonia.\n 3. CT angiography of the head demonstrate no abnormal vascular structures in\n the region of hemorrhage. A tiny 2 mm aneurysm is identified, which may be\n incidental at the anterior communicating artery region.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1154138, "text": " 7:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with sudden onset L ha, then L weakness, then unresponsive.\n intubated\n REASON FOR THIS EXAMINATION:\n ? tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST RADIOGRAPH PERFORMED ON \n\n COMPARISON: Comparison is made with the CTA head and neck performed\n concurrently\n\n CLINICAL HISTORY: Sudden-onset headache, hemiparesis, unresponsive status.\n Assess ET and NG tubes.\n\n FINDINGS: Single AP portable supine chest radiograph is obtained. The ET\n tube is seen with its tip approximately 4.8 cm above the carina. NG tube\n courses into the left upper quadrant. There is diffuse pulmonary vascular\n congestion and hazy ground-glass opacity in the lungs, which could represent\n pulmonary edema, likely neurogenic. An ill-defined mass-like opacity in the\n right perihilar region is of uncertain etiology, though could reflect\n aspiration given the right apical consolidation seen on concurrently performed\n CTA neck. The heart and mediastinal contours appear unremarkable. No large\n pleural effusion or pneumothorax seen. Right CP angle is excluded. NG tube\n tip is seen in the left upper abdomen.\n\n IMPRESSION: Findings concerning for neurogenic pulmonary edema with more\n confluent opacities in the right upper lobe and right perihilar region, which\n could reflect aspiration. ET and NG tubes positioned appropriately.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154631, "text": ", M. NSURG TSICU 1:16 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Eval for cute changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p craniotomy ICH\n REASON FOR THIS EXAMINATION:\n Eval for cute changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Stable to decreased hemorrhagic products within the right cerebral\n hemisphere and ventricular system.\n\n 2. Increased hypodensity in the right cerebral hemisphere compatible with\n encephalomalacia. Multifocal evolving left cerebral and brainstem infarcts.\n No new hemorrhage.\n\n 3. Stable ventricular catheter. Stable effacement of the ambient cisterns.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154178, "text": " 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: IPH, F/U SCAN\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with R IPH s/p EVD and R craniectomy\n REASON FOR THIS EXAMINATION:\n follow-up scan - 6am\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 1:10 PM\n PFI:\n\n 1. Again, a right-sided craniectomy is identified with some blood\n extra-axially at the craniectomy side, which is new and more pronounced since\n the previous CT examination.\n\n 2. Unchanged appearance of the basal ganglia partially indicated hemorrhage\n and intraventricular blood as well as the ventricular drain. The ventricular\n size has decreased since the previous study.\n\n 3. Subtle hypodensity of the cerebral parenchyma at the region of craniectomy\n could be due to slight edema. However, this should be reassessed on followup\n study or any evolving ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: CT of the head.\n\n CLINICAL INFORMATION: Patient with intracranial hemorrhage status post\n craniectomy for followup.\n\n TECHNIQUE: Axial images of the head were obtained without contrast.\n Comparison was made with the CT examination obtained on at 11:45\n p.m.\n\n FINDINGS: Again a right-sided craniectomy is identified. There is now\n increased density identified at the craniectomy site extra-axially which\n indicates blood products collection which are slightly more prominent since\n the previous study. Again pneumocephalus identified. Right-sided basal\n ganglia hemorrhage partially evacuated is again seen and has not increased in\n size. Intraventricular blood is also seen. No hydrocephalus identified. The\n left-sided ventricular drain extends to the right side across the septum\n pellucidum near the right foramen of with the tip visualized projected\n over the caudate nucleus head on the right. Since the previous study, there\n is slight increased protrusion of the cerebral matter identified through the\n craniectomy defect.\n\n IMPRESSION:\n\n 1. Again, a right-sided craniectomy is identified with some blood\n extra-axially at the craniectomy side, which is new and more pronounced since\n the previous CT examination.\n (Over)\n\n 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: IPH, F/U SCAN\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Unchanged appearance of the basal ganglia partially indicated hemorrhage\n and intraventricular blood as well as the ventricular drain. The ventricular\n size has decreased since the previous study.\n\n 3. Subtle hypodensity of the cerebral parenchyma at the region of craniectomy\n could be due to slight edema. However, this should be reassessed on followup\n study or any evolving ischemia.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-20 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1154511, "text": " 10:16 AM\n RENAL U.S. PORT Clip # \n Reason: evaluate kidneys, ureter\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman renal failure\n REASON FOR THIS EXAMINATION:\n evaluate kidneys, ureter\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE RENAL ULTRASOUND\n\n INDICATION: 30-year-old female with acute renal failure. Admitted with\n intracranial hemorrhage.\n\n No priors for comparison.\n\n FINDINGS: Limited portable examination of both kidneys. No gross\n hydronephrosis.\n\n Provided static images of the midline pelvis demonstrate decompressed urinary\n bladder with Foley catheter balloon.\n\n IMPRESSION: No gross hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154179, "text": ", M. NSURG TSICU 5:52 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: IPH, F/U SCAN\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with R IPH s/p EVD and R craniectomy\n REASON FOR THIS EXAMINATION:\n follow-up scan - 6am\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Again, a right-sided craniectomy is identified with some blood\n extra-axially at the craniectomy side, which is new and more pronounced since\n the previous CT examination.\n\n 2. Unchanged appearance of the basal ganglia partially indicated hemorrhage\n and intraventricular blood as well as the ventricular drain. The ventricular\n size has decreased since the previous study.\n\n 3. Subtle hypodensity of the cerebral parenchyma at the region of craniectomy\n could be due to slight edema. However, this should be reassessed on followup\n study or any evolving ischemia.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-18 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1154163, "text": " 1:39 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Right Subclavian line placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman s/p R craniotomy\n REASON FOR THIS EXAMINATION:\n Right Subclavian line placement\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Assess line.\n\n Comparison is made with prior study performed 7 hours earlier.\n\n Right subclavian catheter tip is in cavoatrial junction. There is no evident\n pneumothorax. ET tube is in standard position. NG tube tip is in the\n stomach. Mild cardiomegaly is stable. Bibasilar opacities are a combination\n of small bilateral pleural effusions, right greater than left associated with\n atelectasis. Pulmonary edema is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154246, "text": ", M. NSURG TSICU 5:44 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with pod #1 r crani now with no corneals/ weak cough / bloody\n draiange from evd / BP spike\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Status post right frontotemporal craniectomy with no interval change in\n blood products in the craniectomy bed, right basal ganglia hemorrhage or\n intraventricular hemorrhage. No new hemorrhage. Persistent leftward shift of\n normally midline structures and mass effect, unchanged from earlier the same\n day.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-18 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154245, "text": " 5:44 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with pod #1 r crani now with no corneals/ weak cough / bloody\n draiange from evd / BP spike\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg SUN 7:06 PM\n PFI: Status post right frontotemporal craniectomy with no interval change in\n blood products in the craniectomy bed, right basal ganglia hemorrhage or\n intraventricular hemorrhage. No new hemorrhage. Persistent leftward shift of\n normally midline structures and mass effect, unchanged from earlier the same\n day.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 30-year-old female postop day 1 for right craniectomy now with no\n corneal reflex, weak cough reflex and bloody drainage from . Evaluate for\n interval change.\n\n COMPARISON: at 5:52 a.m.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without IV\n contrast.\n\n FINDINGS: The patient is status post right frontotemporal craniectomy with\n expected post-surgical pneumocephalus. Hyperdense blood products at the\n craniectomy site are similar to the prior exam. There is sulcal effacement in\n the right cerebral hemisphere, similar to the prior study. The large basal\n ganglia parenchymal hemorrhage is unchanged from prior. There is surrounding\n hypodensity in the craniectomy bed and adjacent to the basal ganglia\n hemorrhage which is also similar to prior. There is unchanged 7 mm of\n leftward shift of the normally midline structures. Caliber of the\n quadrigeminal plate cistern and perimesencephalic cisterns is similar to the\n most recent study. Persistent crowding of the foramen magnum is noted.\n\n A ventriculostomy catheter from a left frontal approach terminates in the\n region of the foramen of as before. There is a large amount of\n intraventricular hemorrhage involving the lateral, third and fourth\n ventricles. Ventricular size is similar to the prior study. No new\n hemorrhage or major vascular territorial infarction is noted.\n\n IMPRESSION:\n\n 1. Status post right frontotemporal craniectomy with unchanged appearance of\n blood products in the surgical bed, right basal ganglia hemorrhage and\n intraventricular hemorrhage.\n\n 2. Unchanged leftward shift of the normally midline structures and mass effect\n (Over)\n\n 5:44 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: interval change\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n compared to study performed earlier the same day.\n\n" }, { "category": "Radiology", "chartdate": "2161-10-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154152, "text": " 11:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post-op follow-up imaging\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with R IPH s/p evacuation\n REASON FOR THIS EXAMINATION:\n post-op follow-up imaging\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw SUN 1:48 AM\n PFI:\n\n 1. Status post right-sided craniectomy with post-surgical pneumocephalus.\n\n 2. Partial right intraparenchymal hematoma evacuation. There is residual\n hematoma posteriorly within the site of intraparenchymal hemorrhage.\n\n 3. Stable intraventricular blood extending into the lateral ventricles and\n the fourth ventricle.\n\n 4. New left frontal approach shunt catheter.\n\n 5. Stable ventricular size and midline shift.\n\n 6. Herniation with effacement of the quadrilateral plate.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Right intraparenchymal hemorrhage status post evacuation. Postop\n imaging.\n\n CT HEAD: Axial imaging was performed through the brain without IV contrast.\n\n COMPARISON: CTA head .\n\n FINDINGS: Patient is status post right frontal, parietal, and temporal\n craniectomy. There is a right frontal pneumocephalus. There is extensive\n pneumocephalus in the right frontotemporal lobe at the site of hematoma\n evacuation. There remains a 2.9 x 2.4 cm right temporoparietal hematoma\n posterior to the evacuation region. There is hemorrhage filling the right\n lateral ventricle and extending into the left lateral ventricle. There has\n been interval placement of a left frontal approach shunt catheter with its tip\n near the third ventricle. The size and configuration of the ventricles\n appears normal with slightly enlarged temporal horns, but stable. There is\n stable effacement of the quadrigeminal plate. Hemorrhage extends into the\n fourth ventricle. There is stable approximately 5-mm leftward shift of\n normally midline structures. No new areas of hemorrhage are evident. No\n evidence for vascular infarct. The globes and orbits are intact. The sinuses\n are clear.\n\n IMPRESSION:\n\n (Over)\n\n 11:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post-op follow-up imaging\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1. Status post right-sided craniectomy with post-surgical pneumocephalus.\n\n 2. Partial right intraparenchymal hematoma evacuation. There is residual\n hematoma posteriorly within the site of intraparenchymal hemorrhage.\n\n 3. Stable intraventricular blood extending into the lateral ventricles and\n the fourth ventricle.\n\n 4. New left frontal approach shunt catheter.\n\n 5. Stable ventricular size and midline shift.\n\n 6. Herniation with effacement of the quadrilateral plate.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154153, "text": ", M. NSURG PACU 11:26 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: post-op follow-up imaging\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 40 year old woman with R IPH s/p evacuation\n REASON FOR THIS EXAMINATION:\n post-op follow-up imaging\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Status post right-sided craniectomy with post-surgical pneumocephalus.\n\n 2. Partial right intraparenchymal hematoma evacuation. There is residual\n hematoma posteriorly within the site of intraparenchymal hemorrhage.\n\n 3. Stable intraventricular blood extending into the lateral ventricles and\n the fourth ventricle.\n\n 4. New left frontal approach shunt catheter.\n\n 5. Stable ventricular size and midline shift.\n\n 6. Herniation with effacement of the quadrilateral plate.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1154658, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for acute changes\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p ICH\n REASON FOR THIS EXAMINATION:\n Eval for acute changes\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: Patient with ICH, right craniotomy and pulmonary edema.\n\n Comparison is made with prior study of .\n\n Now mild pulmonary edema has markedly improved. Mild-to-moderate cardiomegaly\n is accentuated by low lung volumes. Bibasilar opacity left greater than right\n are likely atelectasis. There is no evident pneumothorax. The lines and\n tubes remain in place in their standard position.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-19 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1154360, "text": " 1:46 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 30 year old woman s/p R crani for evacuation of IPH, evaluat\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p R crani for evacuation of IPH, evaluate for infarct and\n post operative changes\n REASON FOR THIS EXAMINATION:\n 30 year old woman s/p R crani for evacuation of IPH, evaluate for infarct and\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): PXDb MON 5:55 PM\n 1. Unchanged large right intraparenchymal hemorrhage with now new foci of\n acute embolic infarctions scattered bilaterally including the brainstem,\n cerebellum in bilateral frontoparietal hemispheres.\n 2. Unchanged subfalcine and mild uncal herniation.\n 3. Unchanged foci of hemorrhage within the brainstem, in the setting of\n slight downward transtentorial herniation, raising the possibility of duret\n hemorrhage.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Right craniectomy, evacuation for intraparenchymal hemorrhage.\n Evaluate for infarct and postoperative changes.\n\n COMPARISON: Multiple prior studies including , .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted sequence of the brain without\n intravenous contrast.\n\n FINDINGS: There is a large right hemispheric intraparenchymal hemorrhage\n centered within the putamen, distribution most compatible with a hypertensive\n bleed. The overall measurement is 3.1 x 6.7 cm, comparable to the prior study\n allowing for modality related differences. There is mild perihemorrhagic\n edema with moderate mass effect and persistent mild leftward subfalcine\n herniation, unchanged measuring 7.5 mm. There is a small right subdural\n hematoma layering along the frontoparietal convenxity, relatively unchanged.\n\n There is hemorrhage within the brainstem that in the setting of downward\n transtentorial herniation remains worrisome for Duret hemorrhage. There are\n post-surgical changes from right craniectomy. A ventriculostomy catheter via\n left frontal approach is terminating within the left frontal of the\n lateral ventricle.\n\n There are multiple areas of hyperintensity on FLAIR, the largest along the\n right parieto-occipital cortex and the others are scattered throughout\n bilateral cerebral hemispheres, some of these areas demonstrate slow\n diffusion, compatible with acute infarction. These include bilateral cerebral\n hemispheres, cerebellum, brainstem, right parieto-occipital and right corona\n radiata.\n\n (Over)\n\n 1:46 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 30 year old woman s/p R crani for evacuation of IPH, evaluat\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There continues to be intraventricular extension without evidence of\n hydrocephalus, mostly affecting the right lateral ventricle. There are few\n subcentimeter suboccipital nodes. There is crowding of the posterior fossa\n with downward displacement of the tonsils, suggesting a component of small\n downward transtentorial herniation.\n\n IMPRESSION:\n 1. Unchanged large right intraparenchymal hemorrhage with new foci of acute\n embolic infarctions scattered bilaterally including the brainstem, cerebellum\n in bilateral frontoparietal hemispheres.\n 2. Unchanged subfalcine and mild uncal herniation.\n 3. Unchanged foci of hemorrhage within the brainstem, in the setting of\n slight downward transtentorial herniation, raising the possibility of duret\n hemorrhage.\n\n These findings were discussed with Dr. at the time of the\n study at 4:40 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2161-10-19 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1154361, "text": ", M. NSURG TSICU 1:46 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: 30 year old woman s/p R crani for evacuation of IPH, evaluat\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman s/p R crani for evacuation of IPH, evaluate for infarct and\n post operative changes\n REASON FOR THIS EXAMINATION:\n 30 year old woman s/p R crani for evacuation of IPH, evaluate for infarct and\n post operative changes\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Unchanged large right intraparenchymal hemorrhage with now new foci of\n acute embolic infarctions scattered bilaterally including the brainstem,\n cerebellum in bilateral frontoparietal hemispheres.\n 2. Unchanged subfalcine and mild uncal herniation.\n 3. Unchanged foci of hemorrhage within the brainstem, in the setting of\n slight downward transtentorial herniation, raising the possibility of duret\n hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154989, "text": " 2:00 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? worsening head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with ? worsening head bleed\n REASON FOR THIS EXAMINATION:\n ? worsening head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JMGw FRI 3:27 AM\n PFI:\n\n 1. Little overall change in appearance of extensive right cerebral\n intraparenchymal hemorrhage with intraventricular extension.\n\n 2. Limited evaluation by streak artifact, but the appearance of the posterior\n fossa with brainstem hemorrhage, ambient cistern effacement and downward\n transtentorial herniation is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Evaluate for worsening head bleed.\n\n CT HEAD: Axial imaging was performed through the brain without IV contrast.\n\n COMPARISON: head CT.\n\n FINDINGS: Compared to the earlier examination, there is little change in the\n appearance of a right frontoparietal craniectomy with herniation of the brain\n to the calvarial defect. There are extensive hemorrhagic products within the\n right cerebral hemisphere, tracking into the lateral ventricles, the\n distribution of which appears similar to the prior study. This evaluation is\n limited by streak artifact from patient motion, particularly in the posterior\n fossa. The appearance of the posterior fossa, however, appears grossly\n similar with effacement of the ambient cisterns. There is hemorrhage within\n the brainstem, compatible with a hemorrhage. There are multifocal\n low-attenuation lesions within the left cerebral hemisphere compatible with\n evolving infarcts. A left frontal approach ventriculostomy catheter is stable\n in position.\n\n The visualized paranasal sinuses are clear.\n\n IMPRESSION:\n\n 1. Little overall change in appearance of extensive right cerebral\n intraparenchymal hemorrhage with intraventricular extension.\n\n 2. Limited evaluation by streak artifact, but the appearance of the posterior\n fossa with brainstem hemorrhage, ambient cistern effacement and downward\n transtentorial herniation is unchanged.\n\n These findings were discussed in person with Dr. at 2:30 a.m.,\n (Over)\n\n 2:00 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? worsening head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n .\n\n\n" }, { "category": "Radiology", "chartdate": "2161-10-23 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1154990, "text": ", M. NSURG TSICU 2:00 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? worsening head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 30 year old woman with ? worsening head bleed\n REASON FOR THIS EXAMINATION:\n ? worsening head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI:\n\n 1. Little overall change in appearance of extensive right cerebral\n intraparenchymal hemorrhage with intraventricular extension.\n\n 2. Limited evaluation by streak artifact, but the appearance of the posterior\n fossa with brainstem hemorrhage, ambient cistern effacement and downward\n transtentorial herniation is unchanged.\n\n\n" }, { "category": "Echo", "chartdate": "2161-10-20 00:00:00.000", "description": "Report", "row_id": 89740, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Endocarditis.\nHeight: (in) 65\nWeight (lb): 200\nBSA (m2): 1.98 m2\nBP (mm Hg): 150/80\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:51\nTest: Portable TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. No\nmass/thrombus in the LAA. Depressed LAA emptying velocity (<0.2m/s)\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast in the body of\nthe RA. Mild spontaneous echo contrast in the RAA. No thrombus in the RAA. No\nASD or PFO by 2D, color Doppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Moderate symmetric LVH. Mildly depressed LVEF. No LV\nmass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: No atheroma in ascending aorta. No atheroma in aortic arch. No atheroma\nin descending aorta. No thoracic aortic dissection.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No masses or\nvegetations on aortic valve. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No mass or\nvegetation on tricuspid valve. Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. No\nvegetation/mass on pulmonic valve.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was monitored\nby a nurse throughout the procedure. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications.\n\nConclusions:\nMild to moderate spontaneous echo contrast is seen in the left atrial\nappendage. No mass/thrombus is seen in the left atrium, left atrial appendage,\nright atrium, or right atrial. appendage. The left atrial appendage emptying\nvelocity is depressed (<0.2m/s). No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall\nleft ventricular systolic function is borderline (LVEF= 55 %). There is\nmoderate LVH.No masses or thrombi are seen in the left ventricle. 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 stenosis. No masses or vegetations are seen on the aortic valve. No\naortic regurgitation is seen. The mitral valve appears structurally normal\nwith trivial mitral regurgitation. No mass or vegetation is seen on the mitral\nvalve. No vegetation/mass is seen on the pulmonic valve or the tricuspid\nvalve. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: There is mild to moderate spontaneous echo contrast in the left\natrial appendage (and low emptying velocity) without intracardiac thrombus\nseen (? Prior/recent atrial fibrillaiton?). There is no evidence of\nvegetations or abscesses. There is no ASD or PFO. There is no evidence of\naortic atheroma. There is moderate left ventricular hypertrophy and the\noverall left ventricular systolic function is borderline.\n\n\n" }, { "category": "ECG", "chartdate": "2161-10-18 00:00:00.000", "description": "Report", "row_id": 238759, "text": "Normal sinus rhythm. Left ventricular hypertrophy. Compared to the previous\ntracing of the rate has slowed from 115 to 82 beats per minute and\nthe lateral ST-T wave changes noted at that time have regressed as have the\npeaked T waves in leads V3-V4. No other diagnostic interval change.\n\n" }, { "category": "ECG", "chartdate": "2161-10-17 00:00:00.000", "description": "Report", "row_id": 238760, "text": "Sinus tachycardia. Left atrial abnormality. Left ventricular hypertrophy with\nassociated ST-T wave changes, although ischemia or infarction cannot be\nexcluded. No previous tracing available for comparison.\n\n" } ]

[ { "category": "ECG", "chartdate": "2143-08-28 00:00:00.000", "description": "Report", "row_id": 223032, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-03 00:00:00.000", "description": "TUBE CHOLANGIOGRAM", "row_id": 1090680, "text": " 9:34 AM\n BILIARY CATH CHECK Clip # \n Reason: please do gravity cholangiogram to assess anastomosis\n Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA\n Contrast: OPTIRAY Amt: 8\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C TUBE CHOLANGIOGRAM *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 M ccy, cbd excision , roux hepaticojej for mid duct cholangioca \n REASON FOR THIS EXAMINATION:\n please do gravity cholangiogram to assess anastomosis\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JXXb TUE 2:54 PM\n T-tube cholangiogram demonstrated patent right hepatico-jejunostomy\n anastomosis with contrast flow freely through the anastomosis. No bowel leak\n visualized at the right hepatic duct. No dilation of right hepatic duct and\n its branches visualized.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: The patient is a 65-year-old male status post CCY, CBD\n excision and roux en y hepatico-jejunostomy anastomosis for mid duct\n cholangiocarcinoma. A request was made to perform a T-tube cholangiogram to\n assess anastomosis.\n\n OPERATORS: Dr. , Dr. , Dr. , the\n attending radiologist who supervised during the whole procedure.\n\n PROCEDURE: T-tube cholangiogram.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography suite and\n placed supine on the imaging table. The indwelling T-tube was prepared in a\n sterile fashion. A contrast reservoir was connected to the T-tube. Contrast\n was infused through the tube by gravity. The contrast was infused into the\n right hepatic duct system via the existing tube. The right\n hepaticojejunostomy anastomosis was patent with contrast flow freely through\n the anastomosis into the jejunum. There was no biliary leak visualized at any\n site of the right hepatic duct and its branches. No dilation of the right\n hepatic duct was visualized. The contrast reservoir was then disconnected\n from the T-tube.\n\n The patient tolerated the procedure well, and there were no immediate\n complications.\n\n IMPRESSION: Patent right hepaticojejunostomy anastomosis with contrast flow\n freely into the jejunum. No bile leak or dilation visualized.\n\n\n\n\n (Over)\n\n 9:34 AM\n BILIARY CATH CHECK Clip # \n Reason: please do gravity cholangiogram to assess anastomosis\n Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA\n Contrast: OPTIRAY Amt: 8\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2143-09-03 00:00:00.000", "description": "TUBE CHOLANGIOGRAM", "row_id": 1090681, "text": ", W. FA10 9:34 AM\n BILIARY CATH CHECK Clip # \n Reason: please do gravity cholangiogram to assess anastomosis\n Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA\n Contrast: OPTIRAY Amt: 8\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 M ccy, cbd excision , roux hepaticojej for mid duct cholangioca \n REASON FOR THIS EXAMINATION:\n please do gravity cholangiogram to assess anastomosis\n ______________________________________________________________________________\n PFI REPORT\n T-tube cholangiogram demonstrated patent right hepatico-jejunostomy\n anastomosis with contrast flow freely through the anastomosis. No bowel leak\n visualized at the right hepatic duct. No dilation of right hepatic duct and\n its branches visualized.\n\n" }, { "category": "Radiology", "chartdate": "2143-09-08 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 1091439, "text": " 1:42 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for pSBO, ? volvulus, RLQ pain etiology, patient will n\n Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man s/p CCY , CBD excision, Roux hepaticojej for mid-duct\n cholangiocarcinoma, now c/o RLQ pain and abdominal distention\n REASON FOR THIS EXAMINATION:\n eval for pSBO, ? volvulus, RLQ pain etiology, patient will need PO and IV\n contrast\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: AKPe SUN 6:16 PM\n Prelim:\n expected post surgical changes. Small amount of laminar fluid and focus of\n gas in gallbladder fossa and small laminar fluid tracking in inferior right\n hepatic lobe. Small amount of fluid and gas tracking in right rectus muscle.\n No drainable collections. No evidence of bowel obstruction or inflammation.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: History of mid duct cholangiocarcinoma, status post\n Roux-en-Y hepaticojejunostomy and cholecystectomy performed on ,\n now complaining of right lower quadrant pain and abdominal distention.\n\n TECHNIQUE: MDCT of the abdomen and pelvis was performed following the\n uneventful administration of nonionic intravenous contrast and oral contrast.\n Sagittal and coronal reformatted images were also reviewed.\n\n Comparison exam is dated .\n\n FINDINGS:\n\n Limited images of the lung bases demonstrate trace left pleural fluid and\n bibasilar atelectasis. There has been interval cholecystectomy and bile duct\n excision with hepaticojejunostomy. A drainage catheter enters from the right\n lower quadrant and terminates within the right-sided bile ducts. There is no\n evidence of biliary dilatation. Pneumobilia is noted. There is an area of\n laminar fluid within the inferior right hepatic lobe, measuring up to 9 mm in\n transverse dimension. There is a trace amount of fluid and a focus of gas in\n the gallbladder fossa. There is a trace amount of perihepatic and perisplenic\n ascites with fluid also seen tracking along the ascending colon. There is a\n right-sided abdominal wound with skin staples noted. There is a laminar fluid\n and gas tracking within the right rectus muscle, without focal collection.\n\n There are no focal enhancing hepatic lesions. There are numerous small\n gastrohepatic and retroperitoneal lymph nodes, which are not pathologically\n enlarged by size criteria. Overall, the lymph nodes appear less prominent\n than on the prior exam. The spleen, kidneys, adrenal glands and pancreas are\n within normal limits.\n\n The stomach is unremarkable. The small bowel is not dilated, and there is no\n (Over)\n\n 1:42 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for pSBO, ? volvulus, RLQ pain etiology, patient will n\n Admitting Diagnosis: CHOLANGIOCARCINOMA/SDA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n evidence of wall thickening. Suture material is noted along loops of jejunum\n in the mid anterior abdomen. There is descending colonic diverticulosis,\n without evidence of acute inflammation.\n\n PELVIS: A small amount of fluid is seen around the cecum, with no evidence of\n cecal wall thickening. A small amount of additional fluid is seen in the\n mesentry of the left pelvis: There is sigmoid diverticulosis, without\n evidence of acute inflammation. The bladder is partially decompressed, but\n unremarkable. There are no pathologically enlarged lymph nodes by size\n criteria. There is beam hardening artifact from left total hip arthroplasty.\n\n Bone windows demonstrate degenerative changes of the right hip and spine, but\n no focal suspicious lesions.\n\n IMPRESSION:\n\n 1. No acute findings in the abdomen or pelvis.\n\n 2. Post-surgical changes, status post common bile duct excision,\n cholecystectomy, and Roux-en-Y hepaticojejunostomy. A small amount of fluid\n and a focus of gas are noted in the gallbladder fossa, likely post-surgical.\n There is a small laminar area of fluid within the inferior right hepatic lobe.\n Laminar fluid and foci of gas are also noted within the right rectus muscle,\n without focal collection. There is a trace amount of abdominal and pelvic\n ascites.\n\n 3. Diverticulosis, without evidence of acute inflammation.\n\n\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 76944, "text": "PATIENT/TEST INFORMATION:\nIndication: Intr-op TEE for CABG\nHeight: (in) 69\nWeight (lb): 200\nBSA (m2): 2.07 m2\nBP (mm Hg): 112/64\nHR (bpm): 52\nStatus: Inpatient\nDate/Time: at 09:04\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or\ncolor Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Moderate regional LV systolic dysfunction.\nModerately depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; mid anterolateral - hypo; anterior apex - hypo;\nseptal apex - hypo; lateral apex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size. Mild global RV free wall hypokinesis.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Normal aortic arch diameter.\nSimple atheroma in aortic arch. Mildly dilated descending aorta. Complex\n(>4mm) atheroma in the descending thoracic aorta.\n\nAORTIC VALVE: Three aortic valve leaflets. No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Moderate (2+) MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. No TEE related complications. The\npatient appears to be in sinus rhythm. See Conclusions for post-bypass data\nThe post-bypass study was performed while the patient was receiving vasoactive\ninfusions (see Conclusions for listing of medications).\n\nConclusions:\nPRE-BYPASS:\n1. The left atrium and right atrium are normal in cavity size. No atrial\nseptal defect is seen by 2D or color Doppler.\n2. There is mild symmetric left ventricular hypertrophy. There is moderate\nregional left ventricular systolic dysfunction with anterior, antero septal,\nanterolateral mid to apical hypokinesis. Overall left ventricular systolic\nfunction is moderately depressed (LVEF= 35-40 %).\n3. Right ventricular chamber size is normal. with mild global free wall\nhypokinesis.\n4. There are simple atheroma in the aortic arch. The descending thoracic aorta\nis mildly dilated. There are complex (>4mm) atheroma in the descending\nthoracic aorta.\n5. There are three aortic valve leaflets. There is no aortic valve stenosis.\nMild (1+) aortic regurgitation is seen.\n6. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral\nregurgitation is seen.\n\nPOST-BYPASS: For the post-bypass study, the patient was receiving vasoactive\ninfusions including epinephrine and phenylephrine.\n1. Biventricular function is improved.\n2. MR is mild to moderate with further improvement on after load reduction.\n3. Aorta is intact post decannulation.\n4. Other findings are unchanged\n\n\n" }, { "category": "Echo", "chartdate": "2136-04-22 00:00:00.000", "description": "Report", "row_id": 76945, "text": "PATIENT/TEST INFORMATION:\nIndication: pre-op CABG. Eval , valves, and function.\nHeight: (in) 69\nWeight (lb): 201\nBSA (m2): 2.07 m2\nBP (mm Hg): 131/74\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 09:48\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. Mildly depressed LVEF.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid\ninferolateral - hypo; mid anterolateral - hypo; septal apex - hypo; lateral\napex - hypo; apex - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Mild mitral\nannular calcification. Mild thickening of mitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality - body habitus. Emergency study performed by the\ncardiology fellow on call.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses and\ncavity size are normal. There is mild regional left ventricular systolic\ndysfunction with hypokinesis of the distal anteroseptum, apex, and mid to\ndistal inferolateral walls. Overall left ventricular systolic function is\nmildly depressed (LVEF= 45-50 %). Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The\nmitral valve leaflets are mildly thickened. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. There is no pericardial effusion.\n\nIMPRESSION: Mild left ventricular systolic dysfunction. Mild mitral\nregurgitation.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2136-04-24 00:00:00.000", "description": "Report", "row_id": 1637191, "text": "PROB: S/P CABG\n\nCV: SR NO ECTOPY NOTED, VSS. PACER WIRES INTACT, SENSING AND CAPTURING, AAI MODE. CHEST DRESSING CHANGED FOR MODERATE AMOUNT S/S DRAINAGE. MED FOR PAIN X1 WITH GOOD EFFECT. CT DRAINAGE MINIMAL, NO LEAK NOTED.\n\nRESP: LUNGS COARSE, DIM IN BASES. C/DB WITH ENCOURAGEMENT. CHANGED TO 3L/NP, O2 SATS 93-95%.\n\nGI: BOWEL SOUNDS ABSENT. TOLERATING ICE CHIPS.\n\nGU: ADEQUATE UOP.\n\nNEURO: ALERT AND ORIENTED X3, MAE, APPROPRIATE, PERL.\n\nENDO: INSULIN DRIP, BS DOWN TO 89 WILL SWITCH TO S/S.\n\nASSESSMENT: STABLE NIGHT, RESTING COMFORTABLY.\n\nPLAN: PULM HYGIENE.\n? TRANSFER TO FLOOR TODAY.\nMONITOR BS/LYTES/HCT-LAST K 5.6\nPAIN MED PRN\n" }, { "category": "Nursing/other", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 1637187, "text": "a paced on arrival->nsr,pacer changed to aai mode. epi weaned off for acceptable hemodynamics,rising bp with continued ci > 2. bp controlled with ntg. bs initially coarse with occasional expir. wheezes,suctioned for scant white,albuterol mdi given with improvement.cxr reveals lt. ptx,repeat pending. no air leak noted. moderate dump of dark blood with lots clots after turning from mediastinal tubes. will continue to monitor & delay waking for now.\n" }, { "category": "Nursing/other", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 1637188, "text": "failed cpap wean with resp. acidosis,lethargy. returned to rate,will attempt again.earlier ptx thought to be atelectasis by radiology.suctioned infrequently for thick yellow secretions now. ct dng in lesser amounts but remains dark,thick & clotty,team aware.occasional pvc's(unifocal)seen with 1 episode of non sustained vt. lytes repleted with significant decrease in ectopy.v wires not chacked as yet due to irritability with hypokalemia.\n" }, { "category": "Nursing/other", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 1637189, "text": "BS few wheezes, improving with MDI's; few fine crackles. Weaned to CPAP but became acidotic and placed back on SIMV. 80yr male with CABGx5.\n" }, { "category": "Nursing/other", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 1637190, "text": "ct dng resolved. extubated without incident to open face mask. cooperative with deep breathing but needs assistance with sternal splinting.pain controlled with low dose morphine.daughter in,questions answered & received icu visitor guidelines.\n" }, { "category": "ECG", "chartdate": "2136-04-23 00:00:00.000", "description": "Report", "row_id": 181950, "text": "Atrially paced rhythm with intrinsic A-V conduction as well as sinus rhythm\nwith A-V delay. Left atrial abnormality. Left axis deviation. Compared to\nthe previous tracing of there is intermittent atrially paced rhythm.\nThe T wave inversions previously recorded in leads V2-V6 persist but are\nimproved. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2136-04-21 00:00:00.000", "description": "Report", "row_id": 181951, "text": "Sinus rhythm. Borderline prolonged Q-T interval. Probable anterolateral\nmyocardial infarction. Compared to the previous tracing no definite change.\n\n" } ]

[ { "category": "Echo", "chartdate": "2161-09-06 00:00:00.000", "description": "Report", "row_id": 95257, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion. Shortness of breath. Tamponade.\nHeight: (in) 60\nWeight (lb): 140\nBSA (m2): 1.61 m2\nBP (mm Hg): 100/50\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 12:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nMITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential. No\nechocardiographic signs of tamponade. No RA or RV diastolic collapse.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - patient unable to cooperate. Emergency study performed by the\ncardiology fellow on call. Left pleural effusion.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular chamber size and free wall motion are normal. The mitral valve\nleaflets are structurally normal. Mild (1+) mitral regurgitation is seen.\nThere is a moderate sized pericardial effusion. There is borderline\naccentuated respiratory variation in tricuspid (but not mitral) valve inflows,\nbut no right atrial or right ventricular diastolic collapse is seen. There are\nno echocardiographic signs of tamponade.\n\nIMPRESSION: Suboptimal image quality. Moderate circumferential pericardial\neffusion without evidence for tamponade physiology. Normal biventricular\ncavity sizes with preserved global and regional biventricular systolic\nfunction.\n\nCompared with the prior study (images reviewed) of the effusion is\nprobably slightly larger.\n\n\n" }, { "category": "Echo", "chartdate": "2161-08-31 00:00:00.000", "description": "Report", "row_id": 95281, "text": "PATIENT/TEST INFORMATION:\nIndication: ?Pericardial effusion. SVT/VT.\nHeight: (in) 60\nWeight (lb): 135\nBSA (m2): 1.58 m2\nBP (mm Hg): 117/51\nHR (bpm): 90\nStatus: Inpatient\nDate/Time: at 14:19\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential.\nNo echocardiographic signs of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nEchocardiographic results were reviewed by telephone with the houseofficer\ncaring for the patient.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (?#) appear structurally normal with good leaflet\nexcursion. No aortic regurgitation is seen. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is mild pulmonary artery systolic hypertension. There is\na small to moderate sized echo-lucent circumferential pericardial effusion\nwithout echocardiographic signs of tamponade.\n\nIMPRESSION: Small to moderate circumferential pericardial effusion without\nevidence for tamponade physiology. Normal biventricular cavity sizes with\npreserved global and regional biventricular systolic function.\nCompared with the prior study (images reviewed) of , the pericardial\neffusion is larger.\nIf clinically indicated, serial evaluation is suggested.\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": "2161-09-06 00:00:00.000", "description": "Report", "row_id": 254672, "text": "Sinus rhythm. Premature atrial complexes. Low voltage. Possible anterior\nwall myocardial infarction of indeterminate age. Non-specific repolarization\nabnormalities. Compared to the previous tracing the rhythm is now sinus.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2161-09-06 00:00:00.000", "description": "Report", "row_id": 254673, "text": "Atrial fibrillation with rapid ventricular response. Possible anterior wall\nmyocardial infarction of indeterminate age. Non-specific repolarization\nabnormalities. Low voltage. Compared to the previous tracing the rhythm is\nnow atrial fibrillation. Otherwise, findings are similar.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2161-09-05 00:00:00.000", "description": "Report", "row_id": 254674, "text": "Sinus rhythm. Low voltage. Non-specific repolarization abnormalities.\nCompared to the previous tracing of no significant difference.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2161-09-04 00:00:00.000", "description": "Report", "row_id": 254675, "text": "Normal sinus rhythm with diffuse low voltage. Delayed R wave transition.\nCompared to the previous tracing of the ventricular ectopic activity has\ndiminished.\n\n" }, { "category": "ECG", "chartdate": "2161-08-30 00:00:00.000", "description": "Report", "row_id": 254676, "text": "Sinus tachycardia with ventricular premature beats. Low QRS voltages\nthroughout. Diffuse ST-T wave abnormalities grossly unchanged from previous\ntracing.\n\n" } ]

[ { "category": "ECG", "chartdate": "2200-02-05 00:00:00.000", "description": "Report", "row_id": 242384, "text": "Sinus rhythm. Occasional premature atrial contractions. Otherwise, no other\nsignificant diagnostic abnormality. Compared to the previous tracing of \nthere is no significant diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2200-02-03 00:00:00.000", "description": "Report", "row_id": 242385, "text": "Sinus rhythm. Normal tracing. No change compared to previous tracing.\n\n" }, { "category": "Radiology", "chartdate": "2200-02-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1230601, "text": " 2:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA, other acute?\n Admitting Diagnosis: UPPER GI BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old woman with upper GI bleed, elevated WBC\n REASON FOR THIS EXAMINATION:\n PNA, other acute?\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:32 A.M., \n\n HISTORY: Upper GI bleed, elevated white count. Suspect pneumonia.\n\n IMPRESSION:\n AP chest reviewed in the absence of prior chest radiographs:\n\n Heart size top normal. Lungs clear. No pleural effusion or pulmonary edema.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2103-09-29 00:00:00.000", "description": "Report", "row_id": 62453, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 70\nWeight (lb): 153\nBSA (m2): 1.86 m2\nBP (mm Hg): 156/79\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 09:56\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and 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. Focal calcifications in aortic root.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR. LV inflow pattern\nc/w impaired relaxation.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\n1. The left atrium is normal in size.\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.\n5. Compared with the prior study (images reviewed) of /200, the aortic\nannular calcification is better visualized.\n\n\n" }, { "category": "ECG", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 120711, "text": "Sinus tachycardia. Left atrial abnormality. A-V conduction delay.\nP-R interval 0.28. Right bundle-branch block. Compared to the previous tracing\nof no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2103-09-27 00:00:00.000", "description": "Report", "row_id": 120712, "text": "Sinus tachycardia. A-V conduction delay. Prior inferior wall myocardial\ninfarction. Left atrial abnormality. P-R interval 0.32. No diagnostic interim\nchange.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2103-09-22 00:00:00.000", "description": "Report", "row_id": 120713, "text": "Normal sinus rhythm with A-V conduction delay. Right bundle-branch block. Left\nanterior fascicular block. Possible prior inferior myocardial infarction.\nCompared to the previous tracing of no change.\n\n" }, { "category": "ECG", "chartdate": "2103-09-21 00:00:00.000", "description": "Report", "row_id": 120714, "text": "Sinus rhythm with 1st degree A-V block\nPossible right atrial abnormality\nRight bundle branch block with no left anterior fascicular block seen\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2103-09-21 00:00:00.000", "description": "Report", "row_id": 120715, "text": "Sinus rhythm. A-V conduction delay. Right bundle-branch block. Left anterior\nfascicular block.probable prior inferior wall myocardial infarction. Compared\nto the previous tracing of no diagnostic interim change.\n\n" }, { "category": "Nursing/other", "chartdate": "2103-09-23 00:00:00.000", "description": "Report", "row_id": 1382276, "text": "Nursing progress notes\n72 yr old male w/ hx of cad w/ lad , w/ right CEA, chf w/ ef 25% in , smoker, myasthenia dx 10 yrs ago w/ diplopia s/p thmectomy ' for difficulty breathing after 12 cycles of plasmapharesis, glaucoma, esophageal adenocarcinoma s/p esophagogastrectomy w/ chemo and xrt. right sided ptx x 3 in , sleep apnea w/ co2 retention on bipap at night. Admitted to 2 for egd for esophgeal stricture causing chest pressure, pylorus dilated w/ good results. no further chest pressure w/eating. pt being prepared for discharge when on am rn found pt tachypnic in 70s (sats normal) and somulent. vbg showed co2 95, hco3 >50 bipap placed w/ slow decrease in co3 and bicarb. k+ and phos low repleated on floor. sent to micu for further eval/monitoring. pt arrived alert and oriented x 3 rr60s sats on 3l nc 98% pt htn upon arrival sbp 180s\ndr. called wife tx and code status. Wife wanted pt to be DNR/DNI. Pt maintained on bipap I 15/ E 5 o2 2 liters. sats 98%\n\n\nReview of systems:\n\nNeuro: pt alert and oriented x 3, mae weakly. had been deteriorating over the last year having difficulty walking and preforming ADLs.\nneuro consult obtained.\n\nResp: pt currently on bipap I 15 E 5 o2 2 liters. ls clear but diminished throughout. sats 94-98% pcxr ~ small peripheral wedge shape opacity ? early PNA, pulmonary infarction or altelectasis.\nPt taken off of bipap for assessments and taking medication, when off of bipap rr increases to 50 bpm.\n\nCv: Tele sr-st 90-102 w/ 1 degree av block and rbbb. lytes this am K+ 3.3, mag 1.8, phos 2.5. micu intern aware and repleation orders are being written at present. hct stable 37.4. pt has ns infusing at 100cc/hr x 2500 cc. first liter up. ekg done upon transfer. pt has 2 #20 piv.\n\ngi: pt taking thin liquids and pureed solids per speech and swallow. pt took crushed pills in applesauce last night w/o difficulty except for cellcept (which cannot be crushed) he took of a pill and refused the rest of the dose d/t difficulty breathing (cellcept now changed to iv) 2 rn report no stool x 3 days, pt usally on sennakot hs at home (not ordered here). pt attempted x 2 to use the bed pan w/o results. duccolox supp ordered.\n\ngu: pt c/o bladder discomfort. pt noted to have distended bladder, pt voided 100cc w/ cont bladder discomfort. #20 foley placed w/ 640cc of pale clear yellow urine returned. at present the urine color is light pink tinged w/ no clots.\n\nskin: coccyx pink no open areas noted. pt turned side to side, kinair mattress will be needed.\n\nid: pt pos klebsiella in urine. one dose of levaquin given this evening, however neuro consult suggests we change the antibx d/t it may cause an increase in s/s of myasthenia . antibx changed to ceftriaxone\n\nsocial: pt lives w/ wife\n\ncode: dnr/dni\n\nPlan:\ncont on bipap as much as pt can tolerate.\nf/u abg ~ obtained by dr .\nrepleat lytes as ordered\nadminister colace and ducclox supp\norder kinair bed d/t stage 1 decubi\n" }, { "category": "Nursing/other", "chartdate": "2103-09-23 00:00:00.000", "description": "Report", "row_id": 1382277, "text": "Nursing progress notes\n(Continued)\ntus\nadminister pills crushed w/ applesauce.\n\n" }, { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1382294, "text": "MICU NPN\nS:\"I can't talk that much with my breathing.\"\nO: See vs/objective data per care vue. Afebrile on levoflox for klebsiella UTI.\nHr 90-110's first degree AVB, had 2 episodes of wenckebach, one with using bedpan the other while sleeping. During this rhythm he dropped his pressure to the lowest of 76. He was treated with NS bolus of 500cc X 1, with gradual increase in bp. 2nd episode bp returned to near baseline on own with no fluid bolus. BP 100-120's.\nLungs with diminished aeration due to poor effort. ^^ RR initially while on 2lnp with sats in the upper 90's. Requesting to be put on CPAP at which has remained on for rest of shift. O2 sats remain in the high 90's. No cough.\nAbd soft with good bowel sounds. Small smear of stool. Foley drng yellow urine, small amt of sediment noted. He is strict NPO, has mouth spray to aide with his dry mouth.\nCoccyx is reddened, encouraged to move from side to side and not remain on back.\nA: MG crisis > plasmaphoresis\n tolerating ^^ times off CPAP\n wenkebach with hypotension\nP: follow rhythm ? need for pacer in future\n cont to enc him to stay on his side\n have plasmaphoresis draw am labs.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-23 00:00:00.000", "description": "Report", "row_id": 1382278, "text": "This pt was transferred from to for better monitoring after episodes of tachypnea.. Pt has and uses BIPAP at home. His own machine was brought too the hospital . He has a full face mask and a humidifyed system in line. Pressures are ~ 15/ 5-6 CM\n" }, { "category": "Nursing/other", "chartdate": "2103-09-23 00:00:00.000", "description": "Report", "row_id": 1382279, "text": "micu Nurisng Progress note \n\n Neuro Pt is awake and alert following commands, Pt becomes fatigued with any activity.\n\nCv pt hempdymincally stable BP 90-120/40-60, hr 88 nsr, pulses palp bilateraly, pt repleated with 40 kcl amd 30 mmoles of k pos today, will repeat, labs this evening\n\nResp pt remains on Bipap, with short periods of being able to come off and be placed on 40% shovel mask lasting between 30-45 min off bipap, then RR ^ 30-40 and very shallow breathing, lung sounds decreaed in bases, and small crackles in , pt given albuteral updraft this afternoon and states breathing felt better, pt also given iv lasix this afternoon when u/o<100cc, with good response.\n\nGI abd soft nontender, no stool, taking small amounts of food and fluid , pt becomes soband fatigued with eating.\n\nGU pt has foley passing pink tinged urine, pt given lasix at 1300 and passed 700 cc urine\nId pt afebrile\nsocial family in today visiting with pt, all questions answered\nskin coccyx reddened no breaks in skin, trying to keep pt off coccyx as much as possible , however pt likes to be upright and on back may need to change pt to theraputic bed is resp status does not improve.\n\nA/P contiue with pul toilet, incourage po's and will need nutrional consult, ? theaputic bed follow up with labs this evening repeat lytes as needed.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-24 00:00:00.000", "description": "Report", "row_id": 1382280, "text": "MICU NPN 7P-7A\nNEURO: SLEPT MOST OF SHIFT BUT EASILY AROUSABLE. AAOX3. DENIES PAIN. MOVING ALL EXTREMITIES BUT STIFFLY.\n\nCARDIAC: HR 83-112 SR/ST WITH NO ECTOPY. BP 123-156/60-79. PPP. HCT 40, NO SIGNS OF BLEEDING.\n\nRESP: REMAINED ON BIPAP I-15, E-5 AND 2L BLEED IN OXYGEN. TOOK OFF MASK BRIEFLY FOR MED ADMNINISTRATION BUT WHEN ASKED IF HE WANTED TO TRY SHOVEL MASK HE STATED NO, THAT HE WANTED THE BIPAP BACK ON. RR 14-29 WITH SATS 96-99%. LS CLEAR WITH DIMINISHED BASES, MORE DIMINISHED ON THE RIGHT. OCCASIONAL CONGESTED NONPRODUCTIVE COUGH.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. UOP 70-500CC/HR S/P LASIX. YELLOW AND CLEAR WITH PINKISH HUE AT START OF SHIFT TO LIGHT YELLOW WITH LASIX.\n\nFEN: FLUID BALANCE NEGATIVE WITH 40MG LASIX. NO EDEMA. LYTES PER CAREVUE. EVENING K+ COVERED WITH 40MEQ KCL AND TO GIVE ANOTHER 40MEQ KCL THIS MORNING TO COVER K+3.6 AND THAT HE RECEIVED LASIX. MEDS CRUSHED IN APPLESAUCE WITH NECTAR THICK LIQUIDS. PATIENT TOOK IN VERY LITTLE PO'S.\n\nID: TMAX 97.3 AXILLARY. WBC 4.5. CONTINUES ON CEFTRIAXONE FOR KLEBSIELLA IN HIS URINE.\n\nSKIN: COCCYX DEEP PINK, INTACT. ENCOURAGING PATIENT TO LAY ON HIS SIDE BUT PREFERS TO BE ON HIS BACK.\n\nACCESS: PIV X3.\n\nSOCIAL/DISPO: DNR/DNI. NO CONTACT FROM FAMILY. PLAN TO ENCOURAGE PO INTAKE...MORE TRIALS WITH SHOVEL MASK... NEED KINAIR BED FOR COCCYX STG 1 IF PATIENT IS ADAMANT ABOUT REMAINING ON HIS BACK AND RESP STATUS DOES NOT IMPROVE...\n" }, { "category": "Nursing/other", "chartdate": "2103-09-24 00:00:00.000", "description": "Report", "row_id": 1382281, "text": "Resp Care\nPt. remains on home BIPAP set at 15/5 with 2L O2 bled in. Uneventful shift with RR 15-25bpm/SPO2 96-98%. No distress noted.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-28 00:00:00.000", "description": "Report", "row_id": 1382295, "text": "nsg 7am-7pm\nPLEASE REFER TO CAREVIEW FOR OBJECTIVE DATA\n\nPT A/OX3, SPONTENEOUS, FOLLOWS COMMANDS, DENIES PAIN, MOVES ALL EXT PURPOSEFULLY.\n\nHEART RYTHM 1ST AV BLOCK/TACHY HR 100-108/ TEAM AWARE/ EKG CHANGED NOTED AND DROP IN BP AT NIGHT OF . SERIAL CARDIAC ENZYMES ORDERED/1ST SET SENT AT NOON TIME/ NEXT SET AT / TROP 0.031/ TEAM AWARE? CARDIAC VS MUSCLE/ HX / WILL CONS CARDIO. NO ACUTE EVENT THIS SHIFT. K: 3.6/ RECEIVED 40MEQ KCL IN 500CC.\n\nLUNG SOUNDS CLEAR IN UPPER AIRWAYS AND DIMINISHED AT BASES/TACHYPNEIC RR IN 40S C/O OF DIFFICULTY BREATHING/ REMAINS ON BIPAP ALL DAY/ OFF DURING LINE PLACEMENT/ RR 20S/ SATO2 96-100%\u0013\u0013.\n\nABD SOFT POS BS, SMEAR BM/ REMAINS STRICTLY NPO/ FAILED SWALLOW STUDY ON / NUTRITION CONS/ WILL START TPN/ PICC LINE INSERTED THIS PM FOR THIS PURPOSE.\n\nFOLEY DRAINING CLEAR URINE IN ADEQUATE AMOUNT/ UOP 30-80CC/HR.\n\nSKIN W/D/I. REPOS FREQUENTLY.\n\nPICC LINE TO R ANTECUB/ BOTH PORTS PATENT/ SITE BLEEDING/ DRESSING CHANGED/ L IJ FOR PLASMAPHORESIS TO KVO/ NO HEP/ ? HIT/ R PIV PATENT.\n\nWIFE AND FRIEND THIS PM.\n\nC/O CANCELLED FOR NOW/ WILL STAY OVERNIGHT.\nMONITOR CARDIAC ENZYME\nREMAINS SCTRICTLY NPO/ START TPN.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-30 00:00:00.000", "description": "Report", "row_id": 1382300, "text": "MICU 6 Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. The day was uneventful for this very pleasant gentleman awaiting transfer to the neuro step down unit. Tolerated plasmapheresis without difficulty and is scheduled for one more treatment.\n\nCNS: Alert, oriented and cooperative. States he had a good night sleep and was anxious to get OOB. He transfers easily with one assist and would benefit from physical therapy.Visiting with wife and another relative this afternoon.\n\nRESP:Pt. off on on home bipap this AM, yet has been on nasal cannula all afternoon and tolerating it well with sats of 95-100%. Lungs with diminished breath sounds throughout...no cough or sputum.\n\nCVS: Hemodynamically stable with heart rate in the 90's with B/P 100-134/syst.\n\nGI: NPO except for meds which need to be crushed and put in thickened custard/applesauce, etc. Receiving TPN.\n\nF and E: 600cc positive as of this writing.\n\nSKIN: Duoderm to small broken down area on bridge of nose, presumably from bipap mask.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-26 00:00:00.000", "description": "Report", "row_id": 1382291, "text": "Nursing addendum note 1700:\n\nPt went down to IR @ 1545 for clearance of pheresis line. Pt had episode of V-tach, then back to SR. Pressures ^ to 220's/110's, HR in 100-110's, pt anxious and diaphoretic. Given versed by IR nurse...HR quickly decreased into 150's-160's, HR 90s. O2 sats remained in 93-99% on bipap of 15/5 and 2L O2. RR fluctuated between 20-40's. IR nurse strongly suggested pt to be given pain med/sedative prior to any procedure. Pt returned to floor @ 1645...BP 140's-160's/70's, HR 90's, NSR, rare PVCs, RR 30's, and O2 sats 97-100% on 2L O2 via NC.. pt appears to be calm, no distress noted. Plasmapheresis started @ 1700. Team notified about episode of Vtach in IR and need for medication prior to procedures d/t increased anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-27 00:00:00.000", "description": "Report", "row_id": 1382292, "text": "NURSING\n UNEVENTFUL NIGHT. SEE CARE VUE FOR FULL ASSESSMENT. VSS, AFEBRILE OVERNIGHT. NSR, NO ECTOPY NOTED. SBP 110-145.\n LUNGS CTA UPPER AIRWAYS, DECREASED BASES. BECAME SOB ON 2 L NC, PLACED ON BIPAP AT 15/5. TOLERATED WELL OVERNIGHT. O2 SATS 93-95%.\n MOVING BOWELS ON BEDPAN. FINISHED TOTAL OF 3 DOSES OF LACTULOSE FOR EVACUATION OF BARIUM. MODERATELY LOOSE STOOL OUT. POSITIVE BOWEL SOUNDS. ABDOMEN SOFT AND NON-TENDER.\n FOLEY INTACT, DRAINING CLEAR YELLOW URINE IN QS AMOUNTS.\n PHERESIS LINE LEFT IJ INTACT. DSG INTACT. COCCYX REDDENED, SKIN UNBROKEN. TURNED SIDE TO SIDE.\n NO C/O PAIN.\n CONTINUE TO MONITER RESPIRATORY STATUS. NIF TO BE CHECKED BY RESP IN AM.? DOBOFF TUBE TO BE PLACED TODAY PER RECOMMENDATION OF THORACIC TEAM FOR DECREASED PO INTAKE.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-27 00:00:00.000", "description": "Report", "row_id": 1382293, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n PLEASE SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Speach and swallow eval this pm. Called out as of this time.\n\n Neuro: Alert and oriented x 3. Speach soft, occn. difficult to understand, raspy, but is able to make needs known verbally. Moves all extrem. very weakly. Denies discomfort at this time. Temperature max. 99.4 oral.\n\n Respiratory: Lung sounds are diminished throughout. O2 saturation 95-100% on 2 liters nasal cannula. RR 12-24 and occn appears tachypneic. S&s eval this pm, failed even the applesauce. Pt is presently strict npo.\n\n CV: Sinus rhythm to sinus tachy, rate 80's to 100's. Nbp 90's to 140's systolic. Repleated with 80 meq's kcl over 8 hrs. Dressing changed lt ij.\n\n GI/GU: Abdomen soft with + bs. Strict npo. Did take multiple po's this a.m. At present pt needs peg tube, not surgical candidate as of this time. No bm this shift. Foley catheter patent and draining clear yellow urine 30-60cc/hr.\n\n Integ: Coccyx reddened, stage 1, ota. Skin grossly intact.\n\n Social: Wife in this afternoon. Also reports that face mask on bipap machine was not placed correctly o/n, caused discomfort.\n\n Plan: Plasma pheresis 3rd treatment tomm. Strict npo. Called out to floor.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-26 00:00:00.000", "description": "Report", "row_id": 1382289, "text": "Resp Care\nPt. received on Bipap 15/5 c/ 2L O2 bled in.SPo2 96-100% with RR 12-20bpm. BS: ess. clear equal bilat. dim at bases.No neb tx's overnight. Remained on Bipap entire shift with exception of 5 mins to do mechanics. NIF 10 cmH20/VC .56L. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-26 00:00:00.000", "description": "Report", "row_id": 1382290, "text": "Nursing progress note (7am-7pm):\n\nEvents..Pt to go back to IR this eve for rewiring of pheresis line. Pheresis attempted @ 1400, unable to draw back on either port.\n\nNeuro: Pt A&O x 3, following commands, MAE.\n\nResp: LS diminshed to bil. bases, slightly rhonchorous to Rt upper lobe. Clear to left apex. O2 sats in 94-100%. RR 15-30's. Pt appears Short of breath when speaking, but denies being in distress. Bipap taken off since 0830-placed on NC @ 2L. Productive cough- white/thick sputum. AM VBG 7.34/66/41/37 - pt w/ primary acidosis w/ compensatory met. alkalosis. NIFF performed by RT @ 11am = -15 (-10).\n\nCV: BP 120-150's/60-70's. no ectopy. HR 80-100, SR/ST. Pt continues on plavix, aspirin & heparin d/c'd. INR 1.2. HCT 35.5 this afternoon from 31.5.. ?dilutional HCT/? d/t esophageal CA/? d/t coagulation dysfunction. Calcium this am was 7.3..calcium redrawn this afternoon- still pnd'ing. Given 2gm of CA gluconate today. Albumin and ionized CA pending. Pt repleted w/ 30mmol of postassium phosphate.\n\nGI: abdomen soft, ND, NT. pos. BS, med-large formed BM's x 2 today, guaic neg. given 1st of 3 doses of lactulose. Pt able to make slight improvements in po intake today. Needs continuous encouragement. ? of possibility of pt getting a Dobhoff tube placement tomorrow...thoracics consulted today.\n\nGU: urine yellow w/ some sediment. Hematuria decreased today - no frank red blood seen. U/O adequate.\n\nID: pt cont. on ceftriaxone for UTI.\n\nDerm: Stage 1 ulcer to coccyx remains unchanged - skin intact, pink, no drainage. barrier cream applied. Bridge of nose pink d/t bipap machine - duoderm applied.\n\nPlan:\n *monitor resp and hemodynamic status.\n *Plasma central line rewired in IR today.\n *monitor labs, serial VBGs, HCT Q6H\n *? dobhoff tube placement tomorrow\n *Cont. w/ plasmapheresis Q other day.\n *Cont. w/ BiPap w/ trials periods off.\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2103-09-29 00:00:00.000", "description": "Report", "row_id": 1382296, "text": "EDT NURSING PROGRESS NOTES 1900-0700.\nREVIEW CAREVUE FOR ALL OBJECIVE DATA.\n\nNEURO: ALERT, ORIENTED X3, FOLLOWING COMMANDDS. MILD GENERALIZED WEAKNESS.DENIES ANY PAIN.\n\nRESP: WAS ON BIPAP ALL THROUGHT OUT THE DAY. LS CLEAR AND DIMINISHED AT THE BASE. O2 SATS >95%.\n\nCVS: 1ST DEGREE HEART BLOCK AND OCCASIONAL ECTOPY NOTED. NO COMPLAINTS OF CHEST PAIN. CARDIAC ENZYMES ELEVATED AND ECHO TODAY.\n\nGU/GI: ABD SOFT,BS PRESENT, NPO. TPN STARTED. GOOD URINE OUT PUT VIA .\n\nAFEBRILE.\nSOCIAL: NO TELEPHONE CALLS\nPLAN: ? CALL OUT TODAY?. ? CONTINUE PLASMAPHORESIS TODAY. CONTINUE TPN\n" }, { "category": "Nursing/other", "chartdate": "2103-09-29 00:00:00.000", "description": "Report", "row_id": 1382297, "text": "NPN 0700-1900\n Pt A&O x 3. MAEs in bed well. Transferred to chair with assist of 1 to stand and pivot. OOB most of day. Failed swallow study and has been NPO, however HO wants pt to receive po meds. Swalled them with small amt of custard.\n On 4lnc since this am, was on Bipap overnight. Sats 96-98% and RR in low 30s. Exertional SOB. Lungs clear with markedly diminished bases. Weak cough. Able to use yankuer to clear oral secretions.\n SR with 1st degree AV block, no ectopy. Cardiac ECHO done this am, results pending. Afebrile. TPN infusing via PICC. KVO fluids infusing through both Quinton ports.\n Abd soft with +BS. Mod BM, semiformed. Foley patent with good UO.\n\n Pt to receive 2 more plasmapheresis treatments this week. Once completed will need surigical intervention for permanent feeding tube placement. PT consult oredered. Pt OOB to chair today but would benefit from ambulating as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-30 00:00:00.000", "description": "Report", "row_id": 1382298, "text": "Respiratory care:\nPatient wearing bipap overnight. Patient using his own machine with preset settings of 15/5 and 3l bleed in. Breathsounds are decreased at bases. Patient looking comfortable overnight. Please see respiratory section of carevue for further data.\nPlan: Patient to wear his own bipap @ night.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-30 00:00:00.000", "description": "Report", "row_id": 1382299, "text": "MICU NPN 1900-0700\nUneventful shift\n\nReview of Systems:\n\nCV: Remains in 1 degree AV block. No c/o CP, SOB. BP has been in the 90's-100's.\n\nResp: Maintained on pt's own bipap machine for the entire shift. LS diminished throughout. O2 sats maintained above 90%.\n\nGI: No po's this shift. Pt only to receive pills/meds po in small amt of soft solid. Aspiration precautions. +BS, no BM this shift. Receiving TPN.\n\nGU: Adequate amts of urine output via foley.\n\nNeuro: Alert and oriented. Slept well all night.\n\nIV: PICC placed on the 29th. Noted to be leaking at insertion site. Re-dressed, and has just a small amt of blood at site presently. Pheresis line intact.\n\nDispo: Initially called out to step down unit, but no bed availability. Call out note will need to be updated.\n\nPlan: Needs to complete 2 more sessions of plasma pheresis. Plan is then to assess pt for J-tube.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-25 00:00:00.000", "description": "Report", "row_id": 1382285, "text": "Nursing progress note (7am-7pm):\n\nEvents..Pt off bipap machine since 0900 AM - pt tolerating NC @ 2L, RR 20's-30's, O2 sats 94-100%. Pt subjectively denies being in distress, but pt is tachypnic at times and is mouth breathing. Bolused w/ 500cc NS x 1 this shift for HR in low 100's, BP remains in the 120's-150's/60-70's. Abdominal Xray done this afternoon - ? of old contrast dye logged in esophagus. Nutrition consult today - pt scheduled for PEG tube placement for Tube feeds -to be done at earliest tomorrow.\n\nNeuro: Pt alert and oriented X 3..following commands. Pt MAE.\n\nResp: LS clear throughout, diminshed to RLL. NIFF performed by RT this afternoon = 10 (-19). Pt tachypnic at times, RR 15-30's. No distress noted.\n\nCV: NSR/SR, no ectopy. HR 90's-100's. HCT 39.4. PPP bilaterally. P-boots on. Potassium repleted this morning for K of 3.5. Pt remains on NS IVF @ 75/hr. Bolused x 1 as stated above for tachycardia.\n\nGI: Abdomen soft, ND, NT. Hypoactive BS. Pt able to increase po's, but only small amounts. Pt to receive PEG tube as stated above for poor nutritional intake. No BM. Given 30ml X 1 of MOM today.\n\nGU: Urine output adequate. Urine yellow w/ pinkish hue...UA and UC sent this morning. UA + for large amts. of blood, neg for leukocytes and nitrites. (team aware). UC pending.\n\nID: Pt continues on ceftriaxone for UTI...pt on 3rd day out of 7. PT afebrile. WBC 13.6.\n\nDerm: Stage 1 ulcer on coccyx remains unchanged- pink, no drainage, duoderm applied. Reddness to bridge of nose...pink, skin intact, no drainage - duoderm applied.\n\nSocial: wife in for visit this afternoon.\n\nCode status: DNR/DNI\n\nPlan: Cont w/ BIPAP w/ trials off as tolerated.\n Monitor VBGs Q day.\n Cont w/ ceftriaxone for tx of UTI.\n Cont w/ NIFFs by RT\n Encourage po's.\n ? PEG tube placement tomorrow.\n cont. w/ bowel regimine.\n\n" }, { "category": "Nursing/other", "chartdate": "2103-09-25 00:00:00.000", "description": "Report", "row_id": 1382286, "text": "Nursing progress note addendum 1700:\n\nPt back on BIPAP machine. Pt tachypnic - RR 30-38. VSS. HR 80's, BP 140's/70's. O2 sats 98%. BIPAP settings to be changed by RT to w/ O2 leak at 2L (from 15/5 with 2L O2)...RT . Pt resting comfortably. No signs of distress noted.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-25 00:00:00.000", "description": "Report", "row_id": 1382287, "text": "Nursing progress note addendum 1800:\n\nPt to remain on BIPAP settings of 15/5 w/ O2 leak of 2L. Previous orders of w/ 2L changed back to original settings by Dr. .\n" }, { "category": "Nursing/other", "chartdate": "2103-09-26 00:00:00.000", "description": "Report", "row_id": 1382288, "text": "Uneventful shift for Mr .\n\nNeuro: A+O, slept throughout night, no c/o pain, following commands consistently.\n\nResp: Lung sounds clear in apices diminished in bases. Remained on bipap 15/5 throughout shift. AM VBG showing continued hypercarbia. O2 sats mid 90's.\n\nCardiac: No fluid boluses required to maintain b/p this shift. HR 90's-100 with no ectopy. B/P 110's/60's.\n\nGI: Abd soft/nontender, no bm this shift. To start lactulose this am. go for PEG placement today. positive bowel sounds.\n\nGU: voiding approx 100cc/hr amber urine. BUN 3 Cr 0.4 K 3.4 IVF NS continues at 75cc/hr.\n\nDerm: Pheresis line in LIJ benign, piv x2 in Larm patent, Buttocks with some redness, duoderm intact. Pt tends to refuse positioning, preferring to stay on back for extended periods. Curently on L side however.\n\nPlan: be called out to floor after rounds, monitor hemodynamic and resp status, peg placement.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-24 00:00:00.000", "description": "Report", "row_id": 1382282, "text": "Respiratory Care Note:\n Patient continues on BIPAP of 15/5 with 2lpm O2 bleed in. He went to IR today for line placement and now he is receiving plasmaphoresis. BS bilat are diminished with scattered rhonchi. His cough is weak and non-productive. Plan to reassess post tx for possible NT suctioning.\n" }, { "category": "Nursing/other", "chartdate": "2103-09-24 00:00:00.000", "description": "Report", "row_id": 1382283, "text": "Nursing progress note: (7am-7pm):\n\nEvents... Pt hypotensive this am - sbp 77-84. IV fluid bolused w/ 500cc NS bolus w/ fair improvement. Required additional 1L NS bolus - sbp inc. into 100-150's. Pt able to tolerate BIPAP off for 30 min early this morning to take meds and to drink approx 90cc of nectar thick ensure. Pt later tolerated 1 hour w/o bipap and on FT @ 9L O2 - pt's RR inc. into 50's and HR inc. into 100's - pt requesting to be put back on the bipap. O2 sats remain in the 98-100%. Pt gone down to IR this afternoon for plasmapheresis Left IJ line placement. Pheresis line placed w/ much difficulty - IR attempted right IJ first w/o success, then placed left IJ successfully. Pt returned to floor w/in 90min...plasmapheresis started @ 1730.\n\nNeuro: Pt A&O x 3. Pt anxious at times. Pt able to MAE, but a bit stiff. PERRLA.\n\nResp: LS clear throughout and diminished to bilateral bases. O2 sats 98-100% on both bipap of 15/5 w/ 2L O2 bleed and on FT w/ O2 @ 9L. Pt RR increases into 40-50's w/ FT on after about 30min time period. Pt using accessory muscles. ABG line placement attempted today w/o success.\n\nCV: BP 70-180's/50-40's, HR 70-100's. SR/ST. No ectopy. Pt IVF bolused this am as stated above. PPP bilaterally, P-boots on. HOB kept >30 degrees for respiratory efforts.\n\nGI: abdomen soft, ND, NT. BS present. Positive rectal flatus. Pt on nectar thick regular diet, meds crushed in applesauce. Pt on aspiration precautions. No BM.\n\nGU: Pt voiding yellow blood tinged urine this am - now voiding amber colored urine this afternoon via foley cath. U/O adequate.\n\nDerm: Pt has pink stage 1 to coccyx - duoderm applied. Pt's bridge of nose irritated by the BIPAP mask..skin pink and intact - applied duoderm.\n\nID: UA positive for klebsiella- Pt on ceftriaxone.\n\nsocial: pt's wife this afternoon.\n\nAccess: PIV to Left forearm and PIV to Right hand. Left IJ pheresis line.\n\nCode status: DNR/DNI. Pt stated he does not wish to be intubated for any period of time nor does he wish to be resusitated.\n\nPlan: * cont. to monitor pt's resp status.\n * ? Arterial line placement.\n * Cont to monitor hemodynamic status.\n * Encourage po's.\n\n" }, { "category": "Nursing/other", "chartdate": "2103-09-25 00:00:00.000", "description": "Report", "row_id": 1382284, "text": "Events: Largely uneventful shift. One episode of hypotension with systolic b/p dropping as low as 70. Bolused with 1L ns with resolution.\n\nNeuro: Alert/oriented and cooperative with care. Following commands consistently. No c/o pain.\n\nResp: Lung sounds very coarse and rhonchorous at times. NTS at beginning of shift only produced small amount of thick white sputum. Remained on Bipap throughout night. Pt did not tolerate being off bipap for more than a couple of minutes before becomming subjectively short of breath with RR increasing to 40's. ABG showing adequate perfusion but CO2 levels remain high. (see carevue for data). Bipap settings unchanged this shift. NiF done this am -19. Pt with very poor respiratory effort. Pt will get NiF studies qshift.\n\nCardiac: SR-ST 90-100's with no ectopy throughout night. Aforementioned hypotensive episode relieved with 1L ns bolus. B/P's currently 121/76.\n\nGI: Abd soft/nontender with positive bowel sounds. No BM this shift.\n\nGU: Voiding 40-10cc/hr amber urine. BUN 8 Cr 0.5 K3.7 Mg 1.7 Started on maintenance fluids NS at 75cc/hr\n\nID: Afebrile\n\nDerm: Stage one ulcer on coxxyx remains pink with no break in skin. Duoderm reapplied. PIV patent x2 Pheresis line in RIJ with clot at insertion site. DSG changed. Pt also with developing ulceration on nose from bipap mask. covered with duoderm.\n\nPlan: Monitor hemodynamic status and bolus prn. Negative Inspiratory Flow readings q shift. Replete electrolytes, monitor CO2 levels, skin care, increase po inkake.\n" }, { "category": "Radiology", "chartdate": "2103-10-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 930375, "text": " 8:00 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval change\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with myasthenia , respiratory difficulty.\n\n REASON FOR THIS EXAMINATION:\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: 72-year-old man with history of myasthenia .\n\n COMPARISON: .\n\n FINDINGS: Since prior examination, the right-sided central venous catheter\n has been advanced with its tip projecting over the cavoatrial junction. Stable\n appearance of the left-sided central venous catheter with its tip projecting\n over the right atrium. No other significant changes. Again noted the trachea\n is displaced to the left, probably due to postoperative changes. Stable\n appearance of the sternotomy wires. No other significant change.\n\n IMPRESSION: Interval repositioning of the right-sided PICC line with its tip\n projecting over the cavoatrial junction.\n\n" }, { "category": "Radiology", "chartdate": "2103-10-01 00:00:00.000", "description": "PERIPHERAL W/O PORT", "row_id": 929945, "text": " 7:32 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please advance PICC centrally or replace as needed. THanks\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ********************************* CPT Codes ********************************\n * PERIPHERAL W/O PORT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with myasthenia with SOB and inability to tolerate PO.\n PICC line apparently slid out of place and is no longer central.\n REASON FOR THIS EXAMINATION:\n Please advance PICC centrally or replace as needed. THanks\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with myasthenia and shortness of breath.\n Inability to tolerate p.o. feed. PICC line slide out.\n\n RADIOLOGISTS: Dr. , Dr. , the attending\n radiologist who was present and supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography table.\n Right upper arm was prepped and draped in usual sterile fashion. Previously\n placed catheter was identified with the tip terminating in subclavian\n vein. Outer sheath of the peel-away sheath was inserted over the \n catheter, and pre-existing catheter was removed. New 5 French\n double-lumen catheter was inserted through the peel-away sheath, with\n the tip terminating in distal SVC. Peel-away sheath was removed, and the line\n was flushed, capped, and secured by two statlocks. Final fluoroscopic image\n was obtained to confirm the location of the line. There was no immediate\n complication. The line is ready for use.\n\n IMPRESSION: Successful exchange of the 5 French double lumen \n catheter over the sheath with the tip terminating in distal SVC. The line is\n ready for use.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-25 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 929288, "text": " 3:21 PM\n PORTABLE ABDOMEN Clip # \n Reason: evaluate for retained barium\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with recent barium swallow\n REASON FOR THIS EXAMINATION:\n evaluate for retained barium\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with recent barium swallow, evaluate for retained\n barium.\n\n COMPARISON: .\n\n SINGLE VIEW OF THE ABDOMEN: Retained contrast is noted throughout the colon\n and rectum. Nonspecific bowel gas pattern is seen with gas within several\n loops of small bowel. No evidence of obstruction, however. Median sternotomy\n wires seen overlying the chest.\n\n IMPRESSION: Progression of barium, with retained contrast now noted\n throughout the colon and rectum. Nonspecific bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2103-09-24 00:00:00.000", "description": "NON-TUNNELED", "row_id": 929138, "text": " 12:40 PM\n PHERESIS CATHETER PLMT Clip # \n Reason: please place pheresis catheter for plasmapheresis\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1752 CATH,HEM/PERTI DIALYSIS SHORT *\n * C1769 GUID WIRES INCL INF C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with myasthenia , w/ acute exacerbation\n REASON FOR THIS EXAMINATION:\n please place pheresis catheter for plasmapheresis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR EXAM: 72-year-old man with myasthenia that needs\n pheresis catheter for plasmapheresis.\n\n RADIOLOGISTS: The procedure was performed by Drs. and , the\n attending radiologist who was present and supervising throughout the\n procedure.\n\n PROCEDURE AND FINDINGS: After informed consent was obtained from the patient,\n the patient was placed supine on the angiographic table. The right and the\n left neck were prepped and draped in standard sterile fashion. Using\n ultrasonographic guidance and after injection of 1% lidocaine for local\n anesthetic, the right IJ was accessed and a 0.018 guide wire was then\n advanced. Since this access was too tortuous and we could not advance the\n wire into the SVC, it was decided to access the left internal jugular vein.\n The left internal jugular vein was accessed with ultrasonographic guidance\n using a 19- gauge needle and after injection of 1% lidocaine for local\n anesthetic. Hard copy ultrasound images were obtained before and after\n venous access documenting vessel patency. A 0.018 guide wire was then advanced\n into the distal part of the SVC, using roadmap injection of contrast for\n guidance. The needle was then exchanged for a 4 French micropuncture sheath.\n It was decided that a catheter length of 20 cm would be suitable for\n placement. A J- tipped wire was then was then advanced under fluoroscopic\n guidance into the inferior vena cava. The percutaneous tract was then dilated\n with 8,12, and 14 French dilators. A double-lumen pheresiscatheter was then\n placed over the wire under fluoroscopic guidance into the distal part of the\n SVC. Both lumens were flushed, heplocked. The catheter was secured to the skin\n with 0 silk sutures and a transparent dressing was applied.\n\n Final fluoroscopic image of the chest demonstrates the tip of the catheter to\n be located in the distal part of the SVC. The patient tolerated the procedure\n well with no immediate complications.\n\n IMPRESSION: Successful placement of a 14.5 French 20-cm pheresis catheter via\n the left internal jugular vein with tip in the distal part of the SVC. The\n catheter is ready for use.\n (Over)\n\n 12:40 PM\n PHERESIS CATHETER PLMT Clip # \n Reason: please place pheresis catheter for plasmapheresis\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 929916, "text": " 10:25 PM\n CHEST (PORTABLE AP) Clip # \n Reason: line placement\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with disruption of PICC line.\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with PICC line placement.\n\n COMPARISONS: Comparison is made to .\n\n TECHNIQUE: AP upright single view of the chest.\n\n FINDINGS: There is a left IJ dialysis catheter with the tip in the right\n atrium. There is interval placement of a right-sided PICC line with the tip\n in the right subclavian vein. The patient is status post median sternotomy and\n resection of the esophagus with gastric pull through which contains residual\n barium. There is bilateral pleural thickening with blunting of the\n costophrenic angles which appears to be a chronic finding. There is thickening\n of the right minor fissure. Otherwise the lung fields remain unchanged without\n evidence of new focal consolidation.\n\n IMPRESSION:\n 1. Right-sided PICC line tip is in the right subclavian vein.\n 2. Otherwise normal postoperative appeareance of the chest.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-28 00:00:00.000", "description": "REPOSITION CATHETER", "row_id": 929675, "text": " 1:12 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: Needs urgent PICC for IVF and TPN.\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ********************************* CPT Codes ********************************\n * REPOSITION CATHETER FLUORO 1 HR W/RADIOLOGIST *\n * C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with myasthenia with SOB and inability to tolerate PO.\n REASON FOR THIS EXAMINATION:\n Needs urgent PICC for IVF and TPN.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old male with myasthenia , shortness of breath and\n inability to tolerate p.o.\n\n RADIOLOGISTS: Drs. , Dr. , the attending\n radiologist, who was present throughout the procedure.\n\n PROCEDURE AND FINDINGS: The patient was brought to the angiography table.\n Left upper arm was prepped and draped in usual sterile fashion. Wire was\n inserted from the pre-existing peripheral venous access, exchanged with peel-\n away sheath. 5-French double lumen catheter was inserted over the\n peel-away sheath, with the tip terminating in distal SVC. Peel-away sheath\n was removed, and stylet was removed. The line was flushed, statlocked and\n capped. The final fluoroscopic image was obtained to confirm the position of\n the line is terminating in distal SVC. There was no immediate complication.\n The line is ready for use.\n\n IMPRESSION: Successful placement of 5-French catheter with the tip\n terminating in distal SVC. The line is ready for use.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-10-02 00:00:00.000", "description": "R UNILAT UP EXT VEINS US RIGHT", "row_id": 930081, "text": " 9:56 AM\n UNILAT UP EXT VEINS US RIGHT Clip # \n Reason: ? DVT\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with RUE PICC line and new R arm swelling.\n REASON FOR THIS EXAMINATION:\n ? DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with right upper extremity PICC line placement\n and new right arm swelling. Question DVT.\n\n No comparison studies.\n\n RIGHT UPPER EXTREMITY VENOUS ULTRASOUND:\n\n Grayscale and Doppler son of the right internal jugular, subclavian,\n axillary, brachial, and basilic veins were performed. Normal compressibility,\n augmentation, flow and waveforms were demonstrated. There is no evidence of\n intraluminal thrombus. The PICC line and right cephalic vein are not\n visualized.\n\n IMPRESSION:\n\n No evidence of DVT. Nonvizualization of PICC line and cephalic vein.\n\n" }, { "category": "Radiology", "chartdate": "2103-09-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 928953, "text": " 8:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Respitory distress\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p esophageal dilation, CO2 retainer who refused CPAP machine\n last night now with SOB\n REASON FOR THIS EXAMINATION:\n Respitory distress\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 9:10 A.M.\n\n HISTORY: CO2 retainer in respiratory distress.\n\n COMPARISON: Most recent chest x-ray dated . Patient has undergone\n multiple recently acquired chest CTs, the most recent dated .\n\n FINDINGS: Improved aeration of both lungs and in particular the right middle\n lobe with resolved atelectasis. However, there has been interval development\n of a peripheral based opacity in the lateral aspects of the right upper lobe\n with a somewhat wedge-shaped configuration. Contrast and lucency is noted\n over the mediastinum likely secondary to esophagectomy and gastric pull-\n through. Median sternotomy wires are evident and aligned in the midline.\n There has been interval removal of a left internal jugular approach central\n venous catheter. Currently, no support lines are identified. There is\n blunting of the left costophrenic angle likely due to a small effusion. No\n pleural thickening is noted in the left apex.\n\n IMPRESSION:\n\n 1. Small peripheral wedge-shaped opacity. Differential diagnostic\n considerations include focus of early pneumonia, pulmonary infarction, or\n atelectasis. No pneumonia is seen.\n\n 2. Postoperative changes as detailed above.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2103-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 929639, "text": " 9:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrates\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with esoph. stricture s/p dilation, MG, with witnessed\n aspiration\n REASON FOR THIS EXAMINATION:\n please eval for infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 72-year-old man with esophageal stricture status post dilatation\n with witnessed aspiration, evaluate for infiltrate.\n\n CHEST PORTABLE: Comparison is made to a prior study of . The heart\n size is in the upper limits of normal. The mediastinal and hilar contours are\n unremarkable. The pulmonary vasculature is normal. A previously noted\n opacity in the right lung adjacent to the chest wall has resolved. There are\n no new opacities. A central venous line is seen with its tip in the right\n atrium. There is barium in the colon and possibly in the esophagus.\n\n IMPRESSION:\n\n 1. No definite evidence for aspiration. No new infiltrates in comparison to\n the prior study.\n\n 2. The previously noted opacity in the right lung has resolved.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-09-18 00:00:00.000", "description": "BAS/UGI AIR/SBFT", "row_id": 928496, "text": " 4:01 PM\n BAS/UGI AIR/SBFT Clip # \n Reason: Want to see gastric emptying time.\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p lap esophagogastrectomy p/w difficulty breathing and\n constant chest pressure and now s/p ballooning of the pylorus\n REASON FOR THIS EXAMINATION:\n Want to see gastric emptying time.\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE-CONTRAST UPPER GI STUDY:\n\n INDICATION: 72-year-old man status post esophagectomy with gastric pull-\n through in , presenting with difficulty breathing, constant chest\n pressure, status post ballooning of the pylorus. Evaluate gastric emptying\n time.\n\n COMPARISON: Upper GI series .\n\n FINDINGS: The exam was conducted following administration of thick barium.\n Contrast flows freely through the esophagogastric junction. Approximately\n two-thirds of the stomach is located above the diaphragm. Contrast flows\n freely through the stomach and empties promptly into the duodenum within\n several minutes. Stomach distends normally. The duodenal bulb, and loop are\n unremarkable.\n\n IMPRESSION: Status post esophagectomy with gastric pull-through. Free flow\n of the contrast through the esophagogastric anastomosis and into the stomach,\n with prompt emptying into the duodenum.\n\n" }, { "category": "Radiology", "chartdate": "2103-09-26 00:00:00.000", "description": "CENTRAL NON-TUNNELED", "row_id": 929423, "text": " 3:20 PM\n PHERESIS CATHETER CHECK/REPOS Clip # \n Reason: replacement of plasmapheresis line\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n Contrast: OPTIRAY Amt: 10\n ********************************* CPT Codes ********************************\n * CENTRAL NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1769 GUID WIRES INCL INF *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man with myasthenia , w/ acute exacerbation\n\n REASON FOR THIS EXAMINATION:\n replacement of plasmapheresis line\n ______________________________________________________________________________\n FINAL REPORT\n\n\n\n\n\n\n\n INDICATION: 72-year-old male with myasthenia , acute exacerbation.\n Replacement of plasmapheresis line.\n\n RADIOLOGISTS: Drs. , and , the attending\n radiologist who was present and supervising throughout the procedure.\n\n PROCEDURE/FINDINGS: The risks and benefits of the procedure were explained to\n the patient, and written informed consent was obtained. The patient was\n placed supine on angiography table. Left neck including the area of\n plasmapheresis line insertion site was prepped and draped in usual sterile\n fashion. Fluoroscopic image demonstrated a 14.5 French pheresis catheter via\n left internal jugular vein with the tip terminating in distal SVC. Short\n wire was inserted into the patent lumen of the catheter into IVC, and\n the catheter was exchanged with a new 14.5 French 20-cm double-lumen pheresis\n catheter over the wire under fluoroscopic guidance, with the tip terminating\n in distal SVC. The wire was removed, and both lumens were flushed, heplocked.\n The catheter was secured to the skin with 0 silk sutures and transparent\n dressing was applied. A final fluoroscopic image of the chest was obtained to\n demonstrate the location of the catheter. The patient tolerated the procedure\n well without immediate complication.\n\n IMPRESSION: Successful placement of a 14.5 French 20-cm phoresis catheter via\n left internal jugular vein with the tip terminating in distal SVC. The\n catheter is ready for use.\n (Over)\n\n 3:20 PM\n PHERESIS CATHETER CHECK/REPOS Clip # \n Reason: replacement of plasmapheresis line\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n Contrast: OPTIRAY Amt: 10\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2103-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 929015, "text": " 7:19 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pna, failure\n Admitting Diagnosis: ESOPHAGEAL STRICTURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 72 year old man s/p esophageal dilation, CO2 retainer who refused CPAP machine\n last night now with SOB\n REASON FOR THIS EXAMINATION:\n eval for pna, failure\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST, AT 0730 HOURS.\n\n HISTORY: Shortness of breath. CO2 retainer.\n\n COMPARISON: Multiple priors, most recent dated .\n\n FINDINGS: Post-surgical changes consistent with prior esophagectomy and\n gastric pull-through are again evident. Residual contrast is noted within the\n gastrointestinal tract. There is a stable indistinct peripheral opacity\n laterally in the mid right lung. No new consolidation is seen. There is no\n superimposed edema. Cardiac silhouette is within normal limits for size.\n There is no effusion or pneumothorax.\n\n IMPRESSION: Persisting vague indistinct peripheral opacity in the right lung\n as above. Diagnostic considerations continue to include atelectasis, an early\n focus of pneumonia, or (less likely) pulmonary infarction.\n\n\n DR. \n" } ]

[ { "category": "Radiology", "chartdate": "2111-01-27 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 1224015, "text": " 4:13 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: mass?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hemoptysis\n REASON FOR THIS EXAMINATION:\n mass?\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KKgc 8:59 AM\n 1. No pulmonary masses seen.\n 2. Diffuse airways wall thickening may represent acute tracheobronchitis.\n Borderline enlarged mediastinal nodes.\n 3. Aortic stenosis. Extensive coronary , mitral and aortic annular\n calcifications.\n 4. Moderate hiatal hernia. diffuse dilation of the thoracic esophagus, may\n suggest achalasia. Mild thickening of the distal esophageal wall. Needs\n further evaluation with UGI scopy and an esophagram. Hyperdense gastric\n contents may represent ingested blood.\n 5. 2.4 cm right adrenal nodule and 2.2 cm right upper pole renal lesion are\n not characterized in this study. An MRI can be obatined for further evaluation\n of both. Gallstones, likely left renal cyst. Wedge compression of a lower\n thoracic vertebral body, stable since 8/.\n WET READ VERSION #1 KKgc 5:58 AM\n No pulmonary masses seen. Small airways disease. Borderline enlarged\n mediastinal nodes. Extensive coronary , mitral and aortic annular\n calcifications. Moderate hiatal hernia. Gallstones, likely left renal cyst.\n Wedge compression of a lower thoracic vertebral body, stable since 8/.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 82-year-old man with hemoptysis, to rule out pulmonary mass.\n\n COMPARISON: None available.\n\n TECHNIQUE: MDCT helical images were acquired through the chest without\n intravenous contrast. Sagittal and coronal reformats were generated and\n reviewed.\n\n FINDINGS: There is diffuse wall thickening of the trachea, bronchi and smaller\n airways. No obstructing mass lesions are identified. Minimal secretions are\n seen within the distal trachea. The lungs are well expanded and clear without\n consolidation or concerning pulmonary nodules. A tiny calcified granuloma is\n seen in the right lower lobe (4:184). Prominent mediastinal lymph nodes\n measuring up to 10 mm in the pretracheal regions are noted (2:21). There are\n no pleural effusions or pneumothorax.\n\n Extensive atherosclerotic calcification is seen within the thoracic aorta,\n without aneurysmal dilation. There is no pericardial effusion. Extensive\n coronary arterial calcification is present. Also seen is extensive\n calcification in the mitral annulus and more hemodynamically in the aortic\n valve, likely resulting in aortic stenosis. The main pulmonary artery is\n (Over)\n\n 4:13 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: mass?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n mildly enlarged measuring 3.3 cm, suggesting pulmonary arterial hypertension.\n\n There is diffuse moderate dilation of the thoracic esophagus extending from\n the level of the thoracic inlet down to the esophageal hiatus, just above\n which the lumen is obliterated, making it impossible to exclude mass.\n Retained food material is seen in the distal esophagus. Mild thickening of\n the lower esophageal wall (2:34), could be secondary to esophagitis. Etiology\n of the diffuse dilation of the esophagus is unclear, could be secondary to\n achalasia. The stomach is distended with food material and hyperdense\n contents. Given the clinical concern, this could represent ingested blood.\n\n This study is not tailored for evaluation of the subdiaphragmatic organs.\n Within this limitation, the imaged upper abdomen demonstrates multiple\n gallstones within a decompressed gallbladder. A 2.4-cm right adrenal nodule\n is not fully characterized in this study. A 6.1-cm hypodense lesion adjacent\n to the left kidney, likely represents simple left renal cortical cyst. A 2.2\n cm right upper pole exophytic renal lesion is not fully imaged in this study.\n\n BONES AND SOFT TISSUES: No bone lesions suspicious for infection or\n malignancy are detected. Moderate degenerative changes are seen in the\n thoracic spine. Mild wedge compression of a lower thoracic vertebral body, is\n stable since /.\n\n IMPRESSION:\n 1. No pulmonary or airway mass. Diffuse thickening of the bronchial and\n bronchial wall, may represent tracheobronchitis. A bronchoscopy can be\n performed for further evaluation.\n 2. Extensive calcification of the coronary arteries and mitral and aortic\n annulus, with resultant aortic stenosis.\n 4. Distention of the thoracic esophagus, could be secondary to achalasia.\n Mild thickening of the distal esophageal wall may be secondary to esophagitis,\n and lower esophageal mass is not excluded by this study. Needs further\n evaluation with Upper GI endoscopy and/or esophagram\n 5. Hyperdense contents in the distal esophagus and stomach may be due to\n ingested blood.\n 6. A 2.4 cm right adrenal nodule and 2.2 cm right upper pole renal lesion are\n not characterized in this study. MRI recommended for further evaluation of\n both.\n\n The above findings were discussed with Dr. at 8: 45 A.M on\n .\n (Over)\n\n 4:13 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: mass?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2111-01-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1224016, "text": " 4:19 AM\n CHEST (PA & LAT) Clip # \n Reason: mass?\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with hemoptysis\n REASON FOR THIS EXAMINATION:\n mass?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Hemoptysis.\n\n PA and lateral upright chest radiographs were reviewed in comparison to , .\n\n Cardiomegaly is unchanged. Tortuous aorta is redemonstrated, with suspected\n dilatation. There is more fullness at the level of the hiatus seen on the\n lateral view as compared to prior examinations, obtained on ,\n reflecting large hiatal hernia. For precise details, please review CT of the\n chest obtained the same day and the corresponding report.\n\n" }, { "category": "Radiology", "chartdate": "2111-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1224145, "text": " 6:23 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: OG tube placement\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man in MICU with GIB, intubated and ventilated now s/p OG tube\n placement\n REASON FOR THIS EXAMINATION:\n OG tube placement\n ______________________________________________________________________________\n WET READ: ASpf 10:59 PM\n OG tube in stomach. ET tube in mid thoracic trachea. Low lung volumes possible\n left lower lobe atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: GI bleed. Intubated with new OG placement.\n\n COMPARISON: Chest radiograph at 8:42.\n\n FINDINGS: An endotracheal tube ends approximately 5 cm from the carina. An\n OG tube ends in the stomach. A retrocardiac opacity is likely the known\n hiatal hernia. Lung volumes are low, accentuating the bronchovascular\n structures. There is no definite edema. A small left pleural effusion and\n left basilar atelectasis is unchanged. There is no pneumothorax. Mild\n enlargement of the cardiomediastinal silhouette is stable.\n\n IMPRESSION:\n 1. OG tube in the stomach.\n 2. Stable small left pleural effusion and associated atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2111-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1224048, "text": " 8:42 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ET tube + NG placment\n Admitting Diagnosis: HEMOPTYSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 82 year old man with UGIB now s/p intubation\n REASON FOR THIS EXAMINATION:\n ET tube + NG placment\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of the patient with upper gastrointestinal\n bleeding.\n\n Portable AP radiograph of the chest was compared to prior study obtained the\n same day earlier.\n\n The ET tube tip is 5.4 cm above the carina. The NG tube tip passes below the\n diaphragm terminating in the stomach. Heart size and mediastinum are\n unchanged. Left retrocardiac opacity most likely reflects known hiatal\n hernia. There is no pneumothorax. Small amount of left pleural effusion and\n left basal minimal atelectasis are most likely present.\n\n\n" }, { "category": "ECG", "chartdate": "2111-01-27 00:00:00.000", "description": "Report", "row_id": 154375, "text": "Atrial fibrillation with moderate ventricular response. Compared to\ntracing #1 limb lead reversal has been corrected. Otherwise, no other\nsignificant diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-01-27 00:00:00.000", "description": "Report", "row_id": 154376, "text": "Limb lead reversal. Atrial fibrillation with moderate ventricular response.\nLeft axis deviation with left anterior fascicular block. Poor R wave\nprogression. Intraventricular conduction delay. Compared to the previous\ntracing of heart rate is significantly faster. Clinical correlation is\nsuggested.\nTRACING #1\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2149-06-05 00:00:00.000", "description": "Report", "row_id": 1339244, "text": "64 YR. OLD SPANISH SPEAKING WOMAN WITH H/O IDDM, GI BLEED WITH KNOWN GRADE I & II ESOPHAGEAL VARICIES, PRESENTED TO ED AFTER VOMITTING BLOOD WITH CLOTS X X'S AT HOME.. HCT 27.7(BASELINE HCT 30). TX WITH CIPRO, PROTONIX, 1L NS, & OCTREOTIDE GTT. VSS. NO FURTHER VOMITTING. ADMITTED TO CCU AS MICU BORDER. ENDOSCOPY DONE->BANDING X1.\nSTABLE POST-PROCEDURE. HCT 25.2(27.7). STARTED CL. LIQUIDS.\n\nNEURO: A&0 X3. PLEASANT & COOPERATIVE. UNDERSTANDS MORE ENGLISH THAN SHE SPEAKS.\n\nRESP: O2 SAT 97-100% ON RM. AIR. RR 15-19. BS CLEAR.\n\nCARDIAC: HR 66-77 SR WITH OCC. PAC. BP 98-128/33-59.\n\nGI: TOL. CL. LIXS. ABD. SL. DISTENDED, BUT SOFT. BS+. NO N/V. NO STOOL. OCTREOTIDE GTT INFUSING AT 50MCG/HR. HCT 24.9(25.2). HO AWARE.\n\nGU: VOIDING QS->CLEAR YELLOW URINE.\n\nID: AFEBRILE. CONT. ON PO CIPRO.\n\nENDO: BS HIGH 200'S. SPOKE TO HO->TID NPH ORDERED(1/2 DOSE D/T CLEAR LIQUID DIET). BS 188.\n\nAM LABS PENDING.\n\nPLAN: ADVANCE DIET TO SOFT SOLIDS.\n INCREASE ACTIVITY.\n SERIAL HCTS.\n ?? CALL OUT TO FLOOR.\n" }, { "category": "ECG", "chartdate": "2149-06-04 00:00:00.000", "description": "Report", "row_id": 134570, "text": "Sinus rhythm with atrial premature beats. Compared to the previous tracing\nof no significant change.\n\n" }, { "category": "Nursing/other", "chartdate": "2149-06-04 00:00:00.000", "description": "Report", "row_id": 1339243, "text": "CCU NSG NOTE: ALT IN GI/BANDING OF VARICIES\nS: \" es me higado\".\nO: For complete VS see CCU flow sheet and admission note. This 64y old woman with PMH of IDDM, HTN, non ETOH cirrhosis with know esophageal varices came to EW today with hx is 5-6 episodes of vomiting blood with clots this am. In EW she had no further episodes and had no pain or nausea. Crit was 27.7 from baseline of ~30. She received protonix 40 IV, a liter of NS, 400mg IV cipro and was started on octrotide drip at 50mic/hr. Pt was hemodynamically stable. She was transfered to CCU as MICU border for endoscopy and further care. She arrived in CCU at 1530, pain free and shortly after was consented for endoscopy with her neice acting as translator.\nGI: PT underwent endoscopy and had one varicies banded. She received a total of 75mic/fentanyl and 2mg versed between 1630 and 1640. She was completely awake and in tact neurologically at 1800 and is now taking liquids and swallowing without problem She tolerated proceedure well and team felt she had excellent result. She can have liquids tonight and advance to soft solids tomorrow. She has started sulcrafate and continues on octreotide gtt.\nCV: Pt has remained hemodynamically stable with hr in 70s and BP initially 140/50s and now 120-130/40s.\nRESP: Lungs auscultate clear and she is sating 97-100% on RA. She was transiently on 2L NP during proceedure but is back on RA.\nRENAL: Pt without foley. She voided 500cc in commode.\nHEME: Crit at 1800 dropped to 25.2. Of note she received 1 liter NS in EW. No SS of bleeding. She is to have crits Q 6hr and is due at 1200am.\nENDO: Finger stick after arriving was 282 and she received 6u regular insulin. She did not take her NPH this am. She usually takes 34 NPH at bedtime. HO notified.\nMS/COMFORT: Pt A & O. Speaks little English,but family is helping to translate. The banding can cause chest discomfort and she is written for ultram, which she takes for back pain. She is presently pain free.\nA: UGIB from varicies successfully banded.\nP: Check crit at 12am. Limit pt to liquids until am. Continue octreotide and sulcrafate. GAS. Assist pt to commode. Keep careful I & O. Monitor for pain.\nENDO:\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2172-07-25 00:00:00.000", "description": "LUNG SCAN", "row_id": 767872, "text": "LUNG SCAN Clip # \n Reason: KNOWN PULMONARY EMOBLISM. PREOPERATIVE STUDY.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Eighty-four year old woman with known pulmonary embolism with cecal\n mass.\n\n Ventilation images obtained with Tc-m aerosol in 8 views demonstrate no large\n defects.\n\n Perfusion images in the same 8 views show multiple segmental perfusion\n abnormalities bilaterally.\n\n Minimal atelectasis without other focal opacities and no pleural effusions.\n\n The above findings are consistent with high probability of pulmonary embolism.\n\n IMPRESSION: High likelihood of pulmonary embolism. /nkg\n\n\n , M.D.(dictated)\n , M.D. Approved: 8:26 AM\n West \n\n\n\n RADLINE ; A radiology consult service.\n To hear preliminary results, prior to transcription, call the\n Radiology Listen Line .\n" }, { "category": "Radiology", "chartdate": "2172-07-19 00:00:00.000", "description": "INTERUP IVC", "row_id": 767328, "text": " 9:38 AM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement for a patient with massive PE with larg\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * INTERUP IVC 2ND ORDER OR> VENOUS SYSTEM *\n * -51 MULTI-PROCEDURE SAME DAY PERC PLCMT IVC FILTER *\n * IVC GRAM IV CONSCIOUTIOUS SEDATION PRO *\n * NON-IONIC 30 CC *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with massive PE with large clot burden in right L/E,\n previously hypotensive.\n REASON FOR THIS EXAMINATION:\n IVC filter placement for a patient with massive PE with large right L/E clot\n burden.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Massive PE, right DVT, hypotensive, melena, contraindication to\n anticoagulation.\n\n RADIOLOGISTS: Procedure performed by Drs. and , staff\n radiologist, who was present for the entire procedure.\n\n MEDICATION & CONTRAST: Total of 1 mg IV Versed and 75 mcg IV Fentanyl,\n administered in divided doses with constant hemodynamic monitoring for\n conscious sedation. 3 cc right groin subcutaneous 1% Lidocaine. 40 cc 30%\n nonionic contrast administered due to patient's cardiopulmonary status and\n allergy history.\n\n TECHNIQUE/PROCEDURE: The patient and her daugheter were informed of the\n details and associated risks of the procedure and witnessed telephone consent\n from the daughter was obtained. The patient was placed supine on angiographic\n table and the right groin was sterilely prepped and draped in the usual\n fashion. 1% subcutaneous Lidocaine was administered to the tissues of the\n right groin to provide local anesthesia. Under ultrasonographic and\n fluoroscopic guidance, the right common femoral vein was accessed with a 19-\n gauge single-wall puncture needle. A 0.035 guide wire was advanced under\n fluoroscopic guidance and the needle was exchanged for a 4 French SOS\n Omniflush catheter. The Omniflush catheter was advanced under fluoroscopic\n guidance over a 0.035 Glidewire such that the tip is within the left external\n iliac vein and pelvic and inferior vena caval venograms obtained. The level of\n the renal veins was determined and appropriate position for filter deployment\n is determined. The Omniflush catheter was exchanged over a 0.035 \n wire for a 6 French sheath. Under fluoroscopic guidance, a Trapease (Cordis)\n inferior vena caval filter was deployed in an infrarenal position. The 6\n French sheath was removed and hemostasis obtained.\n\n COMPLICATIONS: There were no immediate complications, and the patient\n tolerated the procedure well.\n\n FINDINGS: Venography of the left external iliac vein and inferior vena cava\n (Over)\n\n 9:38 AM\n IVC GRAM/FILTER Clip # \n Reason: IVC filter placement for a patient with massive PE with larg\n Contrast: OPTIRAY Amt: 40\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n demonstrates a normal-appearing right IVC. No left-sided IVC is present.\n Bilateral single renal veins are demonstrated and their positions noted for\n filter placement. The Trapease IVC filter is deployed in an infrarenal\n location. Post-deployment venogram demonstrates appropriate infrarenal\n position.\n\n IMPRESSION: Successful placement of infrarenal IVC filter (Trapease, Cordis).\n\n" }, { "category": "Radiology", "chartdate": "2172-07-24 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 767825, "text": " 11:53 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: staging, liver mets, etc.\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman admitted for large PE, DVT, colonoscopy revealed 4 cm cecal\n mass\n REASON FOR THIS EXAMINATION:\n staging, liver mets, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84 year old woman admitted with large pulmonary embolism.\n Colonoscopy revealed 4 cm cecal mass. Evaluate for staging, liver metastases.\n\n TECHNIQUE: Helically acquired contiguous axial images obtained from the lung\n bases to the pubic symphysis prior to and following the administration of 150\n cc of Optiray contrast IV per the Oncology protocol.\n\n COMPARISON: Comparison is made to the patient's next prior CT of the abdomen\n dated .\n\n CT ABDOMEN WITH AND WITHOUT IV CONTRAST: There are pacemaker wires present in\n the right atrium and at the apex of the right ventricles. No pulmonary nodules\n are identified at the lung bases. No pericardial or pleural effusions are\n seen. There is minimal atelectasis adjacent to an osteophyte on the right.\n There is a small, well circumscribed low attenuation lesion anteriorly within\n the left lobe of the liver. This is lesion is unchanged since the prior study\n and is most consistent with a simple hepatic cyst. There are at least 2 other\n tiny low attenuation foci within the liver which are also unchanged. Although\n too small to characterize with accuracy, these likely represent simple cysts\n or hemangiomas. There is a small calcification inferiorly in the right lobe\n of the liver, also unchanged. No new hepatic lesions are identified. The\n gallbladder is unremarkable. The adrenal glands, pancreas and spleen are\n normal. Both right and left kidneys demonstrate prompt symmetric excretion of\n contrast without evidence of hydronephrosis, renal stones or masses. The\n visualized loops of large and small bowel in the abdomen are within normal\n limits. There is no free air or free fluid in the abdomen. Note is made of a\n metallic filter within the inferior vena cava.\n\n CT PELVIS WITH IV CONTRAST: There is asymmetric wall thickening of the cecum\n consistent with provided history of cecal mass. There is a prominent lymph\n node measuring 10 mm in short-axis dimension in the mesentery of the right mid\n abdomen. The appendix is normal. The terminal ileum is normal in caliber. The\n remainder of the colon is unremarkable with the exception of a few scattered\n diverticula. There is a small amount of fluid within the endometrial canal,\n unchanged since the prior exam. The urinary bladder is unremarkable. A\n filling defect is identified within the right common femoral vein as well as\n the right external iliac vein and left common femoral vein. There is a small\n fat containing inguinal hernia on the right.\n\n (Over)\n\n 11:53 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: staging, liver mets, etc.\n Field of view: 42 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The osseous structures demonstrate degenerative changes particularly\n pronounced in the lower thoracic and lower lumbar spine. No destructive bone\n lesions are seen.\n\n IMPRESSION:\n\n 1. Asymmetric thickening of the cecal wall consistent with provided history of\n cecal mass. No evidence of metastases of the liver or elsewhere in the\n abdomen, though there is a prominent mesenteric lymph node.\n 2. Filling defects in the right external iliac, common femoral and left common\n femoral veins consistent with known deep venous thrombosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2172-07-16 00:00:00.000", "description": "CHEST CTA WITH CONTRAST", "row_id": 767093, "text": " 5:54 PM\n CHEST CTA WITH CONTRAST; CT 100CC NON IONIC CONTRAST Clip # \n Reason: HTN, AFIB, ATYPICAL CP, HYPOTENSION, RT HEART STRAIN ON ECHO, EVAL FO RPE\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with h/o HTN, AFib, s/p pacer, admitted with ?atypical CP,\n fatigue, now w/ hypotension (SBP to 70s) and R heart strain on echo today.\n REASON FOR THIS EXAMINATION:\n Evaluate for possible pulmonary embolism.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypertension, A fib, post pacemaker placement, atypical chest\n pain, fatigue, now hypotension and right heart strain on echo today.\n\n COMPARISON: None.\n\n TECHNIQUE: Pulmonary CT angiography with multiplanar reformats.\n\n MULTIPLANAR REFORMATS: The multiplanar reformats confirm the findings\n described below.\n\n CONTRAST: 100 cc of Optiray secondary to fast rate of bolus injection.\n\n PULMONARY CTA: There is a large low attenuation thrombus within the right\n main pulmonary artery extending down the interlobar artery into segmental\n branches as well as up the right upper lobe artery into segmental branches.\n Thrombus is also noted in the posterior basal segment artery on the left and\n potentially in the left upper lobe pulmonary artery extending from the distal\n left main PA. There is minor scattered atelectasis in the lungs. The heart is\n enlarged. There is no effusion or pneumothorax. The airways are patent. There\n is no adenopathy. The bones reveal no significant abnormalities. There is\n reflux of contrast material into the hepatic veins compatible with right-sided\n elevated filling pressures.\n\n IMPRESSION: Large pulmonary embolism as above.\n\n" }, { "category": "Radiology", "chartdate": "2172-07-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767090, "text": " 5:13 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for infiltrates.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with hypotension, sob.\n REASON FOR THIS EXAMINATION:\n Please evaluate for infiltrates.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and hypotension.\n\n COMPARISON: \n\n AP CHEST: Stable right-sided ICD with atrial and ventricular leads. The\n cardiac, mediastinal, and hilar contours are unremarkable and unchanged. The\n aorta is tortuous. There is slight hazy opacification at both lung apices\n which is new since the prior study but likley represents differences in\n technique. (This study is relatively underexposed.) The lungs are otherwise\n clear and there are no pleural effusions and no pneumothorax. The pulmonary\n vasculature is within normal limits. No osseous abnormalities.\n\n IMPRESSION: Allowing for differences in technique, no change since the prior\n study one day ago. No evidence of acute cardiopulmonary pathology.\n\n" }, { "category": "Radiology", "chartdate": "2172-07-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 766986, "text": " 4:48 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o consolidation\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with lightheadedness. please assess for edema, consolidation.\n thanks.\n REASON FOR THIS EXAMINATION:\n r/o consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Light-headedness.\n\n COMPARISONS: .\n PA AND LATERAL CHEST: Right-sided ICD with atrial and ventricular leads is\n unchanged. There is interval removal of left-sided PICC. Cardiac, mediastinal\n and hilar contours are stable. Pulmonary vascularity is normal. Lungs appear\n clear. There are no pleural effusions. Osseous strucures show degenerative\n change of the spine. Soft tissues are unremarkable.\n\n IMPRESSION: No acute cardiopulmonary process. No change from prior study.\n\n" }, { "category": "Radiology", "chartdate": "2172-07-18 00:00:00.000", "description": "BILAT LOWER EXT VEINS", "row_id": 767259, "text": " 12:33 PM\n BILAT LOWER EXT VEINS Clip # \n Reason: pt with known PE evaluating for DVT's\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with\n REASON FOR THIS EXAMINATION:\n pt with known PE evaluating for DVT's\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 84 year old woman with known PE, evaluating for DVTs.\n\n TECHNIQUE: -scale, color flow and pulse Doppler images were obtained from\n left and right common femoral, superficial femoral and popliteal veins.\n\n FINDINGS: There is lack of compressibility seen from the right common femoral\n to the popliteal. The veins contain echogenic material and there is no flow\n seen on the pulse Doppler images from the level of the superficial femoral\n vein to the popliteal. There is a normal arterial waveform seen in the right\n superficial femoral artery.\n\n On the left side, within the examined vessels, there is normal\n compressibility, -scale images, color flow and pulse Doppler images.\n\n IMPRESSION:\n\n 1) There is a right-sided DVT seen from the common femoral to the popliteal.\n\n 2) No deep venous thrombus is seen in the left lower extremity.\n\n" }, { "category": "Radiology", "chartdate": "2172-07-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 767115, "text": " 1:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with hypotension, sob s/p line placement\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE:\n\n A permanent pace maker remains in place, with leads within the right atrium\n and right ventricle. No definite central venous catheter is identified. No\n pneumothorax is observed.\n\n The heart demonstrates left ventricular configuration and the aorta is\n tortuous. The lungs appear grossly clear, and no pleural effusions are\n identified. Degenerative changes are observed in the spine.\n\n IMPRESSION:\n 1) Permanent pace maker in satisfactory position.\n 2) No central venous catheter is identified, and no pneumothorax is observed.\n If a central venous catheter was indeed placed, repeat radiograph following\n removal of external overlying structures may be helpful to aide visualization.\n\n\n" }, { "category": "Echo", "chartdate": "2172-07-28 00:00:00.000", "description": "Report", "row_id": 95566, "text": "PATIENT/TEST INFORMATION:\nIndication: Preoperative assessment. Pulmonary embolus.\nHeight: (in) 66\nWeight (lb): 210\nBSA (m2): 2.04 m2\nBP (mm Hg): 134/78\nStatus: Inpatient\nDate/Time: at 10:54\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is mildly dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle. No\natrial septal defect is seen by 2D or color Doppler.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF>55%).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTA: The aortic root is normal in diameter. There are focal calcifications\nin the aortic root. The ascending aorta is mildly dilated. There are focal\ncalcifications in the ascending aorta. The aortic arch is normal in diameter.\nThere are focal calcifications in the aortic arch.\n\nAORTIC VALVE: There are three aortic valve leaflets. The aortic valve leaflets\nare moderately thickened. There is no aortic valve stenosis. No aortic\nregurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. There is no significant mitral stenosis. Mild (1+) mitral\nregurgitation is seen. The transmitral E-wave decelleration time is prolonged\n(>250 ms). The left ventricular inflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\n[2+] tricuspid regurgitation is seen. There is severe pulmonary artery\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets are thickened.\nThere is no pulmonic valve stenosis. Physiologic (normal) pulmonic\nregurgitation is seen. The main pulmonary artery and its branches are normal.\nNo color Doppler evidence for a patent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. No atrial septal defect is seen by 2D or\ncolor Doppler. There is mild symmetric left ventricular hypertrophy with\nnormal cavity size and systolic function (LVEF 70%). Right ventricular chamber\nsize and free wall motion are normal. The ascending aorta is mildly dilated.\nThere are focal calcifications in the aortic arch. There are three aortic\nvalve leaflets. The aortic valve leaflets are moderately thickened. There is\nno aortic valve stenosis. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+)\nmitral regurgitation is seen. The left ventricular inflow pattern suggests\nimpaired relaxation. The tricuspid valve leaflets are mildly thickened. The\nsupporting structures of the tricuspid valve are thickened/fibrotic. Moderate\n[2+] tricuspid regurgitation is seen. There is moderate-to-severe pulmonary\nartery systolic hypertension. The pulmonic valve leaflets are thickened. There\nis no pericardial effusion.\n\nCompared to the previous study of , contractile function of the\nright ventricle appears significantly improved on the currrent study.\n\n\n" }, { "category": "Echo", "chartdate": "2172-07-16 00:00:00.000", "description": "Report", "row_id": 95567, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Shortness of breath.\nHeight: (in) 66\nWeight (lb): 245\nBSA (m2): 2.18 m2\nBP (mm Hg): 95/60\nStatus: Inpatient\nDate/Time: at 15:36\nTest: TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is elongated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is moderately dilated. A\ncatheter or pacing wire is seen in the right atrium and/or right ventricle.\n\nLEFT VENTRICLE: There is symmetric left ventricular hypertrophy.\n\nRIGHT VENTRICLE: The right ventricular free wall is hypertrophied. The right\nventricular cavity is dilated. Right ventricular systolic function appears\ndepressed. There is abnormal septal motion/position consistent with right\nventricular pressure/volume overload.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is normal in\ndiameter.\n\nAORTIC VALVE: The aortic valve leaflets are mildly thickened.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. Physiologic\nmitral regurgitation is seen (within normal limits). The left ventricular\ninflow pattern suggests impaired relaxation.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are mildly thickened. Moderate\nto severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary\nartery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Significant pulmonic regurgitation is seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is elongated. The right atrium is moderately dilated. There is\nsymmetric left ventricular hypertrophy. The right ventricular free wall is\nhypertrophied. The right ventricular cavity is dilated. Right ventricular\nsystolic function appears depressed. There is abnormal septal motion/position\nconsistent with right ventricular pressure/volume overload. The aortic valve\nleaflets are mildly thickened. The mitral valve leaflets are mildly thickened.\nThe left ventricular inflow pattern suggests impaired relaxation. The\ntricuspid valve leaflets are mildly thickened. Moderate to severe [3+]\ntricuspid regurgitation is seen. There is at least moderate pulmonary artery\nsystolic hypertension. Significant pulmonic regurgitation is seen.\n\nCompared with the prior report (tape unavailable) of , the right\nventricle is now dilated and hypokinetic and tricuspid regurgitation is now\nsevere. Estimated pulmonary artery systolic hypertension is now higher.\n\n\n" }, { "category": "ECG", "chartdate": "2172-07-15 00:00:00.000", "description": "Report", "row_id": 253396, "text": "Baseline artifact\nRegular atrial pacing\nInferior+ant/septal ST-T changes are nonspecific\n? Ventricular pacing spikes with pseudofusion - clinical correlation is\nsuggested\nSince previous tracing of , probable no significant change\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-17 00:00:00.000", "description": "Report", "row_id": 1303578, "text": "pmicu nsg admission note\n\n\n pt is an 84 yob woman who was admitted to yesterday after several days c/o weakness and palpitations. she was observed on telemetry and r/out for an mi. she has a pacemaker that was interrogated by cardiology and felt to be in good working order. prior to her planned discharge home last evening, she underwent a cardiac echo which revealed a dilated rv and increased pa pressures. on return to the floor, the pt became diaphoretic and acutely hypotensive to sbp 70's. she received several fluid boluses w/improvement in her blood pressure. she was subsequently sent for a chest ct and found to have a large right-sided pe along w/a smaller left-sided pe. she was transferred to the micu for tpa infusion ~7:30pm.\n\npmh: afib; ddi (@70bpm) pacemaker '; htn; cardiomyopathy w/mild mr tr; ?dementia w/short-term memory loss; ventral hernia repair.\n\nallergies: pcn\n\nreview of systems\n\nrespiratory-> the pt arrived in nard although she developed some mild sob while transferring from stretcher to bed. she is receiving 3l o2 via cannula w/sats >95%. she currently denies c/o sob. lung sounds are diminished bibasilarly. although she arrived on a heparin qtt, the heparin was turned off shortly after her arrival to the micu in anticipation of a central line placement followed by the tpa infusion. after multiple attempts in her right ij and right fem site, a central line was finally placed in her left groin. unfortunately, the pt developed a large neck and right groin hematoma. the housestaff applied pressure to the pt's neck for approx 1 1/2hrs and a pressure dsg was placed around her right groin. so far she has no evidence of stridor and denies any sob. tpa/heparin has been on hold overnoc. she may go to radiology later today for an evacuation of the clots.\n\ncardiac-> hr 70's, av paced. the pt has been hemodynamically stable since her admission to the micu w/sbp ranging 110-150's. antihypertensive meds on hold for now.\n\nneuro-> the pt clearly has some short term memory deficits but is oriented to person, place, and month. she was apparently having increasing difficulty managing at home w/? falling. she was to be discharged w/home services including a PT evaluation. she ambulates using a cane.\n\ngi/heme-> abd is soft, nontender w/+bs. she is currently npo. her repeat hct has fallen to 29 this am and a clot will be sent to the blood bank.\n\ngu-> a foley was placed w/o incident after her arrival to the micu. uo is adequate.\n\naccess-> triple lumen central line located in the left fem site.\n\nsocial-> the pt has a large, very involved family. she has 7 children, several of whom visited last noc. they were updated on the pt's condition prior to leaving.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-18 00:00:00.000", "description": "Report", "row_id": 1303582, "text": "S/P PE TO LUNG\nD: NEUROLOGICALLY UNCHANGED. PLEASANT AND COOPERATIVE. POOR APPETITE. PT CONSTIPATED AND WILL START BOWEL REGIMEN. PT DENIES CP OR SOB. O2 SATS>94% ON 3L/M NC. LUNGS ESSENTIALLY CLEAR ON AUSCULTATION BUT REMAIN DIMINSHED AT THE BASES. PT TO FOR LOWER EXTREMITY STUDIES. FINDINGS: DVT FROM R COMMON FEMORAL TO POPLIETAL ARTERY. POS PALPABEL PULSES TO LOWER EXTREMTIESBUT R UPPER LEG MUCH WARMER THAN L. MEDICAL TEAM AWARE. DESPITE DECREASING DOSAGE OF HEPARIN GTT PTT REMAINED>150. HEPARIN GTT SHUT OFF AT 1200 FOR 2 HRS AND THEN RESUMED AT 800U/HR. WILL RECHECK PTT AT . PT'S HCT DROPPED FROM 28.5 TO 27.4. R NECK HEMATOMA APPEARS TO BE LARGER IN SIZE AS COMPARED TO YESTERDAY. C/O DISCOMFORT AND HAS BEEN MEDICATED WITH TYLENOL 2 TABS WITH GOOD EFFECT. WILL ALSO RECEHCK HCT AGAIN AT . PT NOW BEING CONSIDERED FOR IVC PLACEMENT WHICH NOW DONE ON MONDAY. K+3.1 AND REPLACED WITH 40 MEQ PO X2. MG=1.4 AND ALSO REPLACED WITH 4 GMS MG AS ORDERED. PT'S FAMILY HAS BEEN AT THE BEDSIDE THROUGHOUT THE DAY AND HAVE BEEN UPDATED. PT STABLE BUT BECAUSE OF DROPPING HCT AND HEPARIN GTT NOT BEING THERAPEUTIC YET PT WILL REMAIN IN ICU OVERNOC AND WILL CONTINUE FOLLOWING LABS AS ORDERED. PT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-19 00:00:00.000", "description": "Report", "row_id": 1303583, "text": "MICU NURSING PROGRESS NOTE.\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Neuro: Alert and oriented x 3 with occn periods of confusion, easily reoriented. Speach is clear, able to make needs known. Pupils are 3 mm and brisk. Moving all extrem freely. Temperature maximum 97.5 oral.\n Respiratory: Lung sounds are clear in upper fields, diminished in bases bilat. RR 12-21 and non labored. O 2 saturation 94-100% on 3l nc. No c/o of sob or diff. breathing.\n CV: Av paced with no ectopy noted, rate 81-104. Nbp 107/55-142/86. Palpable pulses all 4 extrem. Heparin dropped to rate of 600, 2 am ptt 88.1, per Dr . Heparin is to be shut off at 0730 for ivc filter placement at 0900. Transfused with 1st of 2 units prbc's this am for decreased hct, large melena stool.\n GI/GU: Abdomen is soft with + bs, non tender. At 2300 passed lg amt of melena, had sm amt later. Ngt tube placed by team, negative for ugi bleeding, removed by pt accidentally. Foley catheter patent and draining good amts clear yellow urine.\n Vascular: Hematoma on attempted rt femoral site unchanged, site at attempt on rt ij is larger than last pm but remains unchanged this shift, is painful with movement and palpation.\n Plan is to tx with 2nd unit prbc's, stop heparin at 0730, place ivc at 0900 and continue to maintain therapeutic level of anticoagulation.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-17 00:00:00.000", "description": "Report", "row_id": 1303579, "text": "S/P PE TO LUNG\nD: PT ALERT AND ORIENTED. VERY PLEASANT AND TALKATIVE. SHORT TERM MEMORY IS EFFECTED BUT NEEDS FREQ UPDATES AS TO WHAT HAS HAPPENED. FOLLOWS COMMANDS APPROPRIATELY. DIET ADVANCED TO HEART HEALTHY DIET BUT APPETITE IS FAIR.\n\nRESP: O2 AT 3L/M NC WITH O2 SATS>93%. LUNGS CLEAR ON AUSCULTATION BUT DIMINSHED AT THE BASES. PT DOES NOT APPEAR TO BE SOB AND NO C/O OF SOB FROM PT. WILL FOLLOW O2 SATS AND NOTIFY MEDICAL TEAM IF SHE DETERIORATES.\n\nCV: VSS. HR 70-90'S AVPACED WITHOUT ECTOPY. K+3.8 AND MG=1.7. SBP128-160.\n\nGI: ABD BENIGN ON EXAM. POS BOWEL SOUNDS ON AUSCULTATION NO STOOL OUTPUT. DIET ADVANCED BUT APPETITE FAIR. WILL NEED ENCOURAGEMENT.\n\nRENAL: FOLEY CATH IN PLACE WITH ADEQUATE UO. BUN=34 AND CREAT=1.0.\n\nHEME:PT R NECK HEMATOMA FROM CL ATTEMPT LAST NOC. PRESSURE DRSG FROM THE SITE AND AREA MARKED BUT IT DOES NOT SEEM TO HAVE INCEASED IN SIZE. R FEM HEMATOM SITE CONTINUES TO HAVE PRESSURE DRSG AND NOT BEEN REMOVED. PALPABLE PULSES TO THAT R FOOT. HCT EARLY THIS AM= 29.3 AND REPEAT THIS AFTERNOON=26.3. PT WILL NEED TO BE TRANSFUSED WITH 2 U PRBC'S. HEPARIN GTT INITIATED THIS AM AND NOW AT 1600U/HR. PTT RESULTS PENDING AND WILL USE WEIGHT BASED ORDER FOR DOSING.\n\nSOCIAL: MUTIPLE FAMILY MEMBERS HAVE BEEN IN TODAY AND HAVE BEEN UPDATED. PT BE CALLED OUT TO THE FLOOR IN THE AM. IF HCT AFTER TRANSFUSIONS IS STABLE. CONTINUE TO MONITOR HEMATOMA SITES. PT REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-17 00:00:00.000", "description": "Report", "row_id": 1303580, "text": "addendum to above note. ptt drawn at 1630 reported back at 150. heparin gtt of 1600u/hr off for 1 hr and then will restart gtt at 1400u/hr and recheck ptt at 0130.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-18 00:00:00.000", "description": "Report", "row_id": 1303581, "text": "MICU/SICU NURSING PROGRESS NOTE\n See careview for objective data.\n Neuro: Alert and oriented to person,place, and month. Moving all extrem. freely and able to reposition self. Able to make needs known. Speach is clear. Temperature max. 98.7 oral.\n Respiratory: Lung sounds are clear in upper fields, diminished in lower fields bilat. RR 8-20 and non labored. Denies sob or difficulty breathing. O2 saturation 94-100% on 3l nc. Mouth breather when sleeping.\n CV: AV paced rythm with rare pvc, rate 60's-80's. No c/o cp or pressure. Nbp 130's to 140's systolic. Good pulses all 4 extrem. Tx with 2 units prbc's without incident. Heparin off at 0330 and restarted at 0430 for ptt of 150, restarted at 1200 units per hr. No signs of increasing hematoma on neck or thigh.\n GI/GU: Abdomen soft with + bs. C/o of gassy feeling, resident aware and evaluated. No bm this shift. Foley catheter patent and draining good amts of clear yellow urine, especially after 2nd unit of blood.\n Social: Family into visit, several calls inquiring about pt.\n Plan: Lennies this am and continue on low dose heparin. Repeat ptt at 1030\n" }, { "category": "Nursing/other", "chartdate": "2172-07-21 00:00:00.000", "description": "Report", "row_id": 1303587, "text": "PMICU Nursing Progress Note 7p-7a\nPT c/o, no beds available, cont to wait to be transeferred out of MICU.\n Review of Systems\n\n Pt axox3, pleasant and cooperative w/ care. PT slept for most of the night.\nCV- HR 70's, AV paced, occasional PVC's. AM labs pending. BP btw 130's-150's/60-70's. Cont to recieve PO lopressor w/ good effect.\nResp- 3L NC, Sats 98%. LS clr in upper lobes, slightly diminished in bases. Strong cough.\nGI- Abd soft, +BS, no BM. Diet clr liquids. PT had 1x c/o nausea, reported feeling better after recieving ice chips and being repositioned. HO notified. Cont to recieve IV protonix.\nGU- Adequate urine out hr, yellow, clr.\nAccess- L Femoral TL cath, site WNL.\nPlan- Nsg tranfer note completed, cont supportive medical care as pt awaits a bed on flr.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-21 00:00:00.000", "description": "Report", "row_id": 1303588, "text": "Pt. remains c/o to Medical floor; no beds in house at present. Transfer note written.\n\nPt. remains VSS, afebrile with adequate I/O.\nGI: HCt 31.5 (29.5). No signs/ symptoms of re-bleeding. Remains on clear liqs with poor appetite. Plan- NPO after MN, to start Bowel Prep at 1700 for colonscopy tom'row and EGD as well. Iron supp. added to med regimen today.\n\nCV/ heme/ mobility: TLC remains in place until after procedures tom'row. Hematomas appear stable. + peripheral pulses. Brusing noted around right shoulder region and right groin. Skin intact. OOB to chair X several hours today with no assistance.\n\nResp: O2 off and sat's have been >97%. LS- clear.\n\nGU: Of note: cloudy urine, urine sample to be sent now! pls. f/u with results.\n\nOther: update transfer note prn. Pt. and family aware of tom'row procedures and pending transfer. Daughter at bedside this afternoon.\n" }, { "category": "Nursing/other", "chartdate": "2172-07-19 00:00:00.000", "description": "Report", "row_id": 1303584, "text": "altered resp status secondary to documented pe/dvt\nd: pt neurolgically intact though pt's short term memory loss often needs reorientation. mae's and follows simple commands appropriately.\nresp: remains on o2 at 3l/m nc with o2 sats>95%. lungs clear on auscultation but diminished at the bases. denies sob or cp.\n\ncv: hr 80-90's with sbp 120-140's. mg,ca and phos replaced today. see careview for specifics. hemodynmaically stable.\n\ngi: abd soft and benign. no melenotic stool output. pt continues to receive ivf of ns at 150cc's/hr. clear liqs tolerated well post radiology procedure and will advance diet as tolerated to heart healthy. will need to encourage pt to eat. hct this am=27.2 and repeated this afternoon was 31.2. will echeck hct at tonoc.\n\nrenal:bun and creat wnr. putting out lg amts of urine hourly but los i&o still pos by 2 l.\n\nradiology: heparin gtt d/c'd t 0730. inr 1.2 and pt was transported to radiology where an ivc was placed via r femoral artery without complication. bandaid to insertion site in place. old hematoma site unchanged and no further bleeding noted. pos palpable pulses to extremities and feet warm to touch. r neck hematoma unchanged in size.\n\nif hct remains stable and pt hemodynamically overnoc pt may be transfered to medical floor in the am. pt's family has been updated and pt remains a full code.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-20 00:00:00.000", "description": "Report", "row_id": 1303585, "text": "MICU/SICU NURSING PROGRESS NOTE\n SEE CAREVIEW FOR OBJECTIVE DATA.\n Neuro: Alert and oriented x 3 with occn periods of confusion, easily reoriented. Pupils 3 mm and brisk. Speach is clear and is able to make needs known. MAE. Temperature max. 98.5. No c/o ha or discomfort.\n Respiratory: Lung sounds are clear in upper fields, diminished in lower fields bilat. RR 10-21 and non labored, o2 saturation 98-100% on 3l nc. Occn congested non productive cough.\n CV: Av paced with no ventricular ectopy noted, rate 70-80s. Nbp 102/58-133/68. Hct at was 30.0, no repletion required. IVC insertion site at rt femoral intact, no drainage noted, bandaid. intact. + pulse and warmth of rt lower extrem.\n GI/GU: Abdomen soft with +bs. No bm but did have some guiac + staining on pad, old digested blood. - c/o nausea. Foley catheter patent and draining clear yellow urine in good amts.\n Integument intact.\n Plan is to send to floor as long as hct is stable.\n\n" }, { "category": "Nursing/other", "chartdate": "2172-07-20 00:00:00.000", "description": "Report", "row_id": 1303586, "text": "IVs: L fem TLC - all ports patent. No IV infusions\n\nNeuro: AAOx3, MAEx4 spont/command. Moves well in bed.\n\nCardiac: BP=130/60's, HR=70s, AVPaced. +periph pulses, +edema in R hand and Rfoot. extrems warm.\n\nResp: 3l n/c w/ 02sat=97% (95% on R/A). Lungs clear, but decreased in bases bilat. No cough\n\nGI: abd soft, tol clear liq diet, although appetite is poor. No BMs.\n\nGU: foley cath, clear yellow urine\n\nSkin: Hematomas R neck and R fem improving. Neck and groin tender.\n\nPlan: transfer to floor when bed available.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2109-09-03 00:00:00.000", "description": "Report", "row_id": 1531046, "text": "MICU/SICU Nursing admission\nBriefly this is a55 yo woman with a PMH significant for tuberculosis in , pulmonary fibrosis (right lung), pseudomonas PMA ', pulmonary HTN, osteoporosis, DJD rhght knee, anemia (thalasemia trait), who presented to the EW today from PCP's office with c/o 2 days pf progressive dyspnea and productive cough. In the EW pt became hypoxic, requiring a trial of mask ventilation, however pt was unable to tolerate this. Pt was electively intubated for impending hypercarbic respiratory failure. CXR reveals LLL infiltrate, right side large volume loss, CTA ruled out PE. Pt was pan-cultured and started on azithromycin and admitted to the ICU for further management.\n\nROS:\n\nNeuro: pt was sedated with propofol, however it was titrated off due to hypotension, pt awakens to voice and is able to follow simple commands\n\nPulm: intubated with #7 ETT, 21cm at the lip, on AC 18x400x0.35/+5, last ABG 7.41/58/86, LS are diffusely coarse with scattered I/E wheezes and significantly diminished at right base, pt has been suctioned hourly for moderate amts thick tan secretions\n\nCV: HR has been 90's to 100's with frequent polymorphic PVC's and occaisional , pt has required boluses to keep MAP > 60, please see flowsheet for data\n\nInteg: skin is C/W/D/I\n\nGI/GU: abd is obese, soft, NT/ND, BS present, OGT clamped, NPO, FOley patent for concentrated yellow urine in adequate amts\n\nLines: #20 angio in left hand, #20 angio in right hand, right radial art line\n\nPlan: continue abx as ordered, continue aggressive pulmonary toilet, consider cortisol stimulaton, bolus to keep MAP >60, consider CVL to monitor CVP\n" }, { "category": "Nursing/other", "chartdate": "2109-09-03 00:00:00.000", "description": "Report", "row_id": 1531047, "text": "Resp Care,\nPt. admitted from ER intubated #7 ET taped at 21 lip. Placed on A/C overnoc. Suctioned for large amount thick tan sputum. Periods of coughing, bronchospasm. Wheezes, started on Albuterol MDI. Cont. to have coughing spasm. Unable to sedate more due to BP. PIP 30's-40. Fio2 weaned to 35%.See carevue ABG.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-03 00:00:00.000", "description": "Report", "row_id": 1531048, "text": "NPN \n\nNeuro: Propofol d/c'd early am. Pt dozing throughout the day but easily awakened. Very alert late afternoon, requesting to eat and have ET tube removed. MAE's, behavior appropriate, wrist restraints removed.\n\nCV: ABP: 91-113/47-58 with MAP 61-75. No fluid boluses required. HR 82-92, occasional PVC's. No peripheral edema; peripheral pulses present and strong. Repeat crit at 1400 26.2 (from 28.8).\n\nResp: Remains intubated and vented in AC mode, settings 18X400X35%X5. Lung sounds are coarse with expiratory wheezing throughout, diminished RLL. O2 sats 96-100%. Pt has a strong cough. Suctioned q 1-2 hrs for large amts yellow/tan sputum.\n\nID: Temp 99.4-101.3. Started on levoquin and remains on ceftaz.\n\nGI: OGT coughed out in afternoon. Abdomen soft, ND, NT, +BS, no BM. Pt reports she is hungry.\n\nGU: Foley draining 40-80cc/hr clear yellow urine.\n\nAccess: PIV's bilateral hands, a-line R radial intact.\n\nPlan: Check ABG's during breathing trial and extubate if possible; Monitor temp, wbc's, cultures; Monitor resp status, sputum, perform aggressive pulmonary toilet; monitor hematocrit, s/sx of bleeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-03 00:00:00.000", "description": "Report", "row_id": 1531049, "text": "Addendum to NPN 0700-1900\n\nVent mode changed to pressure support for trial. Pt only tolerated it for ~10 minutes when she became tachycardic, tachypneic, hypertensive, anxious and agitated. O2 sats in 80's. Given ativan 1mg and put back on AC mode at same settings. Resting comfortable with eyes closed, O2 sats high 90's, BP and HR back to baseline.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1531050, "text": "pt.presently on ac ventilation, mdi albuterol given q4h, breathe sounds with rhonchi bilat., abg alkalotic, rsbi.96.4, will remain as is for now.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1531051, "text": "MICU/SICU NPN HD #2\nS/O:\n\nNeuro: pt is alert, answering yes/no questions by nodding/shaking head, nonverbally indicating that she would like ETT removed, denies pain\n\nResp: remains intubated on AC 18x400x0.35/+5, last ABG 7.43/55/101, SpO2 98-100% LS coarse, dimi at right base, frequent suctioning for copious thick tan secretions\n\nCV: HR 83-97 SR with occasional to frequent PVC's, 87-103/46-55, MAP 61-71, please see flowsheet for data\n\nSkin: C/W/D/I\n\nGI/GU: abd obese, soft, NT/ND, NPO, Foley patent for concentrated yellow urine in adequate amts, UO dropped off over course of the night and pt bolused 500cc NS x1\n\nLines: #20 angio left hand, #20 angio right hand, right radial art line\n\nA:\n\nhigh risk fo infection r/t ETT, indwelling catheter\naltered breathing r/t acute infalmmatory process, chronic pulmonary process\naltered nutrition, LBR r/t poor caloric intake > 48h\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, contiue aggressive pulmonary toilet, continue abx as ordered, consult dietitian for nutrition reccomendations\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1531063, "text": "MICU/SICU NPN HD #5\nS: \"What can I do to help get this tube out?\" (written)\n\nO:\n\nNeuro: pt is A&Ox3, communicating by writing, denies pain, MAEW\n\nPulm: remains intubated on PSV 15+5/0.35, LS are coarse except RLL which is significantly diminished, SpO2 96-100%, suctioned q2-3h for large amts thick tans secretions, pt did not tolerate further weaning of PS, RR has been 26-38 overnight with Vt 200-350cc\n\nCV: HR 77-93 SR, BP 90-115/47-60, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd is softly distended, BS present, pt had been tolerating Promote with fiber at 60cc/h, TF off at 0400 for possible extubation, Foley patent for clear yellow urine in adequate amts\n\nLines: right radial art line day #5, #20 angio left hand, #20 angio right post FA\n\nA:\n\naltered breathing r/t acute inflammatory process, increased resp secretions, chronic pulm process\nanxiety r/t hospitalization, intubation\nhigh risk for infection r/t indwelling catheter, ETT\n\nP:\n\ncontninue to monitor hemodynamic/respiratory status, continue aggressive pulmonary toilet, continue abx as ordered, contniue to wean resp support as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1531064, "text": "Resp: pt on psv 18/+5/35%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal coarse LS with diminished RS. Suctioned for moderate amounts of yellow secretions. MDI's administered Q4 Alb. Attempted to decrease ps and pt did not tolerate. RSBI=113. 02 Sats @ 97%.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1531065, "text": "RESPIRATORY CARE: PT EXTUBATED TO A 70 % AEROSOL\nMASK AFTER DOING WELL ON A SBT FOR 4-5 HOURS.\nRSBI THIS WAS 100-114. DOING PRETTY WELL W/ A\nRR 20-30 BPM AND A SPO2 92-95 %.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-07 00:00:00.000", "description": "Report", "row_id": 1531066, "text": "NPN 0700-1900\nGeneral: Pt A&Ox 3, extubated today, RR 26-28 on 70% open face mask, O2 sats 94-100%.\n\nNeuro: Follows commands, able to move self in bed, denies pain.\n\nPulm: Sx'd thick whitish tan secretions from mouth, cough reflex good, no c/o SOB, breathing even and unlabored.\n\nCV: HR 70-110 SR-ST no ectopy, BP's 120's-130's/50-60's per BP cuff, A-line dc'd, no edema, 2+ Pedal Pulses bilat.\n\nGI: Abd soft non-distended, non-tender, BS (+)x 4 quad, x1 BM loose, golden in color, guaiac (-), currently NPO but tolerating ice chips.\n\nGU: FOley intact draining clear yellow urine with occasional clots.\n\nSocial: Son and daughters in to see pt.\n\nPlan: Cont to monitor resp status, monitor VS, wean O2 as needed, am labs.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531057, "text": "Respiratory Care:\nPt. given a chance to use PSV today but did not do well w/her rr increasing to mid 40's after a couple of hours. Returned to A/C to rest. She will likley be a rapid shallow breather due to her long standing pulmonary fibrosis and poor lung condition. Uses O2 at home.\nsee CareVue for details...\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531058, "text": "MICU NPN 7PM-11PM:\nPt has had no change in vent settings, needs ABG with AM labs. Repeat hct this was stable at 28.8. Repeat K+ was 3.5. Pt given 40meq PO kcl and has kcl infusion going in of 250cc's NS with 20meq K at 50cc/hr. Pt will be NPO after MN for possible extubation tomorrow. Visited with her daughter this . Anxious for the ETT to come out and to start taking PO's.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1531059, "text": "Resp: pt on a/c 18/400/+5/35%. Alarms on and functioning. Ambu/syringe @ hob. BS auscultated reveal bilateral aeration with slighlly diminished bases. MDI's administered Q4 of alb with no adverse reactions. Suctioned small amounts of yellow/white secretions with an occasional plug. AM ABG's 7.40/62/97/40. RSBI=26. No further change noted. Extubation expected this am\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1531060, "text": "NPN 2300-0700\nNeuro: Pt A&O. mae. Able to turn self with minimal assistance. C/o discomfort with ET tube. Medicated with Versed .5mg x2, tylenol 650 pr, and hurricane spray used x2 with fair results. Pt did sleep off and on.\n\nResp: Vent settings as above, not changed on shift. LS coarse. ABG in am essentially unchanged from yest: 7.4/62/97/10/40. RR 18-19, minimal overbreathing. Sx for sm-mod amt tan,thick secretions with # of sm green plugs. Pt suctioning mouth freq when awake. Pt NPO for possible extubation today.\n\nCV: BP remains low 81/46-100/55. 500mls NS fld bolus given for low bp with fair results. HR stable, nsr, no ectopy. Am labs drawn. Tmax on this shift 99.4, but pt spiked to 101.4 during day x2. Abx cont.\n\nGI: Pt made NPO at midnoc, previously on TF at 50mls/hr. +BS, soft abd. No stool this shift, had one on days. FS of 206 covered with 4units reg insulin.\n\nSkin: Intact.\n\nSocial: Have not heard from family members overnight.\n\nGU: Adequate uo, cl,yel urine. Pt + 910mls thus far today, +7L los.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1531061, "text": "RESPIRATORY CARE: PT. W/ 7.0 ORAL ETT IN PLACE.\nSBT THIS AM RESULTED IN TACHYPNEA/TACHYCARDIA\nAND CO2 RETENTION. PS THEN INCREASED TO 18.\nABG NOW STABLE AND C/W PARTIALLY COMPENSATED\nRESPIRATORY ACIDOSIS AND STABLE OXYGENATION\nON PS 18/.35/5. SX FOR WHITE SPUTUM. ALBUTEROL\nMDI GIVEN. WILL C/W PS 18 AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531055, "text": "7-11am.\nRESP: BS'S CLEAR ON RIGHT, RHONCHI ON LEFT. SUCTIONED FOR SMALL THICK WHITE TO LGT TAN SECRETIONS. O2 SATS HIGH 90'S. NO VENT CHANGES DONE YET.\nGI: REMAINS NPO. OGT UP TO INTERM. SUCTION. BILIOUS. PASSING FLATUS. ABD DISTENDED, BUT SOFT.\nRENAL: AUTODIURESING. URINE LGT YELLOW. CREAT 0.5. IVF'S AT 100CC/HR.\nENDOC: REPEAT K+ SENT.\nID: TEMP 99.8AX. AWAITING CX RESULTS FROM LAST NIGHT. CONTINUES ON ANTIBIOTICS.\nNEURO: AWAKE AND ALERT. WRITING QUESITONS. R WRIST UNRESTRAINED. SHOULD HAVE SOME MEDICATION IF NO PLAN FOR WEANING TODAY.\nSOCIAL: JEWELRY IN SAFE. PT. AWARE.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531056, "text": "MICU NPN 11AM-7PM:\nNeuro: Pt is alert, cooperative. Making her needs know easily by writing notes. Given versed .5mg once for c/o discomfort. Also c/o thoat pain/tightness and given hurricaine spray with relief. Can use PRN. MAE, follows commands.\n\nResp: Attempt to switch pt to PSV unsuccessful as pt RR increased to 40 and PCO2 went up to 70. Pt remains back on the AC 18, TV 400, FIO2 35% with 5cm peep. Lungs are coarse with deminished sounds at the bases. Suctioned for pale yellow secretions via the ETT Q2-4hrs as well as frequent oral suction with yankuer for clear secretions. Plan is for attempt at extubation tomorrow if temp curve is better.\n\nCV: BP 90-120/60. HR 70-90 NSR. K+ 3.5 after getting repleted this AM so pt was given another 40meq PO K and repeat labs due at 7PM this evening.\n\nGI: Tube feeds restarted at 30cc's/hr increased to 40cc's/hr at 5PM. Residuals are low. She has great bowel sounds but had not stooled since admission. Pt c/o nausea and was given dulcolax suppositiry with good effect. Passed large soft formed brown stool which was guaiac negative. Pt's nausea subsided and tube feeds continued. Feeds need to be stopped at MN and pt kept NPO except for meds for possible extubation tomorrow.\n\nGU: Pt has been auto diuresing today and UO continues to be brisk via foley.\n\nID: Pt remains febrile to 101.4 today despite two doses of tylenol. WBC is 11.1. Pt getting levo/ceftaz/vanco.\n\nSkin: No problems noted.\n\nHeme: Hct 28 this AM. Repeat in AM.\n\nIV access: Two peripheral IV's working well.\n\nSocial: Pt has three daughters and one son. I have asked them to try to limit the number of people calling in for info and to disignate a spokesperson who will be calling in for info. sister called as well for info and I told her she needs to speak to pt's daughter to get information. Daughter from NJ may come in later tonight to visit.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-04 00:00:00.000", "description": "Report", "row_id": 1531052, "text": "NPN 0700-1900\nGeneral: Pt sleepy but awakens to voice, MAEW in bed. Pt put on CPAP today in order to extubate and became tachycardic HR 130's, Hypertensive SBP's 180's, RR 40's. Also, attempted to climb out of bed and pull on ET tube. Was put on AC FIO2 35% PEEP 5, PS 15, and RR came down to 18, pt was once again calm. At 1500 team inserted OGT, given 2mg Versed, MAP's dropped to 55-60, given bolus 250ml NS IV and MAP's currently 60-65. Given Tylenol 650mg PR for Temp 102.4 with effect, current temp 100.4, BC's drawn, Vanco IV started today. KCL repleted. Started on D51/2NS at 100cc/hr.\n\nNeuro: Opens eyes, able to write questions on paper, able to sit up in bed today and adjust self, no c/o pain.\n\nResp: Lungs Rhonchorous to bilat upper lobes, fine rales noted to bilat lower bases, On AC vent. (as above) RR 18-20, SPO2 100%, sx'd medium amts. of thick yellow secretions from ET tube, pt noted to have bronchospasms with deep sx'ing.\n\nCV: HR 80-124 SR-ST with occasional PVC, MAP's 60-65, no edema, 2+ Pedal pulses bilat.\n\nGI: BS (+) x 4 quad., (+)flatus, no BM today, OGT inserted, waiting on Xray results to confirm placement prior to starting TF'ings.\n\nGU: Foley cath intact draining clear yellow urine with clots.\n\nSkin: Dry and Intact.\n\nSocial: Talked to son and daughter today, Son's telephone number is in MD's note.\n\nPlan: Continue to monitor VS, follow 1900 lytes, continue to wean off venitlatory support, monitor UO.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531053, "text": "pt.remains on ac ventilation, attempted rsbi but with little success-no spont.resp., bs appear clear at present time, abg alkalotic, sx for tan secretion, mdi albuterol given q4h, may attempt wean, possibly extubate today if able. pt.easily agitated.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-05 00:00:00.000", "description": "Report", "row_id": 1531054, "text": "D pt is alert this am with bath responding to commands and attempting to communicate, through facial expressions and movement. light wrist restaint on when not in, room pt geasturing she wants tube out and hold tube in hand . restaint to prevent unplanned extubation.MAE PERL 4-6mm.\nCV: NSR no ectopi noted, Palp DP. R/L PIV patent. D51/2 @ 100 infusing. PRBC infused. MG repleated 40meg KCL via NG given K of 3.2. post HCT 28.\nLungs: coarse to wheezing to clear tx given as indicated by resp. with effect. pt has bronchospasm often. incouraging pt ot breath slowly and decreasing stimuli helps as well as some sedation and tx. Pt on vent as orderd no changes. tolerating well, no breathing above vent unless bronchospastic.\nGI: ABD soft BS present NO BM. TF started at 2100 up to goal of 60cc at 6am but Tf off for possible extubation.\nGU: foley to gravity. urine output marginal improved since blood finished.\nA cause for decrease HCT unclear. cause for decrease K unclear.\nP continue TCDP and suction as needed.continue monitor and repleating lytes and HCT as indicated. guiac stool . resume TF when ordered. monitore closely.\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1531067, "text": "MICU/SICU NPN HD #6\nS: \"When can I eat? My stomach is so empty it hurts.\"\n\nO:\n\nNeuro: pt is A&Ox3, MAEW, denies pain\n\nResp: LS coarse, dim at bases, non-productive cough, SpO2 98-100% on 4L NP\n\nCV: 76-96 SR, 97-136/45-64, please see flowsheet for data\n\nSkin: C/W/D/I\n\nGI/GU: abd softly distended, BS present, tolerating liquids and crackers, Foley patent for clear yellow urine in adequate amts\n\nLines: #20 angio right forearm\n\nA:\n\naltered nutriton r/t poor caloric intake > 3 days\nhigh risk for infection r/t indwelling catheter\n\nP:\n\ncontinue to monitor hemodynamic/respiratory status, continue aggressive pulmonary toilet, continue abx as ordered, d/c Foley, ADAT, activity progression, consult CM to initiate d/c planning\n" }, { "category": "Nursing/other", "chartdate": "2109-09-08 00:00:00.000", "description": "Report", "row_id": 1531068, "text": "RESP; BS'S ESSENT. CLEAR WITH SOME CRACKLES ON RIGHT. NO SOB. TOL 4L NP. O2 SATS IN HIGH 90'S. PRODUCTIVE COUGH-WHITE PHLEGM.\nGI; DIET ADVANCED. TOL. WELL. SEVERAL SMALL LOOSE STOOLS. GIVEN IMMODIUM WITH GOOD EFFECT.\nRENAL: FOLEY D/C'ED THIS AM. HAS VOIDED SEVERAL TIMES. URINE-BLOODSTREAKED D/T PT. MENSTRUATING. PAD REFUSED BY PT.\nID: VANCO D/C'ED. LEVO CHANGED TO ORAL. AFEBRILE TODAY. URINE C&S SENT.\nNEURO: ALERT AND ORIENATATED.\nACTIVITY: OOB ON COMMODE AND IN CHAIR FOR SEVERAL HRS. TOL. VERY WELL.\nSOCIAL: CALLED HER DAUGHTER.\nTRANSFER NOTE WRITTEN. AWAITING A BED.\n\n" }, { "category": "Nursing/other", "chartdate": "2109-09-06 00:00:00.000", "description": "Report", "row_id": 1531062, "text": "RESP: BS'S COARSE SOUNDING. SUCTIONED FOR THICK WHITE-LGT TAN SECRETIONS. PLACED ON PS OF 18/5 THIS AM. AND HAS CONTINUED WITH THIS ALL DAY. RESP 26-34. O2 SATS 94-98%, SEE CAREVUE FOR ABG'S. APPEARS COMFORTABLE.\nGI: TF'INGS RESTARTED AT 50CC/HR AND NOW AT GOAL OF 60CC/HR. STOOLS X3 AFTER K+ EXYLATE GIVEN. MIN. RESIDUALS. PT. STATED SHE WAS HUNGRY THIS AM. BS'S PRESENT, THOUGH ABD STILL SLIGHTLY DISTENDED, BUT SOFT.\nENDOC: K+ AT 4AM WAS HEMOLYZED AT 7.5. REPEATED WITH ABG AND WAS 7.4. EKG DONE. NO CHANGES. GIVEN K=EXYLATE. REPEAT 3.8. K+ REPEATED LATER AND WAS 3.9. NO PRECIPITOUS DROP NOTED. SHOULD RECHECK AGAIN THIS EVENING.\nHEM: HCT DROP TO 26.4 THIS AM. STOOL GUAIAC NEG. WHEN DRAWING BLOOD USE PEDI TUBES. EPOGEN STARTED.\nRENAL: DIURESING WELL. IVF'S TO KVO.\nNEURO: PT. DEPRESSED AND FED UP. I SPOKE WITH HER AND REASSURED HER THAT SHE WAS IMPROVING, BUT THAT IT TAKES TIME FOR THE ANTIBIOTICS TO WORK.\nID: TEMP 99.8-100.8 RECTALLY AT 18PM.\nSOCIAL: NO VISITORS. DAUGHTER DID CALL AND I UPDATED HER.\n" }, { "category": "Radiology", "chartdate": "2109-09-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837308, "text": " 8:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with LLL pna and IPF, persistently febrile on broad-spectrum\n antibiotics\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST:\n\n Compared to .\n\n INDICATION: Fever. Pneumonia.\n\n An ETT and NG tube remain in satisfactory position. There is marked volume\n loss in the right hemithorax with persistent shift of the mediastinum towards\n the right. There is near complete opacification of the right hemithorax with\n the exception of a large cyst in the right lower lobe. Dilated air\n bronchograms are noted in the right upper lobe. A moderate right and small\n left pleural effusion are noted. Within the left lung, there are persistent\n multifocal pulmonary opacities as well as some underlying cystic and fibrotic\n changes. Overall, compared to the recent exam of 1 day earlier, there has\n probably been no significant interval change.\n\n IMPRESSION: Overall stable radiographic appearance of the chest with findings\n likely related to acute infection superimposed upon extensive underlying areas\n of fibrosis.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 836896, "text": " 9:31 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with LLL pna and IPF, s/p intubation and OG placement\n\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Left lower lobe pneumonia and idiopathic pulmonary fibrosis. S/P\n intubation and OG tube placement. Evaluate status.\n\n FINDINGS: A single AP supine image. Comparison study taken 5 hours earlier.\n The patient has now been intubated and the ETT is well positioned with its tip\n approximately 3 cm above the carina. A new OG tube is also noted with its\n distal end well positioned in the stomach below the limits of the image.\n Extensive bilateral pulmonary interstitial fibrosis is again demonstrated with\n marked contracture of the right lung associated with bronchiectatic changes in\n the upper lobe and marked shift of the heart and mediastinum to the right.\n More diffuse interstitial fibrosis is noted in the left lung associated with\n some atelectatic changes in the mid and upper zones. The cardiac silhouette is\n small and the pulmonary vessels are obscured by the interstitial changes. No\n definite evidence of cardiac failure is identified. A large bullous lesion is\n noted in the right lower zone. There is associated pleural thickening or\n possible pleural effusion at the right base.\n\n IMPRESSION: Stable chronic pulmonary fibrosis and contractures again noted.\n The ETT and the NG line appear well positioned.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837128, "text": " 4:15 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Evaluate OG tube placement\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with LLL pna and IPF, s/p intubation and OG placement.\n REASON FOR THIS EXAMINATION:\n Evaluate OG tube placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST AT 4:21 P.M. ON :\n\n INDICATION: Evaluate OG tube placement in woman with pneumonia and fibrosis.\n\n FINDINGS: Compared to the film at 8:35 A.M. this morning, an OGT has been\n introduced and is seen passing to the level of the proximal body of the\n stomach and then is not seen below the edge of the image in the left upper\n quadrant. However, there is a similar radiopaque line seen projecting over\n the right upper quadrant which may be the tip of the OGT coming back up to the\n level of the pylorus.\n\n There has been some reaeration of some of the atelectatic areas in the left\n mid lung field and right upper lobe regions, although there is new patchy\n infiltrate above the left CP angle.\n\n No other significant changes are appreciated.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837181, "text": " 9:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: tube placement on morning of \n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with LLL pna and IPF, s/p intubation and OG placement. now\n with pna\n REASON FOR THIS EXAMINATION:\n tube placement on morning of \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate ETT placement.\n\n PORTABLE AP CHEST X-RAY: Comparison made to study from . Again seen is\n an ETT unchanged in position. NGT is seen with the tip not visualized\n extending below the inferior margin of the image field. There is no change in\n the right upper lobe and left lung field appearances. Partial aeration of the\n right upper lung zone is seen and unchanged. The diffuse patchy opacity seen\n in the left lung fields are unchanged from the previous exam. Previously\n noted patchy infiltrate in the left cardiophrenic angle is again seen.\n\n IMPRESSION: No interval change from previous exam. NGT tip is not\n visualized.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-02 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 836843, "text": " 12:48 PM\n CHEST (PA & LAT) Clip # \n Reason: eval for infiltrate, fluid\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with sob, doe, +green sputum\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, fluid\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath and green sputum.\n\n COMPARISON: .\n\n FINDINGS: PA & lateral views. Volume loss, extensive pleural thickening, and\n upper lobe scarring are again noted in the right lung, unchanged since the\n previous study. There is stable shift of the heart and mediastinum to the\n right. Bilateral bronchiectasis is again seen. Scarring and interstitial\n changes are again noted in the left lung. However, there is probable new\n patchy left lower lobe opacity, which in an appropriate clinical setting could\n be consistent with pneumonia. Follow-up after treatment is recommended. There\n is stable blunting of the left costophrenic angle, likely representing pleural\n thickening. The visualized osseous structures are unchanged.\n\n IMPRESSION: Possible new left lower lobe pneumonia. Follow- up after treatment\n is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 836869, "text": " 3:50 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with s/p intubation\n REASON FOR THIS EXAMINATION:\n assess tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status-post intubation.\n\n COMPARISON: Three hours prior.\n\n FINDINGS:\n AP PORTABLE SUPINE VIEW. The endotracheal tube terminates in satisfactory\n position, approximately 3.5 cm above the carina. Volume loss, extensive\n pleural thickening, and upper lobe scarring is again noted in the right lung.\n Bilateral bronchiectasis is again noted. Upper lobe scarring remains present\n in the left upper lobe. There is increased prominence of a pleural-based\n opacity in the left upper hemithorax, compared to . Correlation with\n chest CT of the same day is suggested. Patchy opacities are again noted in\n the left lower lobe, consistent with pneumonia. Pleural thickening is again\n seen in the left lateral costophrenic angle.\n\n IMPRESSION:\n 1. Satisfactory endotracheal tube position.\n 2. Left lower lobe pneumonia. Follow-up after treatment is recommended.\n 3. Increased prominence of pleural-based opacity in the left upper\n hemithorax. Correlation with chest CT of the same day is recommended.\n\n\n" }, { "category": "Radiology", "chartdate": "2109-09-06 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 837328, "text": " 10:30 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: HYPOXIA.INTUBATED\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with continued hypoxia on vent\n REASON FOR THIS EXAMINATION:\n Please evaluate for DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia on ventilator. Evaluate for DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS US: scale and doppler son of the\n right and left common femoral, superficial femoral and popliteal veins were\n performed. There is normal flow, augmentation, compressibility and waveforms.\n Intraluminal thrombus is not identified.\n\n IMPRESSION: No evidence of deep venous thrombosis.\n\n" }, { "category": "Radiology", "chartdate": "2109-09-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 837073, "text": " 8:43 AM\n CHEST (PORTABLE AP) Clip # \n Reason: comparison to prior film re progress pna\n Admitting Diagnosis: SHORTNESS OF BREATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with LLL pna and IPF, s/p intubation and OG placement. now\n with pna\n REASON FOR THIS EXAMINATION:\n comparison to prior film re progress pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55 y/o woman with lower lobe pneumonia, and IPF. Status post\n intubation. Now with pneumonia.\n\n TECHNIQUE: Portable AP chest radiograph.\n\n COMPARISON: Previous chest radiograph dated .\n\n FINDINGS: The tip of the endotracheal tube is terminating 5 cm above the\n carina. The balloon of the endotracheal tube is slightly overinflated. The\n previously identified OG tube is not identified in the present study.\n\n The volume of the bilateral lungs is decreased, which can be due to different\n respiratory condition.\n\n Again note is made of marked small right hemithorax in right lung. The right\n lung is almost completely opacified with oval-shaped collection of air. Again\n note is made of patchy parenchymal consolidations in the left lung.\n\n The patient is status post cholecystectomy.\n\n IMPRESSION: Bilateral smaller lung volume due to different respiration\n condition compared to the previous study. Small right hemithorax with small\n right lung, with oval-shaped collection of air. Patchy parenchymal\n consolidation on the left, most likely representing infectious process.\n\n Please refer to the chest CT on , as well.\n\n" }, { "category": "ECG", "chartdate": "2109-09-02 00:00:00.000", "description": "Report", "row_id": 141618, "text": "Sinus tachycardia. Left atrial enlargement. Compared to the previous tracing\nof the rate has increased. Otherwise, no diagnostic interim change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2155-03-16 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 784726, "text": " 2:33 PM\n CT CHEST W/O CONTRAST Clip # \n Reason: please comment on pleural effusion;please perform at same ti\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with diabetic ketoacidosis, elevated white blood cell count,\n deminished breath sounds on right side c pleuritic chest pain\n REASON FOR THIS EXAMINATION:\n please comment on pleural effusion;please perform at same time as LENI\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST WITHOUT CONTRAST.\n\n INDICATION: 23 year old male with diabetic ketoacidosis and elevated white\n blood cell count. Patient with decreased breath sounds on the right and\n pleuritic chest pain.\n\n TECHNIQUE: CT imaging of the chest without IV contrast. Contrast\n administration was not performed due to patient's elevated creatinine. There\n are no studies available for comparison.\n\n CT OF THE CHEST WITHOUT CONTRAST: There are bilateral pleural effusions\n (right greater than left) with associated compressive atelectasis bilaterally.\n There is evidence of pulmonary parenchymal air space opacification within\n within the posterior and superior segments of the right lower lobe. There is\n no evidence of pneumothorax. The heart and great vessels are unremarkable on\n this noncontrast study. There are prominent mediastinal and axillary lymph\n nodes; however, the lack of IV contrast limits this examination. The airways\n are patent to the level of the segmental bronchi bilaterally.\n\n The visualized portion of the upper abdomen demonstrates no evidence of free\n air and unremarkable liver, adrenal glands and spleen on this noncontrast\n study.\n\n Bone windows show no suspicious lytic or sclerotic lesions.\n\n IMPRESSION: Right lower lobe pulmonary parenchymal air space\n consolidation(with possible involvement of the left lower lobe) with evidence\n of bilateral pleural effusions and associated compressive atelectasis.\n Prominent mediastinal and axillary lymph nodes.\n\n" }, { "category": "Radiology", "chartdate": "2155-03-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784687, "text": " 5:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for pneumothorax\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with type I DM x 20 years p/w N/V in DKA\n\n REASON FOR THIS EXAMINATION:\n please evaluate for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: DKA.\n\n pCXR: Comparison is made to film from one day earlier.\n\n The cardiac silhouette is prominent as previously noted.\n\n There is interval improvement in aeration diffusely, consistent with resolving\n interstitial edema. There is still nonspecific increased density at both lung\n bases, right greater than left, probably due in part, at least on the right,\n to pleural effusions. Superimposed pneumonia cannot be excluded.\n\n There is no evidence of pneumothorax.\n\n IMPRESSION: 1) Prominent cardiac silhouette.\n 2) Resolving interstitial edema.\n 3) Persistent areas of increased density in both bases, right greater than\n left as described.\n\n" }, { "category": "Radiology", "chartdate": "2155-03-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784805, "text": " 2:57 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p R pleural effusion tap. please eval for PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with type I DM x 20 years p/w N/V in DKA\n\n REASON FOR THIS EXAMINATION:\n s/p R pleural effusion tap. please eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY.\n\n INDICATION: Diabetic ketoacidosis. Right pleural tap.\n\n AP PORTABLE CHEST: Compared to the exam of , there has been interval\n reduction in the size of the right-sided pleural effusion. There is no\n pneumothorax evident. There is haziness of the perihilar vessels, consistent\n with mild CHF. The heart is enlarged. A small amount of right effusion\n probably remains. Skeletal structures are unremarkable.\n\n IMPRESSION:\n\n 1) Interval reduction in size of small right pleural effusion. No\n pneumothorax.\n\n 2) Mild CHF.\n\n" }, { "category": "Radiology", "chartdate": "2155-03-16 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 784718, "text": " 1:04 PM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: RESPIRATORY DISTRESS, R/O DVT\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with pleuritic chest pain; pneumonia\n REASON FOR THIS EXAMINATION:\n please perform at same time as CT chest\n ______________________________________________________________________________\n FINAL REPORT\n BILATERAL LOWER EXTREMITY DVT STUDY.\n\n INDICATION: 23 year old male with pleuritic chest pain, evaluate for DVT.\n\n FINDINGS: scale and color Doppler son examination of the\n bilateral lower extremity venous system was performed. There is evidence of\n normal color flow, augmentation, wave form, and compressibility within the\n bilateral common femoral veins, superficial femoral veins, and popliteal\n veins. No intraluminal thrombus is identified.\n\n IMPRESSION: No evidence of DVT within the bilateral lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2155-03-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784578, "text": " 3:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: DKA, also confirm NGT placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with type I DM x 20 years p/w N/V in DKA\n REASON FOR THIS EXAMINATION:\n DKA, also confirm NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Nasogastric tube placement.\n\n A nasogastric tube terminates within the stomach.\n\n The heart is mildly enlarged and the pulmonary vascularity appears indistinct\n and slightly engorged. There is associated perihilar haziness and more\n confluent areas of opacity at the lung bases. There are bilateral small\n pleural effusions which have slightly increased in size in the interval.\n\n IMPRESSION:\n 1. Nasogastric tube terminates within the stomach.\n 2. Perihilar and basilar lung opacities, most likely due to pulmonary edema.\n Aspiration pneumonia is an additional consideration in the appropriate\n clinical setting.\n 3. Small bilateral pleural effusions.\n\n" }, { "category": "Radiology", "chartdate": "2155-03-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 784633, "text": " 11:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 23 year old man with type I DM x 20 years p/w N/V in DKA\n REASON FOR THIS EXAMINATION:\n please eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Diabetic. Keto acidosis.\n\n PORTABLE CHEST: Comparison is made to film from one day earlier. Nasogastric\n tube has been removed.\n\n The cardiac silhouette appears enlarged, but may be accentuated by film\n technique and rotation. The mediastinal and hilar contours are not well\n evaluated due to adjacent pleural parenchymal abnormality.\n\n Specifically, there is increased prominence of interstitial markings\n suggesting some worsening of diffuse interstitial edema.\n\n There is worsened aeration in the right lung base, which appears to reflect\n interval increase in right pleural effusion, now moderate in size. There is\n also considerably worsened aeration at the left retrocardiac area. Pneumonia\n in one or both lung bases cannot be excluded.\n\n There is also a small area of increased density which marginates and is just\n superior to the right minor fissure; early/limited pneumonia here also cannot\n be excluded.\n\n The left lateral costophrenic angle is sharp, without evidence of effusion.\n\n IMPRESSION: 1) Mild worsening of diffuse interstitial edema.\n\n 2) Increase in right pleural effusion.\n\n 3) Worsened aeration in the left retrocardiac area and caudal most aspect of\n the right upper lobe; pneumonia in these locations as well as the right base\n cannot be excluded.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1346877, "text": "admission note secondary to dka\nD: PT IS 23 YO MALE WITH PMH: DM SINCE AGE OF 2,RENAL INSUFFICIENCY AND EF=35%,VENTRICTOMY 2 WKS AGO,PERIPHERAL NEUROPATHY,MIGRAINES,DEPRESSION, CHF AND HTN. PT HAS . ADMITTED TO EW TODAY WITH C/O VOMITTING/DIARRHEA FOR 1-2 DAYS. BS IN EW 1149 AND INSULIN GTT WAS STARTED. K+ 6.7. NGT WAS PLACED AND BILIOUS RETURN AND GUIAC POS. TRANSFERED TO MICU FRO FURTHER MANAGEMENT OF DKA.\n\nREVIEW OF SYSTEMS:\n\nNEURO: LETHARGIC BUT ALERT AND ORIENTED. FOLLOWS SIMPLE COMMANDS AND MAE'S. NEUROLOGICALLY INTACT.\n\nRESP: PT ON ROOM AIR WITH O2 SATS>98%. LUNGS ESSENTIALLY CLEAR BUT WITH CRACKLES AT L BASE. NO C/O SOB/CP. WILL FOLLOW O2 SATS AND LUNG SOUNDS BECAUSE OF PT'S HX OF CHF.\n\nCV: HR IN THE 90'S NSR WITHOUT ECTOPY. SBP 160'S. HAVE RESTARTED HI CARDIAC MEDS OF LABETOLOL,ISORBIDE DINITRATE AND HYDRALAZINE. PT TAKES NORVASC AT HOME BUT WILL CONTINUE TO HOLD FOR NOW. K+ INITIALLY 6.7 AND REPEAT UPON ADMISSION=4.7. WILL FOLLOW CHEM 7 Q 2 HRS AS ORDERED BY MEDICAL TEAM.\n\nGI: PT C/O DISCOMFORT TO THROAT FROM NGT IN PLACE AND IT WAS D/C'D . PT NOW TAKING FULL CLEAR LIQS AS PT TOLERATES. HIS ORAL MUCOSA IS VERY DRY. ABD SOFT AND BENIGN ON EXAM WITH POS BOWEL SOUNDS ON AUSCULTATION. AUSCULTATION. NO FURTHER C/O N/V AT PRESENT.\n\nRENAL: PT REFUSES FOLEY CATH TO BE PLACED. MEDICAL TEAM NOTIFIED AND WILL NOT PLACE IF PT IS ABLE TO VOID ADEQUATELY ON HIS OWN. BUN=116 AND CREAT=8.1.DR . FROM RENAL TEAM FOLLOWING PT. WE ARE NOT TO USE PT'S LEFT ARM IN CASE IT IS NEEDED FOR HD ACCESS. WILL FOLLOW I&O CLOSELY AS WELL AS BUN AND CREAT AS TEAM ORDERS. PT BEING HYDRATED WITH NS WITH 40 MEQ KCL AT 250CC'S/HR AND NS AT 250 CC'S/HR BOTH FOR 1 LITER EACH.\n\nENDOCRINE: PT 'S BS 877 ON ADMISSION TO MICU AND INSULIN GTT NOW AT 10U/HR AND WILL RECHECK CHEM 7 AT 1830. CONTINUE TO CHECK BLOOD SUGARS Q 1 HR WHILE PT ON INSULIN GTT. LAST CO2 REPORTED TO BE 11.\n\n\nIV ACCESS: PT HAS 2 PIV'S IN PLACE TO R ARM - 1 18G AND 1 20G. DO NOT USE L ARM FOR IV ACCESS AND OR PHLEBOTOMY- TO BE SAVED FOR HD ACCESS IF NEEDED.\n\nSOCIAL: PT IS A FULL CODE. FATHER IN TO VISIT WITH PT AND WAS UPDATED AND INFORMED OF THE PLAN OF TX.\n\nCONTINUE TO FOLLOW LABS AS ORDERED.TITRATE INSULIN GTT AS NEEDED TO KEEP BLOOD SUGARS WELL CONTROLLED. MONITOR FLUID STATUS CLOSELY AND NOTIFY MEDICAL TEAM IF RALES TO LUNG INCREASE OT HIS O2 SATS DROP TO LOW 90'S ON ROOM AIR WE NEED TO APPLY NASAL CANNULA O2 OT DECREASE AMT OF IVF PT RECEIVES.\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 1346878, "text": "correction to the above note; pt is allergic to zestril-please note\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1346883, "text": "NPN\n\nCV: VSS 130-160/70-80s, tolerating his cardiac meds. CPKs sent this evening.\n\nResp: LS with rales 2/3 up from the bases on the R, clear on the L, 02 SAT is improving, he is presently 97-98% on RA. He conts to have intermitant mid CP with coughing and deep breathing - no sputum, he states that his pain is , states that it is tolerable. He had a CT scan which showed bilat pleural eff R>L, compressive atalectesis, and pulm perenchemal airspace opacification. He was started on IV hep at 1200U/hr for ? PE, LENI done which were neg, he now has pneumo boots on.\n\nGI: Conts to have intermitant nausea - no vomiting, though he is hungry and is not sure if his nausea is from the hunger or the illness that brought him in. He had juice which he tolerated well, had chicken soup and some mac and cheese, after dinner he had diarrhea which he was having at home. Stool to be sent for cdif, if neg than anti diarrhea will be started.\n\nGU: Very good u/o 500-1000cc at a time, conts to be followed by renal, he is 500 pos for LOS and almost 2000cc neg today, D51/2 at 50cc/hr was stared.\n\nNeuro: A&Ox3, slept on and off through the day.\n\nEndo: Conts on an insulin gtt, he went from 10u/hr to 0 units in 2.5 hrs, he is presently on 5U/hr and the team would like to cont the insulin gtt and given him sugar either with food or IV to maintain his BS. He does drop his BS quickly and it rises as fast as it falls, q 1 -1/2 hr BS cont.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-17 00:00:00.000", "description": "Report", "row_id": 1346884, "text": "D Neuro: Alert and oriented MAE.\nCV: NSR no Ectopi noted. feet with slight edema palp DP with difficulty venodynes on heparin initially at 1200 up to 1350 per protocol. Insulin titrated for BS 80-120 currently off. D5NS + 20 at 50 k 3.0 20meg po given pt tolerated .L aline . good wave draws well.\nLungs: upper lobes clear bases initially very coarse much less coarse this am.when awake o2 sat >94 on Ra when asleep < 90 on RA . NC at 3L while sleeping.\nGI: abd soft BS present. pt with nausea and most of evening had small amts of yellow emmisis. around 2200 C/o of sever Heartburn different from earlier nausea. \" it hurts.\" EKG done no Change. pt said not chest pain. HO saw pt felt GI complant. pt had recieved phenergan and zofran as well as MSo4 with little relief. unable to take po meds. reglan and pepcid order given with effect. Pt was able to sleep and this morning had no nausea tolerated po meds and apple juice.\nGU: voiding\nSkin dry and intact.\nA GI distress and DKA resolving.\nP repleat lytes as order and restart 2nd IV. continue reglan. start on food and sc insulin today.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1346881, "text": "NPN\nMICU\n7 PM -7 AM\nS \" I HAVE SUCH CRUSHING CHEST PAIN ..THAT I CAN'T BREATHE \"\nO PLS SEE CAREVIEW FLOWSHEET FOR ALL OBJ/NUMERICAL DATA\nCV HR 90'S...SBP 120-130'S/70 ..CONTINUES ON LABETOLOL/HYDRALAZINE/ISORDIL....SIGNIFICANT ^^ IN HR TO THE 120'S WITH MINIMAL ACTIVITY ....EKG DURING CHEST PAIN EPISODE WITHOUT CHANGES ..CPK 210..TROPONIN NL...\nRESP ON 3L NP ..RESP EFFORT VERY SHALLOW ..PT VOICED CONCERNS ABOUT INABILITY TO \"CATCH HIS BREATH / TAKE A DEEP BREATH \" ..MARKEDLY DIMINISHED BREATH SOUNDS ON THE RIGHT ..WITH CXS 3/4 UP BILAT ON LEFT ..REPORTS FEELING OF PULM CONGESTION FROM UPPER CHEST DOWNWARD\nGI DENIED NAUSEA UNTIL 0600..IV ATIVAN ONE MG WITHOUT MUCH AFFECT\nGU UNABLE TO STAND TO VOID WITHOUT ASSIST ..REFUSING FOLEY ....\nENDOCRINE LABILE BLOOD SUGARS ..ON Q1 FINGERSTICKS..WITH SERUM BLDS Q3-4 ..TITRATION OF INSULIN GTT TO FINGER STICKS ...\nVOICED CONCERNS ABOUT POTENTIAL PAINFUL PROCEDURES ( SUCH AS A-LINE,QUINTON CATH PLACEMENT, FOLEY PLACEMENT ) MAKING IT DIFFICULT FOR HIM TO UNDERSTAND THE REASONS FOR THE ABOVE PROCEDURES ...\nA CRITICALLY ILL YOUNG MALE WITH PULM/RENAL/ENDOCRINE COMPROMISE\nP CHECK AM CXR...?? RIGHT PULM TAP...? FOLEY INSERTION FOR AGGRESSIVE DIURESIS... ?? DIALYSIS DATE ..ALINE INSERTION ASAP -\n" }, { "category": "Nursing/other", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 1346882, "text": "MICU NSG 7A-11A\nRESP--REMAINS ON 2L NC, DESATTS TO 89-90% WHEN ON RA, O2 SAT 96-98% WHEN LYING STILL, DROPS TO 93% WITH MOVEMENT. LUNG FIELDS WITH DIMINSHED ON LOWER OF RIGHT SIDE WITH CRACKLES IN UPPER AIRWAY, LEFT WITH CRACKLES WAY UP. BREATHING APPEARS MORE LABORED. C/O RIGHT SIDED AND ACROSS CHEST PAIN, PT STATES , RECEIVED MSO4 2MG TOTAL WITH IMPROVEMENT IN CP TO . PT WITH INC IN PAIN WHEN TAKES A DEEP BREATH. PT TENDS TO MINIMIZE DISCOMFORT UNLESS ASKED SPECIFIC QUESTIONS TO RATE PAIN, EXAMPLE..STATES \"FEELS FINE\" THEN RATES PAIN AS . PLAN IS FOR CT OF CHEST TO EVAL EFFUSION AND POSSIBLE RIGHT SIDED PNX.\nCV--WILL BE R/O VIA CK'S, #1 AND 2 SENT, DUE FOR 3RD THIS EVE. CONTS WITH CP AS ABOVE. CONTS WITH (+) EDEMA IN EXTREMITES. TO BE STARTED ON IV HEPARIN AND HAVE LENI'S TODAY TO R/O DVT.\nGI--C/O N/V WITH 1 EPISODE OF VOMITTING THIS AM. RECEIVED ZOFRAN 2MG IV X1 WITH EFFECT. NO BM SINCE ADMIT, ABD SL DISTENDED, PT DENIES ABD PAIN.\nGU--REF CONDOM CATH AND FOLEY. VOIDING IN URINAL IN BED. CREAT REMAIN IN 7 RANGE. ? WILL NEED HD IN NEXT 1-2 DAYS.\nENDO--REMAINS ON Q3 CHEM 7, HCO3 ~10. ALINE BEING PLACED FOR FRQ LABS. REMAINS ON INSULIN GTT, SEE CAREVIEW FOR RATES AND FS.\nSOCIAL--MOTHER CALLED THIS AM, UPDATED ON PT'S CONDITION. FATHER IS PLANNING TO VISIT THIS AFTERNOON.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1346879, "text": "MICU NPN 7P-7A\nEvents of shift: Blood sugars have trended down from highs in the 700's at start of shift to 99-102 now. See flowsheet for insulin titration over time. Hct @ 1830 24; 1U PRBCs given; repeat Hct to be drawn with AM labs. A few episodes in the early PM of RUQ abd. pain, probably secondary to gastritis/ ? - tear due to earlier vomiting. EKG obtained to R/O CP; no changes noted. Vomiting x 1 of small amt. guiac + bile. Total 25 mg Phenergan 2 mg MSO4 2 mg Zofran given with relief. Pt. now sleeping, denies pain, no further episodes of vomiting.\n\nReview of systems:\n\nNeuro: Pt. AAO x 3, MAE, sleeping continuously throughout night, wakes for brief periods when stimulated.\n\nResp: Lungs clear upper, slt. amt. crackles bilat bases. On 2L NC while sleeping to maintain O2 sat>91%.\n\nCV: BP stable, HR remains NSR in 80-90's without ectope. No edema noted; strong pulses T/O.\n\nGI: + BS x 4; abd. soft, not distended, tender in RUQ at times; team aware, have evaluated this. Taking PO meds and H2o without issues. No BM.\n\nGU: Pt. has not voided yet this shift; 1 void of 350 cc on shift prior. Pt. has also been sleeping all night; if he does not void upon waking this AM, I will alert the team. BUN/Creat have been coming down steadily all night, from 116/8.1 in the ER to 102/7.7 @ 0030. Continue to follow trends. Renal team following pt. currently. Current IVF is D5NS @ 100 cc/hr x 1L.\n\nAccess: 2 PIVs in R arm working well. No phebotomy or IVs in L arm in case it is needed for dialysis access.\n\nEndo: Insulin gtt up to max of 14 u/hr overnight, now at 1 u/hr with BS 99-102. Continue to titrate gtt to between 80-120 for now; pt. will be switched to humalog SSI during the day.\n\nSocial: No calls/visits from family overnight.\n\nSee Carevue for further details.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-03-15 00:00:00.000", "description": "Report", "row_id": 1346880, "text": "MICU NSG 7A-7P\nRESP--LUNGS WITH CRACKLES WAY UP BOTH SIDES. CONTS ON 2-3L NC WITH SATS 92-98%. HAS COUGH, BUT HAS NOT PRODUCED ANY SPUTUM YET, WILL NEED SPEC WHEN AVAILABLE. RECEIVED SUDAPHED FOR C/O NASAL CONGESTION. CXR DONE.\nCV--CONTS ON MULTIPLE BP MEDS WITH GOOD CONTROL. (+)2 GENERALIZED EDMA IN EXTREMITES, RESTARTED ON PO LASIX DOSE. IONIZED CA 1.0 AND RECEIVED 2 AMPS CA GLUCONATE. HCT STABLE AT 27, PLANS ON TO TRANS IF DROPS TO UNDER 25.\nENDO--REMAINS ON Q3 CHEM 7. LABS IMPROVING, BUT CONTS ON IV INSULIN SEE CAREVIEW. FS RANGING FROM 65-180. D5NS STOPPED AS PT VOLUME OVERLOADED, AND PT ABLE TO TOL CLEAR LIQS.\nGI--RECEIVED ZOFRAN 2MG IV X1 FOR C/O NAUSEA, MSO4 1MG IV X1 FOR C/O FLANK PAIN. TOL PO'S, NO BM THIS SHIFT.\nGU--CREAT IMPROVED, DOWN TO 7.1. VOIDS IN LG AMOUNTS.\nNEURO--SLEEPING MOST OF SHIFT, AWAKENS EASILY.\n" }, { "category": "Nursing/other", "chartdate": "2155-03-17 00:00:00.000", "description": "Report", "row_id": 1346885, "text": "altered endocrine state\nd: pt a&o x3. neurologically intact.\nresp: on o2 at 2l/m nc. crackles 1/2 up on r and at the left base. r thoracentesis done and tapped for 1250cc's flui 02 sats>96%. all ivf have been d/c'd because of adequate po intake.\n\ngi: pt tolerating reg diet. no c/o nv and now on reglan. hct stable and receiving epogen sc bid. will follow hcts as ordered.\n\nrenal: renal team following pt on daily basis has voided >1 l of urine. bun and creat remain elevated but improved since admission. will eventually need dialysis and will not use l arm for piv's or phlebotomy.\n\niv access: pt has 2 piv's 1 -18g and 1 20 g to r upper extremity.\n\nsocial: pt is a full code and his father has been updated.\n" }, { "category": "ECG", "chartdate": "2155-03-16 00:00:00.000", "description": "Report", "row_id": 145208, "text": "Sinus rhythm. Prolonged Q-T interval. Low amplitude T waves in lead I, inverted\nT waves in lead aVL. Compared to the previous tracing of T wave\namplitude has diminished as described and the Q-T interval remains prolonged.\n\n" }, { "category": "ECG", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 145209, "text": "Sinus rhythm. Compared to the previous tracing no diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2155-03-14 00:00:00.000", "description": "Report", "row_id": 145210, "text": "Sinus rhythm. Left atrial abnormality. Compared to the previous tracing\nof no significant change.\nTRACING #1\n\n" } ]

[ { "category": "Echo", "chartdate": "2156-04-23 00:00:00.000", "description": "Report", "row_id": 68330, "text": "PATIENT/TEST INFORMATION:\nIndication: VT. Cardiomegaly on x-ray.\nHeight: (in) 68\nWeight (lb): 220\nBSA (m2): 2.13 m2\nBP (mm Hg): 149/90\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 15:45\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, cavity size and regional/global\nsystolic function (LVEF >55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Borderline PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thickness, cavity size and regional/global systolic function are normal\n(LVEF >55%). Right ventricular chamber size and free wall motion are normal.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic stenosis or aortic regurgitation. The mitral valve\nleaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There\nis borderline pulmonary artery systolic hypertension. There is no pericardial\neffusion.\n\nIMPRESSION: Normal global and regional biventricular systolic function. Mild\nmitral regurgitation.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-04-22 00:00:00.000", "description": "BY DIFFERENT PHYSICIAN", "row_id": 1232956, "text": " 4:35 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: r dl power picc 45cm iv \n Admitting Diagnosis: TONGUE SWELLING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 54 year old man with picc\n REASON FOR THIS EXAMINATION:\n r dl power picc 45cm iv \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: PICC line insertion.\n\n TECHNIQUE: AP portable chest radiograph.\n\n COMPARISON: at 2:27 a.m.\n\n FINDINGS: A new right PICC terminates in the low SVC. The ET tube terminates\n approximately 4 cm above the carina. There is no pneumothorax or pleural\n effusion. The heart size is borderline. There is no interval change from\n 2:27 a.m.\n\n Results were discussed with , IV nurses.\n MJMgb\n\n" }, { "category": "ECG", "chartdate": "2156-04-21 00:00:00.000", "description": "Report", "row_id": 147376, "text": "Normal sinus rhythm. Normal tracing. Compared to the previous tracing\nof inferior Q waves are no longer seen.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 1523112, "text": ",rrt\npt. remained on a/c 500,14,fio2< to60% following abg, will monitor.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 1523113, "text": "CCU NURSING PROGRESS NOTE\nS:TUBED\nO:PT FROM REHAB. INTUBATED IN FIELD, TO ER IN PULM EDEMA. EKG AVP, W/ POST MI. RECENT ADMIT FOR STEMI AND 10 STENTS IN RCA.\nPT IS PRIMARY SPEAKING. MD NOT ABLE TO CONTACT FAMILY. PT REQUIRING SEDATION W/ VERSED AND FENTANYL OTHERWISE ATTEMPTING TO SIT UP IN BED. UNABLE TO MAX SEDATION D/T LABILE BP.\nCV:AVP, SBP 70-100. DP PAL BUT WEAK, EXTREMITIES COOL, HANDS COLD. STARTED ON HEPARIN GTT, NO BOLUS, PTT DUE AT 10:00.\nRESP:VENT, AC/14/500/60/8, LAST ABG 7.33/39/141/21/. LS COARSE BS AND CRACKLES BILAT. LASIX GTT STARTED NOW THAT BP >90\nGI:VOMITED UNDIGESTED FOOD DURING OGT INSERTION ATTEMPT. RECIEVED ANZIMET. HYPO BS.\nGU:PALE YELL.\nA/P:PULM EDMA, W/ MI. LASIX GTT, CPK PENDING. PT WAS A DNR/DNI AT REHAB, PLS DISCUSS CODE STATUS WITH FAMILY TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 1523114, "text": "CCU Progress Note:\n\nThis is a yr old female who developed SOB @ Rehab- sats were low- 911 called - Pt given lasix & intubated in route to Pt was discharged from to Rehab DNR/DNI- paperwork was not readily available & code status unclear @ , 911 was called- This Pt has a Hx CAD, MI X3 (recent STEMI ) 3VD S/P stents RCA (hepacoat stents X5 in & cyper stents X5 ), 95% occluded LCx & LAD, A/V pacemaker, AV node ablation to prevent tachycardia (Afib RVR), HTN, CRI and hypothyroid- She was admitted to CCU on vent for further management.\n\nS- speaking only.\n\nO- see flowsheet for all objective data.\n\nresp- intubated on vent this am- Placed on CPAP & tolerated well- weaned down to 50% 5/5 ABG 7.39-36-92-23-97%- Pt successfully extubated- lung sounds with bibasilar crackles- In O2 50% CN- SpO2 94-97%- expectorated brown/blood tinged colored mucous.\n\ncv- Tele: AVP rhythm- HR 80- R radial Aline- ABP 90-121/45-59- MAPs 60-80- Hct 30.9 (last 34.3)- K 4.4- Mg 1.8- heparin gtt D/ PT 19.1 (was on coumadin) PTT 28.7 INR 2.6 CPK 99\n\ngi- abd soft (+) bowel sounds- OGT D/C'd when extubated- no BM today.\n\ngu- foley draining pale yellow colored urine- con't on lasix gtt @ 10mg/hr- (-) 900cc since 12am- BUN 36 Crea 2.2\n\nneuro- alert- interpreter in & states Pt is oriented- moving all extremities- pleasant & cooperative- understands simple sign language.\n\n MD & interpreter spoke with Pt regarding code status- Pt is a full code- Her daughter is (in @ present).\n\n Pt with 3VD developed flashed pulmonary edema requiring intubation & diuretics- successfully extubated this afternoon.\n\nP- monitor vs,lung sounds, I&O and labs- repeat Hct tonight- advance PO- increase activity tomorrow- ? discharge to floor if stable overnight.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2155-11-18 00:00:00.000", "description": "Report", "row_id": 1523115, "text": "CCU NPN 7p-7a\nS: speaking, per family translation pt. states that her breathing is much improved after diuresis. C/o sore throat.\nO: please see carevue for complete assessment data\nNo events overnight\nNERUO: Pleasant and cooperative speaking woman. Communicated via hand gestures and bilingual cards provided by guests. No c/o pain, only soreness in throat r/t ETT, relieved w/ juice/ice chips. Requested sleeping med but pt. slept soundly w/o. MAE, normal strength, A&Ox3 per visitors but c/o not being able to remember past 24hrs.\n\nCV: HD stable, lasix gtt 10mg/hr off @ 0030 d/t brief hypotension (SBP 80s w/ MAP 60). Cont to autodiurese, currently ~2.5L net neg. No c/o CP, BP 100s-130s/50s, HR 80 AV paced, no ectopy noted. Distal pulses +3 bilaterally, no peripheral edema noted. PM hct stable, awaiting am labs. MG repleted w/ 2gm mg sulfate\n\nRESP: breathing comfortably on 3L NC w/ SpO2 ~95%. LS clear anteriorly, rales @ bases bilaterally (). Intermittent cough productive of thick rust colored sputum. RR low/mid 20.\n\nGI/GU: abdomen soft, nontender, mildly distended. +BS/-BM, no c/o N/V/D/C. Tolerating CLs w/o incident, minimal appetite. Foley draining CLYU, -2.5L. BUN/Cr pending.\n\nENDO: BG wnl, no RISS coverage needed.\n\nID: afebrile. Cont levaquin and flagyl for ? asp event and possibly ASP PNA while intubated. WBC trending down, awaiting am result.\n\nSKIN: cool, dry, pale, intact. No breakdown noted. Multiple PIVs R/L arms and R radial art line intact.\n\nSOC: dtr is out of the country on business, multiple friends in to visit, very supportive.\n\nA: yo w/ extensive cardiac hx presented to ED via rehab late for resp failure; requiring brief intubation, diuresis and BP control. Currently HD and resp stable s/p extubation , tolerated diuresis.\nP: f/u am labs, replete as needed. Monitor fluid balance HD sts w/ lasix gtt off, ? start standing lasix PO? PT consult, ^ diet and activity as tolerated. C/o awaiting available bed.\n" }, { "category": "ECG", "chartdate": "2155-11-21 00:00:00.000", "description": "Report", "row_id": 309559, "text": "Regular A-V sequential pacing\nPacemaker rhythm - no further analysis\nNo change from previous\n\n" }, { "category": "ECG", "chartdate": "2155-11-19 00:00:00.000", "description": "Report", "row_id": 309560, "text": "A-V paced rhythm\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2155-11-18 00:00:00.000", "description": "Report", "row_id": 309561, "text": "A-V paced rhythm\nSince previous tracing of , precordial lead ST-T wave changes decreased\n\n" }, { "category": "ECG", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 309562, "text": "Taken with magnet\nA-V paced rhythm\nSince previous tracing of same date, Taken with magnet\n\n" }, { "category": "ECG", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 309563, "text": "Taken without magnet\nA-V paced rhythm\nSince previous tracing of same date, further precordial ST-T wave changes T\nwave changes\n\n" }, { "category": "ECG", "chartdate": "2155-11-17 00:00:00.000", "description": "Report", "row_id": 309564, "text": "A-V paced rhythm\nSince previous tracing of , probably no significant change\n\n" }, { "category": "ECG", "chartdate": "2155-11-16 00:00:00.000", "description": "Report", "row_id": 309565, "text": "A-V paced rhythm\nSince previous tracing of , further precordial ST-T wave changes\npresent\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2199-05-28 00:00:00.000", "description": "Report", "row_id": 1517263, "text": "FOCUS; NURSING PROGRESS NOTE\nREVIEW OF SYSTEMS-\nNEURO- SHE IS LETHARGIC BUT ORIENTED TO PERSON AND PLACE. DOES NOT KNOW DATE. SHE ALSO DOES NOT KNOW WHO THE PRESIDENT IS.\nRESP- ON 3L NC WITH SATS HIGH 90'S. WEANED TO 2L NC WITH SATS 98-100%. RESP 14-21. BS CLEAR DIMINISHED AT THE BASES.\nCARDIAC- HR 50-54 SB WITHOUT ECTOPI. MAP RANGING 60-80 TODAY. NA DOWN TO 155. CONT ON NS AT 250CC/HR X 2L. THIS WILL FINISH AT 2200 TODAY. WILL NEED TO CHECK WITH HO FOR FURTHER IV ORDERS AT THAT TIME. RECEIVED 1 L NS OVER 2 HOURS THIS SHIFT. K IS 3.8.\nGI- ABD SOFT WITH POS BS. STARTED ON DIABETIC HEART HELATHY DIET. HAD SOME DIABETIC CUSTARD AND GINGERALE. TOLERATED THIS WELL. IS ON ASPIRATION PRECAUTIONS. BED MUST BE PUT IN ARTERIAL POSITION WITH HOB UP 30 DEGREES TO LEFT FEM LINE.\nGU/RENAL- UO 60-120CC/HR. BUN AND CREAT 74 AND 2.1 WHICH IS DECREASING.\nENDO- BS 177-98. ON SS INSULIN.\nSOCI9AL- SON IN AND WAS UPDATED BY NURSING. PLEASED WITH HIS MOTHER'S PROGRESS.\nDISPO- IS CALLED OUT TO FLOOR WHEN A BED IS AVAILABLE. BED IS BEING SAVED IN NH WHERE SHE CAME FROM. REMAINS A FULL CODE.\n" }, { "category": "Nursing/other", "chartdate": "2199-05-28 00:00:00.000", "description": "Report", "row_id": 1517264, "text": "FOCUS; ADDENDUM\nGI- PATIENT DID OK WITH CUSTARD THIS AFTEROON AND GINGERALE. THIS EVENING COUGHED A LOT WITH TAKING SOUP. ? IF SWOLLOW EVAL WOULD BE BENEFICIAL AT BEDSIDE. WILL LET HO KNOW OF THIS.\n" }, { "category": "Nursing/other", "chartdate": "2199-05-27 00:00:00.000", "description": "Report", "row_id": 1517261, "text": "CCU NRSG ADMIT NOTE\n79 NURSING HOME FEMALE, WITH PAST MED HX OF DEMENTIA, DEPRESSION, PSYCHOSIS, AODM AND OSTEOARTHRITIS. IN NURSING HOME THE FOUND PT WITH ^^ BLOOD SUGAR, SLURRED SPEECH AND LETHARGIC, REC'D 8U REG INSULIN SQ WITH NO SIGNIFICANT CHANGE IN BS THEREFORE CALLED EMTS WHO GAVE .4MG NARCAN AND TRANSFERRED HER TO . HERE WE NOTED ^^NA ^^BS AND ^^ BUN/CREAT. REC'D 8U IV REGULAR INSULIN WITH A DECREASE IN HER BS. STARTED D5W AND ALSO REC'D ONE DOSE OF IV LEVOQUIN FOR (+) UTI. TRANSFERRED TO CCU FOR FURTHER MANAGEMENT.\n ON ARRIVAL, SHE IS PLEASANTLY CONFUSED, STATING THAT SHE IS \"WHITE AND \". SHE IS ORIENTED TO PLACE AND PERSON ONLY. SHE HAS A LOW GRADE TEMP. HR 50'S SB WITH BP 110-120'S. LUNGS ARE CLEAR BUT SLIGHTLY DIMINISHED (DUE TO POOR EFFORT), O2 AT 2L NP WITH SATS 95-97%, NO COUGH NOTED. FOLEY DRNG YELLOW VERY CLOUDY URINE. NO BM. D5W INFUSING AT 125CC/HR. SEE CAREVUE FOR BS AND FREQUENT LYTE CHECKS. L PERIPH IV WAS INFILTRATED UPON ARRIVAL, IV DC'D AND NEW IV PLACED IN R ARM.\n" }, { "category": "Nursing/other", "chartdate": "2199-05-28 00:00:00.000", "description": "Report", "row_id": 1517262, "text": "NEURO; PT. REMAINS LETHARGIC AND CONFUSED THROUGHOUT THIS SHIFT. PT. AROUSES EASILY TO VERBAL STIMULI AND DOES DENY ANY PAIN OR DISCOMFORT DURING THIS SHIFT. PT. IS NOTED TO MAE'S AND HAS REMAINED AFEBRILE DURING THIS SHIFT.\n\nC.V; PT. HAS BEEN NSB 53-58 WITH NO NOTED ECTOPY DURING THI SSHIFT. PT'S B/P HAS BEEN 90-100/ 30-50'S, TEAM IS AWARE OF MAP'S 57-60. PULSES EASILY PALPABLE. RECENT LYTES HAVE EXHIBITED NA+ 162 NOW DOWN TO 158.\n\nRESP; PT. HAS BEEN CLEAR IN MID-UPPER LOBES WHILE DIM IN THE BASES. O2 ON AT 2L/MIN VIA N/C AND SATS READ 97-100% RESP RATE CONTROLLED.\n\nGI; PT. REMAINS NPO AT THIS TIME. B.S. ARE EASILY AUDIBLE IN ALL QUADRANTS AND NO STOOL NOTED. ABD. ASSESSMENT IS BENIGN AT THIS TIME.\n\nGU; PT. HAS FOLEY CATHETER DRAINING SMALL BUT AMPLE AMT'S OF CLOUDY YELLOW URINE.\n\nIV; PT. HAS LEFT FEMORAL TLC IN PLACE WITH .45 N/S INFUSING AT 250CC/HR AND KVO OF N/S IN SECOND LINE. PT. ALSO RECEIVES LEVPFLOXIN IVPB.\nDISPO; MAINTAIN FREQUENT LYTES AND MONITOR SODIUM LEVEL, GOAL IS TO DECREASE NA+ 11MEQ IN A 24HR PERIOD UNTIL WNL'S.\n" }, { "category": "Echo", "chartdate": "2199-05-27 00:00:00.000", "description": "Report", "row_id": 96733, "text": "PATIENT/TEST INFORMATION:\nIndication: Aortic valve disease. Hypertension. Hypertrophic cardiomyopathy. Left ventricular function. Urosepsis.\nHeight: (in) 60\nWeight (lb): 170\nBSA (m2): 1.74 m2\nBP (mm Hg): 122/30\nStatus: Inpatient\nDate/Time: at 13:30\nTest: Portable TTE (Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy with\nnormal cavity size. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Left ventricular systolic function is\nhyperdynamic (EF>75%). A mid-cavitary gradient is identified. A false tendon\nis seen in the left ventricle (normal variant).\n\nRIGHT VENTRICLE: Right ventricular chamber size and free wall motion are\nnormal.\n\nAORTIC VALVE: The aortic valve leaflets appear structurally normal with good\nleaflet excursion.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is\nmoderate mitral annular calcification. Moderate (2+) mitral regurgitation is\nseen.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. The pulmonary artery systolic pressure could not be\ndetermined.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve is not well seen.\n\nPERICARDIUM: There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor apical views. The patient is\nbradycardic (HR<60bpm). Based on AHA endocarditis prophylaxis\nrecommendations, the echo findings indicate a moderate risk (prophylaxis\nrecommended). Clinical decisions regarding the need for prophylaxis should be\nbased on clinical and echocardiographic data. The echocardiographic results\nwere reviewed by telephone with the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size and hyperdynamic systolic function\n(LVEF>75%). Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. No is seen, but a moderate resting\nmid-cavitary/LVOT gradient is identified (peak 44mmHg). Right ventricular\nchamber size and free wall motion are normal. The aortic valve leaflets appear\nstructurally normal with good leaflet excursion. Trace aortic regurgitation is\nsuggested. The mitral valve leaflets are mildly thickened. Moderate (2+)\nmitral regurgitation is seen. The pulmonary artery systolic pressure could not\nbe determined. There is an anterior space which most likely represents a fat\npad, though a loculated anterior pericardial effusion cannot be excluded.\n\nCompared with the prior report (tape unavailable for review) of , a\nmid/LVOT gradient is now identified c/w hypertrophic obstructive\ncardiomyopathy and the severity of mitral regurgitation has increased.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2199-05-26 00:00:00.000", "description": "Report", "row_id": 263370, "text": "Sinus bradycardia\nBaseline artifact makes interpretation diffult\nSince previous tracing, absent\n\n" } ]

[ { "category": "Radiology", "chartdate": "2147-10-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 774915, "text": " 4:05 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for acute cardiopulmonary process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with CP\n REASON FOR THIS EXAMINATION:\n assess for acute cardiopulmonary process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73 year old man with chest pain.\n\n PORTABLE AP UPRIGHT VIEW OF THE CHEST: No comparisons. The heart size is\n likely within normal limits given AP technique. The heart has a left\n ventricular configuration. The aorta is unfolded. There is slight prominence\n of the pulmonary vasculature without overt evidence of failure. Lungs are\n otherwise clear. Osseous structures are grossly unremarkable.\n\n IMPRESSION: No definite evidence of failure or pneumonia.\n\n" }, { "category": "Echo", "chartdate": "2147-10-24 00:00:00.000", "description": "Report", "row_id": 68067, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease. Left ventricular function.\nHeight: (in) 73\nWeight (lb): 170\nBSA (m2): 2.01 m2\nBP (mm Hg): 101/53\nStatus: Inpatient\nDate/Time: at 11:25\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is mildly dilated.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: There is mild symmetric left ventricular hypertrophy. The left\nventricular cavity size is normal. Overall left ventricular systolic function\nis severely depressed. There is no resting left ventricular outflow tract\nobstruction. No masses or thrombi are seen in the left ventricle.\n\nRIGHT VENTRICLE: The right ventricular wall thickness is normal. Right\nventricular chamber size is normal. There is focal hypokinesis of the apical\nfree wall of the right ventricle.\n\nAORTA: The aortic root is mildly dilated. There are focal calcifications in\nthe aortic root. The ascending aorta is mildly dilated. There are focal\ncalcifications in the ascending aorta.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened but not\nstenotic. No aortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened. There is no\nmitral valve prolapse. There is mild mitral annular calcification. There is\nmild thickening of the mitral valve chordae. The tips of the papillary muscles\nare calcified. Mild (1+) mitral regurgitation is seen.\n\nTRICUSPID VALVE: The tricuspid valve leaflets are normal. Mild tricuspid [1+]\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: The pulmonic valve leaflets appear\nstructurally normal with physiologic pulmonic regurgitation. The main\npulmonary artery and its branches are normal. No color Doppler evidence for a\npatent ductus arteriosus is visualized.\n\nPERICARDIUM: There is no pericardial effusion. There is an anterior space\nwhich most likely represents a fat pad, though a loculated anterior\npericardial effusion cannot be excluded.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity size is normal. Overall left\nventricular systolic function is severely depressed (ejection fraction 20-30\npercent) secondary to severe hypokinesis of the inferior septum, anterior\nseptum, and anterior free wall; there is extensive apical akinesis. No masses\nor thrombi are seen in the left ventricle. Right ventricular chamber size is\nnormal. There is focal hypokinesis of the apical free wall of the right\nventricle. The aortic root is mildly dilated. The ascending aorta is mildly\ndilated. The aortic valve leaflets (3) are mildly thickened but not stenotic.\nNo aortic regurgitation is seen. The mitral valve leaflets are mildly\nthickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation\nis seen. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\n\n" }, { "category": "ECG", "chartdate": "2147-10-23 00:00:00.000", "description": "Report", "row_id": 164908, "text": "Sinus rhythm. P-R interval 0.20. First degree atrio-ventricular conduction\ndelay. Compared to the previous tracing of multiple abnormalities as\ndescribed persist without diagnostic change.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2147-10-23 00:00:00.000", "description": "Report", "row_id": 164909, "text": "Sinus bradycardia with supraventricular premature depolarizations. Compared to\nthe previous tracing of multiple abnormalities as described persist\nwithout diagnostic change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2147-10-23 00:00:00.000", "description": "Report", "row_id": 164910, "text": "Sinus rhythm with supraventricular premature depolarizations. Right\nbundle-branch block pattern. Left axis deviation. Left anterior fascicular\nblock. Probable prior anteroseptal myocardial infarction. First degree\natrio-ventricular conduction delay. No previous tracing available for\ncomparison.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2147-10-25 00:00:00.000", "description": "Report", "row_id": 164906, "text": "Sinus rhythm\nMarked left axis deviation\nRBBB with left anterior fascicular block\nLow QRS voltages in precordial leads\nAnterolateral myocardial infarct -? age - possible acute/recent\nSince previous tracing of : further ST-T wave changes - possible\nevolutionary pattern\n\n" }, { "category": "ECG", "chartdate": "2147-10-24 00:00:00.000", "description": "Report", "row_id": 164907, "text": "Sinus rhythm. Compared to the previous tracing of multiple\nabnormalities as described persist without diagnostic change.\nTRACING #4\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-24 00:00:00.000", "description": "Report", "row_id": 1425633, "text": "CCU NPN 2300-0700\nO: afeb. HR 60's SR. BP 90-100/50's. integrillin at 2mcq/kg/min. tng .29mcq/kg/min. post cath fluids done at 5am.\nno CP/SOB. CK up to 4300/600 at 2300. HCT 37. plts 246. K+4.2. Mg 1.7- given 2amps mgsulfate IV.\nvoiding with urinal for total 1L for night. (+) 1.2L 12am .\nright groin site D/I. pressure dsg intact. pulses palp.\npt. 's wife staying night in room. pt. able to use limited english to communicate effectively.\nLS clear. sats 99% on 2lnc.\n\nA: s/p cath. ongoing MI with CK's rising.\nP: start heparin at 0900 per order. d/c integrillin at 1100. contin. tng gtt. pt. may sit up this morning. contin. captopril/lopressor.\n" }, { "category": "Nursing/other", "chartdate": "2147-10-24 00:00:00.000", "description": "Report", "row_id": 1425634, "text": "SR NO ECTOPY .BP 90S. NITRO GTT DC. STARTED ON PO CAPTOPRIL, LOPRESSER . GROIN SOFT ,ECCYMOTIC , DISTAL PULSES DOPPLERED. INTEGRILLIN DC 11 AM ,HEPARIN STARTED 9AM. PTT PENDING .NON COMPLIANT C ACTIVITY RESTRICTIONS ,DR C PT THROUGH INTERPRETER. HE AGREES TO STAY IN BED AT PRESENT .\n\nSAT 94 RM AIR ,BS CL.\n\nE/D WELL, PASSING GAS\n\nVOIDS SM AMTS\n\nPT IS ORIENTED BUT NON COMPLIANT , MANY EXPLANATIONS GIVEN . DIAZAPAM GIVEN AS ORDERED, NICOTINE PATCH STARTED\n\nCONTINUE TO MONITOR FOR BLEEDING\nWIFE STATING C PT\nCPK PENDING\n\n" }, { "category": "Nursing/other", "chartdate": "2147-10-25 00:00:00.000", "description": "Report", "row_id": 1425635, "text": "CCU Nursing Progress Note\n73 yr old Russian speaking gentleman w/ no sign PMHx admitted w/ SSCP x several hrs radiating to both arms. EKG changes> transferred to cath. S/P Totally occluded LAD, RCA 40-50%. Angiojet to LAD for thrombectomy and stent X3 placed. CP free upon transfer to CCU. Peak CK 4396.\n\nS: \" I get out of here\"\n\nO: Neuro: Intact. Pt A&Ox3. Russian speaking able to converse with some broken english. Wife translates for pt as well. Shortly after the change of shift pt found trying to get out of bed. (Report given stated pt was noncompliant with directions last night and yesterday. Pulling at access lines, refusing treatment.) Posey placed and given ordered dose of Valium with good effect. Slept comfortably overnight with minimal interuption. Required minimal reorientation. More compliant than previously noted. Attempted to refuse meds but accepted once translated by wife.\n\nCV: HR 65-74. SR. No ectopy noted. PT denies CP or ^SOB. NBP 84-100/30-76. Maps remain >60 but pressure continuously remains less than established parameter of 100, therefore unable to give PO Captopril and Lopressor doses. R Groin site CDI but remains ecchymotic. Dopplerable pulses bilaterally. Integrellin dc'd/ heparin gtt started earlier yesterday. Earlier PTT 41.2 rechecked @ 2300> 85.6 therapeutic requiring no adjustment per s/s. CPK continues to trend downward last draw 1101. (Peaked @ 4396) HCT 34.4. K+ 3.6/ Ca 8.7/Mg 1.7. Repleted w/ 60meq KCL, Calcium 500 and 400 Mag oxide. No diuresis this shift. Am labs still pending.\n\nResp: LS CTA. O2 sat 93-97 on RA. RR 17-28. No cough present.\n\nGI/GU: Tolerating PO meds. Abd soft. BS present. No BM since last night. Continues on bowel regimen. Voiding sm amts of cyu via urinal. Did void approx 575cc @ 0400. Current output status -600 24hrs/ +1200 LOS.\n\nID: Afebrile. Tmax 99.1 PO. WBC stable\n\nSocial: Wife remained at bedside overnight.\n\nA/P: Stable overnight. BP less than parameter of 100 requiring po Captopril & Lopressor to be held. Continue to give doses and increase doses as tolerated. Checked HCT stable. ? decreased BP d/t Hypovolemia. No diuresis overnight. Repeat Ptt remains therapeutic requiring no adjustment. UO improving. Still remains positive. Pt much more compliant to nursing care. Seemed to rest comfortably overnight.\nContinue to follow lytes and replete as necessary.\n" } ]

[ { "category": "Echo", "chartdate": "2100-12-08 00:00:00.000", "description": "Report", "row_id": 60578, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Right ventricular function.\nHeight: (in) 70\nWeight (lb): 185\nBSA (m2): 2.02 m2\nBP (mm Hg): 95/46\nHR (bpm): 54\nStatus: Inpatient\nDate/Time: at 12:35\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: Marked LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Low normal LVEF.\n\nRIGHT VENTRICLE: RV function depressed. Abnormal septal motion/position\nconsistent with RV pressure/volume overload.\n\nAORTA: Moderately dilated aortic sinus. Mildly dilated ascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. Trace AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild thickening of\nmitral valve chordae. Mild (1+) MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is markedly dilated. The right atrium is markedly dilated.\nLeft ventricular wall thicknesses are normal. The left ventricular cavity is\nunusually small. Due to suboptimal technical quality, a focal wall motion\nabnormality cannot be fully excluded. Overall left ventricular systolic\nfunction is low normal (LVEF 50-55%). Right ventricular systolic function\nappears depressed. There is abnormal septal motion/position consistent with\nright ventricular pressure/volume overload. The aortic root is moderately\ndilated athe sinus level. The ascending aorta is mildly dilated. The aortic\nvalve leaflets are mildly thickened. There is no aortic valve stenosis. Trace\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nMild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are\nmildly thickened. Moderate (2+) tricuspid regurgitation is seen. There is no\npericardial effusion. Pulmonary artery systolic pressure was not estimated.\n\nCompared with the prior study (images reviewed) of , findings are\nsimilar.\n\n\n" }, { "category": "ECG", "chartdate": "2100-12-08 00:00:00.000", "description": "Report", "row_id": 109592, "text": "Regular rhythm, mechanism is uncertain. It may be accelerated junctional or\npossible idioventricular rhythm with intermittent diminutive pacer spikes seen\nof uncertain mechanism. Right bundle-branch block. Right bundle-branch block.\nLeft anterior fascicular block. Borderline generalized low voltage. Clinical\ncorrelation is suggested. Since the previous tracing of markedly wide\ncomplex (question ventricular paced rhythm) is absent.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2100-12-07 00:00:00.000", "description": "Report", "row_id": 109593, "text": "Probable ventricular paced rhythm although pacing spikes are difficult to see.\nAtrial mechanism is uncertain. Since the previous tracing of irregular\nbrady-arrhythmia is now absent.\nTRCAING #1\n\n" }, { "category": "ECG", "chartdate": "2100-12-05 00:00:00.000", "description": "Report", "row_id": 109594, "text": "Atrial fibrillation with a slow ventricular response. Occasional ventricular\nectopic beat noted. No significant change compared to the previous tracing\nof .\n\n" }, { "category": "ECG", "chartdate": "2100-12-03 00:00:00.000", "description": "Report", "row_id": 109595, "text": "Most likely atrial fibrillation with moderate ventricular response. However,\ndue to profound generalized low QRS voltage, interpretation is difficult.\nIntraventricular conduction defect. Diffuse non-specific ST-T wave change.\nCompared to the previous tracing of pacemaker beat is no longer\nobserved. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2100-12-02 00:00:00.000", "description": "Report", "row_id": 109596, "text": "Ventricular paced rhythm. Since the previous tracing of no significant\nchange.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2100-12-01 00:00:00.000", "description": "Report", "row_id": 109597, "text": "Ventricular paced rhythm. Compared to the previous tracing of there may\nbe retrograde P waves in the ST segments. The paced QRS has somewhat different\nmorphology, it is more vertical.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 940646, "text": " 4:15 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: please eval position of L sided cordis\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker , s/P L SC cordis\n placement\n REASON FOR THIS EXAMINATION:\n please eval position of L sided cordis\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: End-stage renal disease, CHF, ascites and pacemaker. Now status\n post left subclavian approach Cordis catheter placement, evaluate position.\n\n FINDINGS: AP single view of the chest obtained with patient in supine\n position is analyzed in direct comparison with a similar preceding study\n obtained one and a half hour earlier. Indications on the film show certain\n degree of Trendelenburg position. Chest findings with pacer electrodes and\n status post bypass surgery are unchanged. It is now recognized that the\n left-sided apical line consist of a sheath directed in retrograde direction in\n the left jugular vein. Observe that the sheath is kinked in its mid portion.\n No complication such as hematoma or pneumothorax has occurred.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 940623, "text": " 2:21 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm line placement\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker\n\n REASON FOR THIS EXAMINATION:\n confirm line placement\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, AP PORTABLE SINGLE VIEW\n\n INDICATION: End-stage renal disease, CHF, ascites, and pacemaker, confirm\n line placement.\n\n FINDINGS: AP single view of the chest has been obtained with patient in\n supine position. Analysis is performed in direct comparison with a previous\n chest examination ( AP view with patient in upright\n position).\n\n Comparison indicates marked cardiac enlargement status post sternotomy\n presumably related to previous bypass surgery. A permanent pacer is seen in\n right anterior axillary position. Total of three intracavitary electrodes are\n identified, one of which with the two enforcements indicating an ICD. The\n other wires terminate in position of the right atrial appendage and the apical\n portion of the right ventricle correspondingly. There is no pulmonary\n vascular congestion, nor is there any evidence of pneumothorax or acute\n infiltrates. Observed is the presence of a catheter sheath combination\n located in the left upper area above the pulmonary apex. It is possible that\n this relates to a subclavian placed line which under such circumstances is\n directed in cranial rather than mediastinal direction. Effort is made to\n reach referring physician, . .\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 940663, "text": " 7:15 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: assess re-placement of cordis and swan\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker , s/P L SC cordis\n placement with swan\n REASON FOR THIS EXAMINATION:\n assess re-placement of cordis and swan\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: End-stage renal disease, congestive heart failure, status post\n replacement of left subclavian Cordis and Swan-Ganz catheter.\n\n Portable AP chest dated at 19:34 is compared to the same examination\n from three hours earlier. There is a left-sided dual-lead biventricular\n ICD-pacemaker with the leads terminating in the right atrium and right\n ventricle in unchanged position. The patient is status post median\n sternotomy. Overlying the region of the left subclavian vein, the prior\n Cordis sheath has been removed. In its place is another line which is also\n directed upwards in the left jugular vein. There is right mid lung zone\n linear atelectasis but no evidence for pleural effusion.\n\n IMPRESSION: Left subclavian Cordis has been removed and replaced with another\n line, also projecting upwards towards the left jugular vein. Otherwise, there\n has been no significant change in the appearance of the chest. This finding\n was discussed through the telephone with the physician caring for the patient,\n Dr. at 11 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-08 00:00:00.000", "description": "P CHEST FLUORO WITHOUT RADIOLOGIST PORT", "row_id": 940825, "text": " 8:12 PM\n CHEST FLUORO WITHOUT RADIOLOGIST PORT; -77 BY DIFFERENT PHYSICIANClip # \n Reason: need to reposition central line in CCU\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, septic arthitis, ARVD, septic shock with subclav\n line in LIJ\n REASON FOR THIS EXAMINATION:\n need to reposition central line in CCU\n ______________________________________________________________________________\n FINAL REPORT\n CHEST FLUOROSCOPY WITHOUT RADIOLOGIST PORTABLE.\n\n A chest fluoroscopy was performed portably in the CCU to assist with a\n repositioning of a central line. 15 minutes and 12 seconds of fluoro time was\n used. No images were saved.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 939858, "text": " 10:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for CHF flare, infiltrate\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker\n REASON FOR THIS EXAMINATION:\n Please evaluate for CHF flare, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath.\n\n The heart size is markedly enlarged but unchanged comparing to .\n\n The patient has had CABG. The sternal wires are intact. The right-sided\n pacemaker is inserted with its three leads terminating in the right ventricle\n and in the coronary sinus in the left ventricle epicardial location. There is\n no evidence of congestive heart failure or consolidation. There is no\n sizeable pleural effusion.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 940547, "text": " 5:11 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL,\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man right knee septic bursitis, s/p fall\n REASON FOR THIS EXAMINATION:\n ? subdural hematoma\n CONTRAINDICATIONS for IV CONTRAST:\n CRI\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 73-year-old male with right knee septic bursitis, status post\n fall.\n\n HEAD CT WITHOUT CONTRAST: There is no comparison. Evaluation is somewhat\n limited due to motion artifact, especially at the upper most area of frontal\n lobes. There is no acute intracranial hemorrhage. There is no mass effect.\n No shift of normally midline structure is noted. Ventricles are not dilated.\n -white differentiation is preserved. There is no fracture. The\n visualized portion of paranasal sinuses, nasopharynx, and mastoid air cells\n are clear.\n\n IMPRESSION: Limited study due to motion. No acute intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-08 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 940804, "text": " 5:10 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval position of L SC triple lumen\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, s/p L SC line replacement\n REASON FOR THIS EXAMINATION:\n please eval position of L SC triple lumen\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: 73-year-old man with end-stage renal disease, CHF, status post\n line placement.\n\n CHEST, AP SUPINE PORTABLE: The patient is status post sternotomy.\n Discontinuity in the uppermost sternal wire is unchanged. There is a three-\n lead pacemaker in a similar position. The heart is markedly enlarged, as\n before.\n\n There is a new left subclavian central venous catheter terminating near the\n cavoatrial junction. There is no pneumothorax.\n\n IMPRESSION: New central venous catheter terminating in the superior vena\n cava.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-04 00:00:00.000", "description": "R KNEE (AP, LAT & OBLIQUE) RIGHT", "row_id": 940242, "text": " 5:03 PM\n KNEE (AP, LAT & OBLIQUE) RIGHT Clip # \n Reason: SEPSIS\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with septic arthritis of the right knee along with gout.\n REASON FOR THIS EXAMINATION:\n Please do a portable STAT film per ortho recs.\n ______________________________________________________________________________\n FINAL REPORT\n RIGHT KNEE, \n\n HISTORY: Septic arthritis along the right knee.\n\n IMPRESSION: Three views of the right knee show generalized osteopenia and a\n large soft tissue swelling, abscess, or mass anterior to an intact patella.\n Lateral view shows no evidence of a joint effusion. Vascular graft material is\n noted in the lower thigh. The joint spaces are well maintained and there is\n no subluxation.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940632, "text": " 3:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: new line with swan heading up to head--pulled back--pls eval\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker\n\n REASON FOR THIS EXAMINATION:\n new line with swan heading up to head--pulled back--pls eval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n The left subclavian Cordis catheter/SG remains within the left jugular vein.\n Suggest withdrawal for approximately 7 cm. No pneumothorax. Status post CABG\n with cardiomegaly as previously noted. There is some new discoid atelectasis\n in the right lower zone. Left-sided pacer and ICD with atrial and two\n ventricular leads in situ.\n\n" }, { "category": "Radiology", "chartdate": "2100-12-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 940708, "text": " 7:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, assess for effusions, vascular congestion.\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with ESRD, CHF, ascities, pacemaker with hypotension following\n OR I/D of right knee bursitis. With low MAPs, receiving fluid boluses.\n\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, assess for effusions, vascular congestion.\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST AT 11:00 A.M., \n\n HISTORY: End-stage renal disease and CHF. Hypotension.\n\n IMPRESSION: AP chest compared to :\n\n Very mild interstitial edema which developed on is unchanged.\n Severe cardiomegaly is longstanding. There is no pneumothorax or pleural\n effusion. Mediastinal venous engorgement suggests elevated central venous\n pressure. Transvenous right atrial and right ventricular pacer leads and\n right ventricular pacer defibrillator lead are unchanged in their positions;\n the proximal electrode of the defibrillator traverses the SVC and upper right\n atrium, and the tip projects superiorly over the right ventricular apex.\n\n The left subclavian sheath still heads cephalad presumably into the internal\n jugular vein and is sharply kinked at the right angle turn. Clinical\n attention to this is advised and Dr. was paged to report these\n findings, at the time of dictation.\n\n\n" }, { "category": "Radiology", "chartdate": "2100-12-08 00:00:00.000", "description": "ABDOMEN U.S. (COMPLETE STUDY)", "row_id": 940724, "text": " 9:25 AM\n ABDOMEN U.S. (COMPLETE STUDY) Clip # \n Reason: assess cbd, rule out cholangitis, duct blockage.\n Admitting Diagnosis: SYNCOPE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 73 year old man with right knee bursitis and right ventricular dysplasia with\n sepsis-like picture and rising lfts, specifically conjugated bilirubin.\n REASON FOR THIS EXAMINATION:\n assess cbd, rule out cholangitis, duct blockage.\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE GALLBLADDER ULTRASOUND\n\n INDICATION: Rule out cholangitis.\n\n Limited focused portable ultrasound of the gallbladder and liver were\n performed. Note is made of significant ascites. No focal liver lesions. The\n gallbladder is visualized and is relatively unremarkable. An area of\n increased echogenicity is identified on the anterior wall. This does not\n appear to move with positioning. However the appearances are most likely\n consistent with cholelithiasis. The common bile duct measures 0.6 cm, which\n is within normal limits for the patient's age. No evidence of any gallbladder\n wall thickening.\n The kidneys are within normal imits for the patient's age.\n\n IMPRESSION:\n 1. Cholelithiasis with no evidence of cholecystitis.\n 2. Ascites.\n\n" }, { "category": "Nursing/other", "chartdate": "2100-12-07 00:00:00.000", "description": "Report", "row_id": 1448768, "text": "NPN 1530--1900\n\ns: \"I 'm in the hospital\"\n\no: please see careview for vitals and other objective data\n\nPT came here from OR, I and D of infected right knee ( pus present per OR) pt became Hypotensive during case, also hyperkalemic,( 6.0) pt is dialysis pt. Here at CCU dopamine titrated up to 20 Ug kg/min, levophed added as well and titrated up to 30 UG, fluid bolus 500 cc x 2, cal gluconate given upon arrival was given insulin in PACU.\nBP in the 70's responded to measures, up to 90-100, and CVVHDF was started for hyperkalemia. Pt came here with a PA catheter on the left, malposition CXR, md here to restart line, renal fellow and cardiology fellow also placed quinton line in left femoral area.New introducer placed on left subclavian, repeat XRAY also showed malposition, line not able to be utilized. Cardiology team her to place new cordis.\n\nNeuro: arousable, knows he is in the hospital, moves all extrem to commands, pupild dilated, pt does turn head to voice and looks at nurse.\n\nRespiratory: We followed abg, o2 was down to 7o, co2 39 and we placed him on 100 percent non rebreather. continue to follow ABG, o2 sats are dificult to obtain as pt is clamped down on max dopamine.\n\n pt is paced, wide QRS, however this has not changed in relation to lower , md's aware. pt on CVVH for hyperkalemai, follow K.\nHypotensive, on max dopamine and now levophed added, epi drip off around 1600. Pt has a left av fistular on left upper arm, I palpated a pulse but not a strong bruit, ? clotted or decreased blood flow secondary to hypotension, no bp cuff on left arm.\n\nID: pt is presumed septic and given vanco and nafcillin this afternoon.\n\naccess- We were using the quinton for fluids, and pressors, MD are currently placing a new cordis for access. CVVHDF running and all infusions pressors in return line, and antibiotics via right ac PIV.\naline right radial.\n\nGU/ renal- likely anuric, on CVVHDF, 2 k bath/ 32 HCO3- 500 cc hour. replacement also 2k /32 hco3 at 1500 cc per hour. no heparin, no UF.\n\nA: septic pt, hypotensive requires pressors, fluids, and lines for access.\np: follow cv, resp status closely, cvvhdf, no fluid removal,continue antibiotics, follow Labs, lytes Q 6 hours or less,keep pt family updated on POC as discussed in CCU rounds\n" }, { "category": "Nursing/other", "chartdate": "2100-12-08 00:00:00.000", "description": "Report", "row_id": 1448769, "text": "CCU NPN 1900-0700\nS: \"Call me ...\"\nO: please see carevue for complete objective/assessment data\nThis is a 73yo man initially admitted s/p fall @ home , OSH found pt w/ ^WBC/Cr and CtnI, volume overloaded->HD and paracentesis for 5L, R knee bursitis v. gout. tx'd to () for management of AMI and R knee process. On floor remained CV/resp stable while cont w/ HD and paracentesis per home regimen, R knee s/p tap x 2, fluid growing S.Aureus. pt went to OR for R knee I&D/wash out/bursectomy, during case pt became hypotensive to 70s->epi w/ little effect->dopa. Extubated w/o difficulty in PACU and tx'd to CCU for further management of hypotension. Levophed was added for BP management, also recieved 2nd L NS w/ effect, MAP maintained >60. L fem line placed for CRRT initiation, cont abx for suspected sepsis. pt has required max dose dopa/levo and sm amt fluid to maintain MAP >55, Resp sts stable, weaning O2 as tolerated.\nROS:\nNEURO: Somnolent/lethargic but arouses to vocal stim, A&OX3, follows commands. MAE, C/o pain in R knee rx'd w/ fent IVP prn (unable to tol po's at this time d/t dysphagia ?r/t ETT/dry mucous membranes). pupils ~6mm and slugish bilat.\n\nCV: HR A-paced/V-sensed (rare AV/V pacing noted on tele) MHR 75. Initially able to wean levophed, however later in shift (~0100) pt becoming hypotensive w/ MAP 50 req gtts back ^ dopa @ 18 and levophed @ .3. Additional 250cc NS given w/ little effect and BFR decreased to 80 on CRRT. MAPs maintained 55-60, additional 500cc NS currently infusing, results pending. All extremities are purple/mottled, distal pulses by dop, color and temp improving sl. t/o shift. Denies CP/SOB, lactate improving, CKs bumped this am. Hct stable and lytes repleted per CRRT guidelines. LSC cordis is to be used for slow fluid admin ONLY per CXR.\n\nRESP: LSCTA, diminished @ bases bilaterally w/ rare rales. O2 weaned from NRB to 35% cool mist face tent, SpO2 >96% (added mist d/t dry mucous membranes). Denies dyspnea, most recent ABG revealing compensated metabolic acidosis w/ marginal oxygenation.\n\nGI: Abd soft, distended/ascites, RLQ area of ecchymosis d/t recurrent taps. Abd intermittently tender to palpation RUQ. Pt has remained NPO after coughing w/ attempts at sips of water. BS are hypoactive and no BM. LFTs cont elevated/rising.\n\nGU: incont sm amt urine. Cont CVVHDF w/ goal PFR 0. BUN/Cr improving w/ cont treatment. K/Ca gluc gtts titrated per CRRT guidelines. All pressures wnl.\n\nENDO: type 2 DM, BG wnl w/ no RISS coverage required.\n\nID: hypothermic initially->bair hugger applied, now temp 96.8 po. WBC down slightly this am, cont vanco and nafcillin for presumed sepsis. BCs sent x 2 (aline and CRRT).\n\nSKIN: RLE w/ ace-wrap dsg in place, oozing min amt s/s drainage. No orders to change, CCU resident aware, surgery to eval this am. Multiple areas of ecchymosis, skin tears. RAC 20G PIV patent and w/ good blood return, oozing slightly when fast flushed. RRadial aline patent and intact. LSC introducer w/ KVO, no\n" }, { "category": "Nursing/other", "chartdate": "2100-12-08 00:00:00.000", "description": "Report", "row_id": 1448770, "text": "CCU NPN 1900-0700\n(Continued)\nt to be used for meds or fluid bolusing as tip is curved up into RIJ. L fem quentin line w/ all meds/fluid/CRRT running, patent and intact.\n\nSOC: spoke w/ pts wife re: pt condition and .\n\nA: 73y/o w/ multiple medical problems s/p R knee washout c/b hypotension req max pressors x 2/fluid and CRRT for management of lyte disturbances/uremia, remains CV stable but tenuous on current therapy, ? sepsis/hypovolemia v. peri-op MI.\nP: cont present ICU management. pressors for MAP >55-60, f/u outcome of fluid bolus. Cont CRRT per protocol. Monitor resp sts given pt 4l +. Cont support to pt/family.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-08 00:00:00.000", "description": "Report", "row_id": 1448771, "text": "CCU NSG NOTE: ALT IN CV/SEPSIS/RENAL\nO: For complete VS see CCu flow sheet.\nCODE STATUS: after consultation with physicians pts wife, the HCP made pt DNR/DNI. Treatment will continue, but no resusitative efforts made.\nID: Pt remains afebrile with temp ~97 po. No longer on barehugger. WBCs decreased to 11.3 (13.1). He is receiving flagyl and ceftriaxone and vanco by level.\nCV: Pt started the day with maps in the mid 50s despite maxed out dopamine 20mic/kilo and levo at .3mic/kilo. Vasopressin was started at 0945 at 1.2u/hr. He was increased to 2.4u at 11:15 and has tolerated it well. At the same time pacer was reprogramed to vvi with rate of 50 to prevent pacing. Both of these changes have improved maps to 60s and levophed has been decreased to .09mic/kilo and can probably come off. Dopamine is to remain at 20 mic/kilo for now. A venous sat was drawn off the subclavian line that was known to be going retrograde. It gave a CO of 6.0/2.8 with SVR 453. At 1600, after receiving 1 U FFP, another attempt at line placement, now under fluro was done. A swan was floated, but it was not possible to advance it beyond RA, most likely due to lg RV. At a result the PA port is RA, the RA port is in the cortis and blood cannot be drawn from it, the RA infusion port is likewise not useable. THe RV infusion port is usable as is the cortis. His pressures have been moved from his dialysis line to the sideport of the swan with new tubing.The site is eccymotic, but there is no oozing. All pulses are dopplerable. Feet and all extremities are only slightly cool.\nRENAL: Pt remained on CCVHD, tolerating dialysis well, but have no fluid removal. The filter clotted at 1800, just as line was in. RRT has been temporarily stopped until new filter can be primed. He is 4.5 liters pos for the day and 7.2 liters LOS.\nRESP: Pts sats unreliable due to periferal vasoconstriction. Last GAs on 35% neb was 7.31/41/75/23. Breath sound decreased. Pt has fairly strong cough.\nGI: Pt kept NPO as he is unsafe swallowing. He has ultrasound of acites and later was tapped for sample to send to lab.\nSKIN: Dsg on R lower leg changed by ortho. Area very bloody, and open, but appears clean. He has lg eccymotic area on R abdomen, perhaps from recent paricentesis which he has 2 X week. Some skin tears noted on R anticub, but otherwise skin has no breakdown at this point.\nMS: Pt intially very somnulent and barely responsive. Speak was incomprehensible, and he followed no commands. With improved hemodynamics he is able to say his name and follow some simple commands. He responds to his family who visited most of the day. He does not seem to be in pain when left alone. He had significant pain with dsg change. He receives fentanyl 12.5-25 IV for pain.\nA: Improved hemodynamics on vasopressin/weaning levo/dnr/dni\nP: continue weaning levo as tolerated. Restart CVVHD when possible. Monitor I & O. Cont with ABX. Due for labs at 10pm. Monitor for pain.\n" }, { "category": "Nursing/other", "chartdate": "2100-12-09 00:00:00.000", "description": "Report", "row_id": 1448772, "text": "ccu nsg progress note.\no:attempted cvvhd wo success-hypotension-requiring increased dose of pressors-levophed, dopa, & vasopressin. septic w decrease svr, elevated lactic acid, & decreacing ph. medical team & family made aware of severity of condition. decission made to dc cvvhd, increase pressors & fl bolus till family present. wife, son & daughter present-discussion re:care goals--decision made to stop fl/ pressors & provide adeq comfort measures to pt. catholic priest in to see pt. family present.\n\na:sever sepsis.\n\np:adeq comfort support to pt. support family as indicated.\n" } ]

[ { "category": "Nursing", "chartdate": "2150-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439360, "text": "Altered mental status (not Delirium)\n Assessment:\n Continues to be forgetful and disoriented today. Remembers being in\n the hospital, however forgets what year it is or where specifically he\n is. Continues to be sleepy at times. Moves all extremities with equal\n strength, mild pronator drift noted. Mild nystagmus noted when patient\n is looking upward. Complaining of painful headache this morning.\n Action:\n Diagnostic angiography performed this morning. Given PRN fentanyl this\n morning for acute headache. Advanced to full diet this afternoon.\n Response:\n Tolerated procedure well. AVM diagnosed.\n Plan:\n Current plan for embolization on Monday. Continue to closely monitor\n neuro status while in the SICU.\n" }, { "category": "Nursing", "chartdate": "2150-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439421, "text": "SICU\n Dx: intraventriluar hemorrhage\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n underwent diagnostic angiography via Rt fem site; small AVM found\n region of germ of corpus callosum;\n pt\ns neuro checks have remained unchanged; rt fem site w/out s/s\n bleeding; pt w/ continued c/o h/a w/ varying severity (very mild to\n), intermittently treated w/ Tylenol and small dose of fentanyl\n (12.5); HOB maintained 30 degrees;\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n SICU\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Pt w/out tachycardia, hypertension, tremors this night so far\n Action:\n Continued to monitor pt for s/s\n Response:\n *******\n Plan:\n Cont to monitor for s/s w/drawal\n Altered mental status (not Delirium)\n Assessment:\n Pt oriented x1; speech clear; needs re-orientation of date,time and\n place; able to use urinal in bed per self;\n Action:\n Re-oriented frequently w/a; date written on board in room\n Response:\n Pt continues to need re-orienting\n Plan:\n Cont to re-orient pt; engage pt in conversation; provide for safety d/t\n pt\ns current short-term memory defecits which could result in decreased\n self safety;\n Pt to have serum dilantin level drawn this morning approx 06:00.\n" }, { "category": "Nursing", "chartdate": "2150-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439526, "text": "Altered mental status (not Delirium)\n Assessment:\n Continues to be confused. Alert and disoriented. Continually\n forgetting where he is, however remembers with reinforcement. Able to\n report being in a hospital. Does not know why or for how long he has\n been here. Complaining of headache this afternoon, .\n Action:\n Gave Fentanyl totaling 125 mcg over 3 hours. SICU resident spoke with\n Neurosurg team and they had requested a head CT.\n Response:\n Patient continuing to complain of headache when asked however is sleepy\n and appears comfortable.\n Plan:\n Continue to assess neuro status Q 2 hours, alert team to any changes.\n Treat headache with Fentanyl when appropriate. Embolization on Monday.\n" }, { "category": "Physician ", "chartdate": "2150-01-09 00:00:00.000", "description": "Intensivist Note", "row_id": 439281, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n Acetaminophen, Famotidine, Fentanyl Citrate, Folic\n Acid/Multivitamin/Thiamine-1000mL NS, Insulin, Lorazepam, Nimodipine,\n Nitroprusside Sodium\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 AM\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.6\nC (99.7\n HR: 78 (66 - 80) bpm\n BP: 105/52(61) {105/52(61) - 138/78(88)} mmHg\n RR: 12 (9 - 13) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 237 mL\n PO:\n Tube feeding:\n IV Fluid:\n 237 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 237 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///28/\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, No(t) Trace)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 234 K/uL\n 13.5 g/dL\n 89 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 102 mEq/L\n 139 mEq/L\n 37.5 %\n 11.2 K/uL\n [image002.jpg]\n 01:06 AM\n WBC\n 11.2\n Hct\n 37.5\n Plt\n 234\n Creatinine\n 0.9\n Troponin T\n <0.01\n Glucose\n 89\n Other labs: PT / PTT / INR:14.7/25.1/1.3, CK / CK-MB / Troponin\n T:134/1/<0.01, ALT / AST:40/28, Alk-Phos / T bili:72/0.7, Amylase /\n Lipase:148/129, Albumin:4.3 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan:\n Neurologic: tight SBP <140, nicardipine gtt if needed, nimodipine,\n dilantin loaded, repeat CT head in AM, CIWA scale, banana bag, SW\n consult, angio in AM with , q1h neuro check. Angio today\n Cardiovascular: neg enzymes\n Pulmonary: intubate if needed for mental status, currenly doing well on\n NC\n Gastrointestinal / Abdomen: elevated lipase and amylase. No evidence\n of clinical pancreatitis. keep NPO and gentle hydration (although with\n a careful balance due to possible increased ICP given his bleeding),\n follow LFTs, lipase and amylase\n Nutrition: NPO, banana bag at 50ml/hr\n Renal: no urine output yet, no foley\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds:\n Imaging: Angio today.\n Fluids: banana bag at 50ml/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:48 AM\n 22 Gauge - 12:49 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2150-01-10 00:00:00.000", "description": "Intensivist Note", "row_id": 439477, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n AVM\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n Acetaminophen 3. Famotidine 4. Fentanyl Citrate 5. Folic\n Acid/Multivitamin/Thiamine-1000mL NS\n 6. Insulin 7. Influenza Virus Vaccine 8. Lorazepam 9. Nitroprusside\n Sodium\n 24 Hour Events:\n ANGIOGRAPHY - At 09:00 AM\n FEVER - 101.1\nF - 08:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 08:08 AM\n Famotidine (Pepcid) - 11:30 PM\n Other medications:\n Flowsheet Data as of 07:27 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.2\nC (99\n HR: 61 (58 - 79) bpm\n BP: 139/79(94) {102/42(57) - 140/80(94)} mmHg\n RR: 14 (11 - 21) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 683 mL\n 40 mL\n PO:\n 290 mL\n 40 mL\n Tube feeding:\n IV Fluid:\n 393 mL\n Blood products:\n Total out:\n 1,400 mL\n 475 mL\n Urine:\n 1,400 mL\n 475 mL\n NG:\n Stool:\n Drains:\n Balance:\n -717 mL\n -435 mL\n Respiratory support\n SPO2: 98%\n ABG: ///25/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 237 K/uL\n 12.5 g/dL\n 85 mg/dL\n 0.7 mg/dL\n 25 mEq/L\n 3.7 mEq/L\n 13 mg/dL\n 104 mEq/L\n 139 mEq/L\n 35.8 %\n 9.6 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n WBC\n 11.2\n 9.6\n Hct\n 37.5\n 35.8\n Plt\n 234\n 237\n Creatinine\n 0.9\n 0.7\n Troponin T\n <0.01\n Glucose\n 89\n 85\n Other labs: PT / PTT / INR:14.7/25.1/1.3, CK / CK-MB / Troponin\n T:134/1/<0.01, ALT / AST:40/28, Alk-Phos / T bili:72/0.7, Amylase /\n Lipase:148/129, Albumin:4.3 g/dL, Ca:8.9 mg/dL, Mg:2.1 mg/dL, PO4:2.8\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan:\n Neurologic: tight SBP <140, nicardipine gtt if needed, nimodipine,\n dilantin loaded, CIWA scale, banana bag, SW consult, angio in AM with\n showed AVM to be embolized on monday, q1h neuro check\n Cardiovascular: neg enzymes, check CXR\n Pulmonary: intubate if needed for mental status, currenly doing well on\n NC\n Gastrointestinal / Abdomen: elevated lipase and amylase, keep NPO and\n gentle hydration (although with a careful balance due to possible\n increased ICP given his bleeding), follow LFTs, lipase and amylase\n Nutrition: Reg diet NPO Mon 12 am, banana bag at 50ml/hr\n Renal: follow UOP, no issues\n Hematology: serial Hct, check coags prior to angio\n Endocrine: RISS\n Infectious Disease: no 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: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:48 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2150-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439638, "text": "Altered mental status (not Delirium)\n Assessment:\n Continues to be confused. Alert, oriented x2-3. Continually\n forgetting where he is, however remembers with reinforcement. Able to\n report being in a hospital. Does not know why or for how long he has\n been here. Complaining of headache this overnight ranging from a \n out of scale. Extremities with normal strength, no pronator\n drift. Follows all commands. Pupils equal and reactive. Temperature max\n 102.2.\n Action:\n oxycodone q4 hours . tylenol x2.\n Response:\n Patient continuing to complain of headache, oxycodone decreases pain\n level to .\n Plan:\n Continue to assess neuro status Q 2 hours, alert team to any changes.\n Treat headache with oxycodone when appropriate. If ineffective fioricet\n available. Embolization on Monday.\n" }, { "category": "Nursing", "chartdate": "2150-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439854, "text": "Altered mental status (not Delirium)\n Assessment:\n Alert, oriented x2-3. neuro status waxes and wanes. Knows hospital,\n oriented to person, knows the month most of the time, unable to\n remember the year. Does not know why or for how long he has been\n here. Complaining of headache overnight ranging from a out of\n scale. Extremities with normal strength, no pronator drift.\n Follows all commands. Pupils equal and reactive. Temperature max 100.3.\n cultured within 24/hours. Npo at midnight for angio.\n Action:\n oxycodone q4 hours . tylenol x2.\n Response:\n Patient continuing to complain of headache, oxycodone decreases pain\n level to .\n Plan:\n Continue to assess neuro status Q 2 hours, alert team to any changes.\n Treat headache with oxycodone when appropriate. If ineffective fioricet\n available. Embolization today.\n" }, { "category": "Physician ", "chartdate": "2150-01-11 00:00:00.000", "description": "Intensivist Note", "row_id": 439617, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n head bleed\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n 1. 2. Acetaminophen 3. Acetaminophen-Caff-Butalbital 4. Famotidine 5.\n Fentanyl Citrate 6. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 7. Insulin 8. Influenza Virus Vaccine 9. Lorazepam 10. Nitroprusside\n Sodium 11. OxycoDONE (Immediate Release)\n 12. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 12:53 AM\n URINE CULTURE - At 12:53 AM\n FEVER - 102.1\nF - 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 01:30 PM\n Other medications:\n Flowsheet Data as of 05:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.9\nC (100.3\n HR: 70 (54 - 82) bpm\n BP: 135/83(95) {90/40(50) - 152/124(131)} mmHg\n RR: 16 (10 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 840 mL\n 200 mL\n PO:\n 840 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 1,025 mL\n 0 mL\n Urine:\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 200 mL\n Respiratory support\n SPO2: 94%\n ABG: ///24/\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, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli)\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 101 mEq/L\n 135 mEq/L\n 36.2 %\n 10.1 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n 01:00 AM\n WBC\n 11.2\n 9.6\n 10.1\n Hct\n 37.5\n 35.8\n 36.2\n Plt\n \n Creatinine\n 0.9\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n Glucose\n 89\n 85\n 100\n Other labs: PT / PTT / INR:14.4/26.3/1.3, CK / CK-MB / Troponin\n T:97/1/<0.01, ALT / AST:25/22, Alk-Phos / T bili:69/0.6, Amylase /\n Lipase:142/109, Albumin:4.3 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan: 51yM with likely AVM of the lateral ventricle\n Neurologic: nimodipine, dilantin loaded, embo planned for monday. Pain\n control with fioricet, oxycodone\n Cardiovascular: HD stable, nicardipine prn HTN\n Pulmonary: no issues\n Gastrointestinal / Abdomen: regular diet, NPO after midnight for\n embolization\n Nutrition: NPO\n Renal: Adequate UO, KVO\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: Other: cerebral AVM\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2150-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439856, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma.\n Presented to after a period of 5 days reportedly\n where no one had seen him and he was found to have a large amount of\n blood in the LEFT lateral ventricle extending to the third and 4th as\n well as slightly on the RIGHT as well likely from AVM or aneurysm\n (anterior cerebral artery RIGHT). Profound encephalopathy but no\n focality. His screening labs were otherwise remarkable for elevated\n lipase and amylase.\n Altered mental status (not Delirium)\n Assessment:\n Alert, oriented x2-3. neuro status waxes and wanes. Knows hospital,\n oriented to person, knows the month most of the time, unable to\n remember the year. Does not know why or for how long he has been\n here. Complaining of headache overnight ranging from a out of\n scale. Extremities with normal strength, no pronator drift.\n Follows all commands. Pupils equal and reactive. Temperature max 100.3.\n cultured within 24/hours. Npo at midnight for angio.\n Action:\n oxycodone q4 hours . tylenol x2.\n Response:\n Patient continuing to complain of headache, oxycodone decreases pain\n level to .\n Plan:\n Continue to assess neuro status Q 2 hours, alert team to any changes.\n Treat headache with oxycodone when appropriate. If ineffective fioricet\n available. Embolization today for avm.\n" }, { "category": "Physician ", "chartdate": "2150-01-11 00:00:00.000", "description": "Intensivist Note", "row_id": 439677, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n head bleed\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n 1. 2. Acetaminophen 3. Acetaminophen-Caff-Butalbital 4. Famotidine 5.\n Fentanyl Citrate 6. Folic Acid/Multivitamin/Thiamine-1000mL NS\n 7. Insulin 8. Influenza Virus Vaccine 9. Lorazepam 10. Nitroprusside\n Sodium 11. OxycoDONE (Immediate Release)\n 12. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n BLOOD CULTURED - At 12:53 AM\n URINE CULTURE - At 12:53 AM\n FEVER - 102.1\nF - 12:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Fentanyl - 01:30 PM\n Other medications:\n Flowsheet Data as of 05:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102.1\n T current: 37.9\nC (100.3\n HR: 70 (54 - 82) bpm\n BP: 135/83(95) {90/40(50) - 152/124(131)} mmHg\n RR: 16 (10 - 25) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 840 mL\n 200 mL\n PO:\n 840 mL\n 200 mL\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 1,025 mL\n 0 mL\n Urine:\n 1,025 mL\n NG:\n Stool:\n Drains:\n Balance:\n -185 mL\n 200 mL\n Respiratory support\n SPO2: 94%\n ABG: ///24/\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, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli)\n Labs / Radiology\n 280 K/uL\n 13.6 g/dL\n 100 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 3.9 mEq/L\n 12 mg/dL\n 101 mEq/L\n 135 mEq/L\n 36.2 %\n 10.1 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n 01:00 AM\n WBC\n 11.2\n 9.6\n 10.1\n Hct\n 37.5\n 35.8\n 36.2\n Plt\n \n Creatinine\n 0.9\n 0.7\n 0.7\n Troponin T\n <0.01\n <0.01\n Glucose\n 89\n 85\n 100\n Other labs: PT / PTT / INR:14.4/26.3/1.3, CK / CK-MB / Troponin\n T:97/1/<0.01, ALT / AST:25/22, Alk-Phos / T bili:69/0.6, Amylase /\n Lipase:142/109, Albumin:4.3 g/dL, Ca:9.4 mg/dL, Mg:2.1 mg/dL, PO4:2.7\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan: 51yM with likely AVM of the lateral ventricle\n Neurologic: nimodipine, dilantin loaded, embo planned for monday. Pain\n control with fioricet, oxycodone\n Cardiovascular: HD stable, nicardipine prn HTN\n Pulmonary: no issues\n Gastrointestinal / Abdomen: regular diet, NPO after midnight for\n embolization\n Nutrition: NPO\n Renal: Adequate UO, KVO\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains:\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: Other: cerebral AVM\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 09:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2150-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 440019, "text": "Altered mental status (not Delirium)\n Assessment:\n S/p angio today for attempted emobolization of AV malformation. Pt\n arrived to unit extubated, moving all extremities, cooperative,\n following commands, pupils equal and reactive, oriented x\ns 1, more\n confused than prior to procedure\n sicu team is aware. Angio site\n intact, pulses palpable. Sbp goal verbally verified with neuro .\n P.a. < 160. Sbp 130\ns-150s.\n Action:\n q 2 hour neuro checks, angio site monitored.\n Response:\n Neuro status unchanged\n Plan:\n Transfer to step down when bed available, continue to monitor neuro\n status, check angio site and pulses, maintain safety.\n" }, { "category": "Physician ", "chartdate": "2150-01-12 00:00:00.000", "description": "Intensivist Note", "row_id": 439903, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n Head bleed\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acetaminophen-Caff-Butalbital 5.\n Famotidine 6. Influenza Virus Vaccine\n 7. Lorazepam 8. Nitroprusside Sodium 9. OxycoDONE (Immediate Release)\n 10. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n No acute events overnight\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 06:37 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: 81 (56 - 88) bpm\n BP: 122/81(89) {100/57(69) - 149/90(104)} mmHg\n RR: 25 (9 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 620 mL\n PO:\n 620 mL\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 1,300 mL\n 450 mL\n Urine:\n 1,300 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n -450 mL\n Respiratory support\n SPO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 305 K/uL\n 14.3 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 102 mEq/L\n 136 mEq/L\n 39.2 %\n 10.0 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n 01:00 AM\n 02:18 AM\n WBC\n 11.2\n 9.6\n 10.1\n 10.0\n Hct\n 37.5\n 35.8\n 36.2\n 39.2\n Plt\n 05\n Creatinine\n 0.9\n 0.7\n 0.7\n 0.8\n Troponin T\n <0.01\n <0.01\n Glucose\n 89\n 85\n 100\n 95\n Other labs: PT / PTT / INR:14.4/26.3/1.3, CK / CK-MB / Troponin\n T:97/1/<0.01, ALT / AST:25/22, Alk-Phos / T bili:69/0.6, Amylase /\n Lipase:142/109, Albumin:4.3 g/dL, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan: 51 y/o with likely AVM of the lateral ventricle\n Neuro: no change in neuro status, embo planned for today. Pain\n control with fioricet, oxycodone\n CV: HD stable, nicardipine prn HTN, SBP <160\n Resp:no issues\n GI: regular diet, NPO after midnight for embolization today\n FEN: NS at 70 cc/hr\n Renal:follow UOP, no issues\n Heme:Hct stable\n Endo:RISS\n ID:no issues\n TLD:PIV\n Wound:none\n Prophylaxis: H2B and boots\n Consults: neurosurgery, neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2150-01-12 00:00:00.000", "description": "Intensivist Note", "row_id": 439918, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n Head bleed\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acetaminophen-Caff-Butalbital 5.\n Famotidine 6. Influenza Virus Vaccine\n 7. Lorazepam 8. Nitroprusside Sodium 9. OxycoDONE (Immediate Release)\n 10. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n No acute events overnight\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 06:37 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: 81 (56 - 88) bpm\n BP: 122/81(89) {100/57(69) - 149/90(104)} mmHg\n RR: 25 (9 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 620 mL\n PO:\n 620 mL\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 1,300 mL\n 450 mL\n Urine:\n 1,300 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n -450 mL\n Respiratory support\n SPO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 305 K/uL\n 14.3 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 102 mEq/L\n 136 mEq/L\n 39.2 %\n 10.0 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n 01:00 AM\n 02:18 AM\n WBC\n 11.2\n 9.6\n 10.1\n 10.0\n Hct\n 37.5\n 35.8\n 36.2\n 39.2\n Plt\n 05\n Creatinine\n 0.9\n 0.7\n 0.7\n 0.8\n Troponin T\n <0.01\n <0.01\n Glucose\n 89\n 85\n 100\n 95\n Other labs: PT / PTT / INR:14.4/26.3/1.3, CK / CK-MB / Troponin\n T:97/1/<0.01, ALT / AST:25/22, Alk-Phos / T bili:69/0.6, Amylase /\n Lipase:142/109, Albumin:4.3 g/dL, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan: 51 y/o with likely AVM of the lateral ventricle\n Neuro: no change in neuro status, embo planned for today. Pain\n control with fioricet, oxycodone\n CV: HD stable, nicardipine prn HTN, SBP <160\n Resp:no issues\n GI: regular diet, NPO after midnight for embolization today\n FEN: NS at 70 cc/hr\n Renal:follow UOP, no issues\n Heme:Hct stable\n Endo:RISS\n ID:no issues\n TLD:PIV\n Wound:none\n Prophylaxis: H2B and boots\n Consults: neurosurgery, neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2150-01-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440055, "text": "51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Upon\n admission, pt not oriented and no contact. Presented to after a period of 5 days reportedly where no one had seen him?\n CT showed large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n s/p angio for attempted embolization of AV malformation. Extubated\n after procedure. Admitted back to SICU for monitoring\n Altered mental status (not Delirium)\n Assessment:\n Alert and oriented X2. Pt knows his name. Knows he is in a hospital (he\n says ) moving all extremities, cooperative, following\n commands, pupils equal and reactive.\n Action:\n q 2 hour neuro checks, angio site monitored.\n Response:\n Neuro status unchanged.\n Plan:\n Transfer to step down. Continue to monitor neuro status, check angio\n site and pulses, maintain safety. Continue to monitor Blood Pressure,\n give hydralazine as needed for SBP>140.\n BP Goal:\n SBP Goal <140, Hydralazine IV for SBP>140. Throughout evening, SBP\n <140 by Cuff.\n Post Angio:\n Pt not on bedrest from angio as of 2130 tonight. Right fem site drsg\n . No ecchymosis or bleeding. Pulses palpable\n Report given to 11 Nurse. Transferred to 1120.\n - RN CCRN\n" }, { "category": "Nutrition", "chartdate": "2150-01-09 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 439327, "text": "Subjective: Unable to interview pt.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 173 cm\n 70.5 kg\n 23.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 69.9 kg\n 100%\n Diagnosis: ICH\n PMH : polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse\n /day, +tob\n Food allergies and intolerances:\n Pertinent medications: RISS, NS c/ Mvit, Thiamine & Folic Acid @\n 50cc/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 89 mg/dL\n 01:06 AM\n Glucose Finger Stick\n 85\n 12:15 PM\n BUN\n 20 mg/dL\n 01:06 AM\n Creatinine\n 0.9 mg/dL\n 01:06 AM\n Sodium\n 139 mEq/L\n 01:06 AM\n Potassium\n 3.8 mEq/L\n 01:06 AM\n Chloride\n 102 mEq/L\n 01:06 AM\n TCO2\n 28 mEq/L\n 01:06 AM\n Albumin\n 4.3 g/dL\n 01:06 AM\n Calcium non-ionized\n 9.3 mg/dL\n 01:06 AM\n Phosphorus\n 3.7 mg/dL\n 01:06 AM\n Magnesium\n 2.1 mg/dL\n 01:06 AM\n ALT\n 40 IU/L\n 01:06 AM\n Alkaline Phosphate\n 72 IU/L\n 01:06 AM\n AST\n 28 IU/L\n 01:06 AM\n Amylase\n 148 IU/L\n 01:06 AM\n Total Bilirubin\n 0.7 mg/dL\n 01:06 AM\n WBC\n 11.2 K/uL\n 01:06 AM\n Hgb\n 13.5 g/dL\n 01:06 AM\n Hematocrit\n 37.5 %\n 01:06 AM\n Current diet order / nutrition support: Diet: NPO\n GI: abd soft\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO / hypocaloric diet, ETOH abuse, polysubstance\n abuse\n Estimated Nutritional Needs\n Calories: 1760-2115 (BEE x or / 25-30 cal/kg)\n Protein: 84-106 (1.2-1.4 g/kg)\n Fluid: per team\n Estimation of previous intake: possibly Inadequate\n Estimation of current intake: Inadequate (NPO)\n Specifics:\n 51 y.o. M with ? recent head trauma, adm with large ICH, found to have\n a small AVM in angio today. Pt also has elevated amylase & lipase,\n however without evidence of clinical pancreatitis. Pt is NPO; will\n provide TF recs in case pt is unable to take po\ns. If it is suspected\n that pt has pancreatitis, rec placing tip of feeding tube past the\n ligament of trietz to avoid stimulating pancreas.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) If enteral feeds are needed, rec Replete with Fiber @ 75cc/hr\n (1800kcal, 112g protein).\n 2) Will follow progress/plan. Please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441722, "text": "TITLE:\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n" }, { "category": "Physician ", "chartdate": "2150-01-21 00:00:00.000", "description": "Intensivist Note", "row_id": 441716, "text": "TSICU\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n .\n EVENTS:\n : CTA showed AVM with a draining vein that drains into the right\n septal vein.\n : angio showed small AVM@ corpus callosum, Nimodipine d/ced (not\n needed). Post angio check unremarkable. Pulses X4 palp. Rt groin\n clear,Knee immobilizer in use. A +O x2. Doesn't remember procedure\n being done.\n : non focal exam. pt c/o headache unrelieved by pain\n medication-stat head Ct unchanged- pm exam non-focal, headache\n diminished.\n NO embolization/ pt oriented to self only\n : spiked temp to 101.2, pan-cultured\n transferred to floor status\n alert to name, not year states in \"the rehab\" otherwise non-focal,\n unsteady on feet with amb per nsg due to lethargy, Venadyne \n reordered, pt oob to chair\n Exam as above.\n : exam stable.\n neuropsych unable to do eval mental status\n .\n 24 HOUR EVENTS:\n : admitted to TICU s/p bifrontal craniotomy and excision of\n arteriovenous malformation; fever -> pan cultured; seen by endo and\n psych;\n .\n MEDICAL: polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse\n /day, +tob\n .\n : unknown\n .\n SOCIAL Hx: polysubstance abuse\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Metoprolol - 08:30 PM\n Haloperidol (Haldol) - 09:45 PM\n Other medications:\n Haloperidol 1 mg IV ONCE, LeVETiracetam 1500 mg IV BID,\n Acetaminophen-Caff-Butalbital TAB PO Q6H:PRN, Acetaminophen 650 mg\n PO Q6H:PRN, Bisacodyl 10 mg PO/PR, Lopressor 5 mg IV Q4H,\n DiphenhydrAMINE 12.5 mg PO Q6H:PRN, OxycoDONE (Immediate Release) 10\n mg PO Q4H:PRN, Docusate Sodium (Liquid) 100 mg PO BID, Senna 1 TAB PO\n BID:PRN, Famotidine 20 mg IV Q12H, HYDROmorphone (Dilaudid) 0.25 mg IV\n Q3H:PRN\n Flowsheet Data as of 10:29 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.8\n T current: 38.6\nC (101.4\n HR: 95 (95 - 107) bpm\n BP: 149/81(134) {143/70(89) - 167/97(134)} mmHg\n RR: 29 (21 - 32) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,345 mL\n PO:\n Tube feeding:\n IV Fluid:\n 385 mL\n Blood products:\n Total out:\n 0 mL\n 5,385 mL\n Urine:\n 950 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -3,040 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 97%\n ABG: ////\n Physical Examination\n General Appearance: No acute distress, Well nourished, fidgity in bed\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : ), (Sternum:\n Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities, not answering questions at present but will\n follow commands\n Labs / Radiology\n 0.6 mg/dL\n 4 mg/dL\n 140 mEq/L\n [image002.jpg]\n 08:15 PM\n Creatinine\n 0.6\n Assessment and Plan\n ASSESSMENT AND PLAN: 51M s/p bifrontal craniotomy and excision of\n arteriovenous malformation with persistant mental status changes and\n fevers.\n .\n NEUROLOGIC: Pt. s/p crani with persistant mental status changes -\n possibly secondary to withdrawl from suboxone v. etoh v. other\n substances v. changes related to bleed from AVM; will continue Haldol\n as first line med for aggitation - appreciate recs from psych; will\n consider benzos if aggitation non-responsive to haldol and accompanied\n with other symptoms of etoh withdrawl; on keppra for seizure prophy;\n goal SBP<140\n Neuro checks Q:1 hour\n Pain: dilaudid prn\n CARDIOVASCULAR: unknown if h/o HTN -> will continue on lopressor 5IV q4\n for goal SBP<140 and adjust as needed; will transition to PO when\n mental status safe for PO intake\n PULMONARY: continue aggressive pulmonary toilet -> OOB and deep\n breathing as tolerated; follow-up final read of CXR tonight\n GI / ABD: mental status not quite amenable to PO intake at this time;\n will re-eval in am and consider speech and swallow eval\n NUTRITION: written for a diet but not taking much po; see above\n RENAL: Cr normal and stable; making large volumes of urine > 200cc/hr;\n urine osms>serum osms -> pt. able to concentrate so at this time the\n diuresis appears to be secondary to fluid mobilization post-OR rather\n than DI; appreciate Endo recs and will continue to follow UOP, serum\n Na, osms frequently through the night; currently getting 1/2NS at\n 100cc/hr\n HEMATOLOGY: INR normal and no history of anticoagulation; Hct stable ->\n will follow daily hct\n ENDOCRINE: RISS; see renal section as well\n ID: pt. spiking fevers overnight and pan cultured -> given tylenol and\n cooling blanket; no abx at present - will follow cultures\n LINES/TUBES/DRAINS: PIV and foley\n WOUNDS: crani wound -> dressing C/D/I\n IMAGING: f/u final read from CXR from this evening\n FLUIDS: 1/2NS @ 100cc/hr\n CONSULTS: Neurosurg, Endocrinology, Psych\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - , discuss with NSurg when hep sq can start\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: () (c)/ (h)\n ICU Consent: yes\n CODE STATUS: Full\n DISPOSITION: ICU\n ICU Care\n Nutrition: NPO at present secondary to mental status and not taking\n food well\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:45 PM\n 16 Gauge - 06:46 PM\n Prophylaxis:\n DVT: \n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting planning, Family meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441727, "text": "TITLE:\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2150-01-22 00:00:00.000", "description": "Intensivist Note", "row_id": 441790, "text": "TSICU\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n .\n 24 HOUR EVENTS:\n : admitted to TICU s/p bifrontal craniotomy and excision of\n arteriovenous malformation; fever -> pan cultured; seen by endo and\n psych\n .\n 24 Hour Events:\n BLOOD CULTURED - At 08:28 PM\n URINE CULTURE - At 08:28 PM\n FEVER - 102.8\nF - 09:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:45 PM\n Famotidine (Pepcid) - 10:31 PM\n Metoprolol - 04:09 AM\n Other medications:\n Haloperidol 1 mg IV ONCE, LeVETiracetam 1500 mg IV BID,\n Acetaminophen-Caff-Butalbital TAB PO Q6H:PRN, Acetaminophen 650 mg\n PO Q6H:PRN, Bisacodyl 10 mg PO/PR, Lopressor 5 mg IV Q4H,\n DiphenhydrAMINE 12.5 mg PO Q6H:PRN, OxycoDONE (Immediate Release) 10\n mg PO Q4H:PRN, Docusate Sodium (Liquid) 100 mg PO BID, Senna 1 TAB PO\n BID:PRN, Famotidine 20 mg IV Q12H, HYDROmorphone (Dilaudid) 0.25 mg IV\n Q3H:PRN\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.8\n T current: 37.4\nC (99.3\n HR: 83 (83 - 107) bpm\n BP: 149/92(105) {123/69(85) - 167/98(134)} mmHg\n RR: 33 (20 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,550 mL\n 978 mL\n PO:\n Tube feeding:\n IV Fluid:\n 590 mL\n 978 mL\n Blood products:\n Total out:\n 5,625 mL\n 1,320 mL\n Urine:\n 1,190 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,075 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Well nourished, moving quite a\n bit in bed\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 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, (Responds to: Verbal stimuli),\n Moves all extremities, occasionally will say his name - not answering\n questions reliably\n Labs / Radiology\n 417 K/uL\n 11.5 g/dL\n 127 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 104 mEq/L\n 140 mEq/L\n 31.8 %\n 14.7 K/uL\n [image002.jpg]\n 08:15 PM\n 12:03 AM\n 02:41 AM\n WBC\n 14.7\n Hct\n 31.8\n Plt\n 417\n Creatinine\n 0.6\n 0.6\n 0.6\n Glucose\n 127\n Other labs: PT / PTT / INR:13.9/26.5/1.2, Ca:9.4 mg/dL, Mg:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n ANEURYSM, OTHER, DELIRIUM / CONFUSION, FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), INTRAVENOUS DRUG ABUSE (IVDU, IVDA),\n ALCOHOL ABUSE\n .\n ASSESSMENT AND PLAN: 51M s/p bifrontal craniotomy and excision of\n arteriovenous malformation with persistant mental status changes and\n fevers.\n .\n NEUROLOGIC: Pt. s/p crani with persistant mental status changes -\n possibly secondary to withdrawl from suboxone v. etoh v. other\n substances v. changes related to bleed from AVM; will continue Haldol\n as first line med for aggitation - appreciate recs from psych; will\n consider benzos if aggitation non-responsive to haldol and accompanied\n with other symptoms of etoh withdrawl; on keppra for seizure prophy;\n goal SBP<140\n Neuro checks Q:1 hour\n Pain: dilaudid prn\n CARDIOVASCULAR: unknown if h/o HTN -> will continue on lopressor 5 IV\n q4 for goal SBP<140 and adjust as needed; will transition to PO when\n mental status safe for PO intake\n PULMONARY: continue aggressive pulmonary toilet -> OOB and deep\n breathing as tolerated; follow-up final read of CXR tonight\n GI / ABD: mental status not quite amenable to PO intake at this time;\n consider speech and swallow eval\n NUTRITION: written for a diet but not taking much po; see above\n RENAL: Cr normal and stable; making large volumes of urine > 200cc/hr;\n urine osms>serum osms -> pt. able to concentrate so at this time the\n diuresis appears to be secondary to fluid mobilization post-OR rather\n than DI; appreciate Endo recs - UOP steady through the night with\n stable serum sodium and osms -> unlikely DI; currently getting 1/2NS at\n 100cc/hr\n HEMATOLOGY: INR normal and no history of anticoagulation; Hct stable ->\n will follow daily hct\n ENDOCRINE: RISS; see renal section as well\n ID: pt. spiking fevers overnight and pan cultured -> given tylenol and\n cooling blanket; no abx at present - will follow cultures\n LINES/TUBES/DRAINS: PIV and foley\n WOUNDS: crani wound -> dressing C/D/I\n IMAGING: f/u final read from CXR from last evening -> no obvious\n infiltrate per my eval\n FLUIDS: 1/2NS @ 100cc/hr\n CONSULTS: Neurosurg, Endocrinology, Psych\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - , discuss with NSurg when hep sq can start\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: () (c)/ (h)\n ICU Consent: yes\n CODE STATUS: Full\n DISPOSITION: ICU\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:45 PM\n 16 Gauge - 06:46 PM\n Prophylaxis:\n DVT: \n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\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:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441792, "text": "TITLE:\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n Assessment:\n Pt confused and non-coop with care, remains lethargic though has\n improved overnoc. Oriented x1 at times, answers\n to most questions.\n Normal strength in all extremites, which he frequently flails in bed.\n PERRLA 3-5mm, briskly react, +corneals, brief tracking to speaker.\n Difficult to assess sensation in extremities-pt appearing to be\n hypersensitive to tactile stimuli and yells out. Cough and gag appear\n to be normal. Tremulous throughout night but has lessened as his fever\n ha subsided. Denies pain.\n Action:\n Psych consult obtained. Keppra continued. Q1 neuro exam monitored.\n Response:\n Psych recommending Haldol instead of Ativan. Haldol given x1 overnight\n with little effect.\n Plan:\n Consider changing neuro exams to Q2-4 as his exam is stable, ? repeat\n head CT, continue Keppra.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 103\n Action:\n Cooling blanket, PRN tylenol, and fan provided. Blood and urine cx\n obtained.\n Response:\n Pt continuously pulling off cooling blanket (despite soft wrist\n restraints), temp briefly down to 99.8, though is beginning to rise\n again.\n Plan:\n f/u cx results, continue anti-pyretic measures.\n" }, { "category": "Physician ", "chartdate": "2150-01-09 00:00:00.000", "description": "Intensivist Note", "row_id": 439234, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n Acetaminophen, Famotidine, Fentanyl Citrate, Folic\n Acid/Multivitamin/Thiamine-1000mL NS, Insulin, Lorazepam, Nimodipine,\n Nitroprusside Sodium\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Famotidine (Pepcid) - 01:00 AM\n Flowsheet Data as of 05:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.7\n T current: 37.6\nC (99.7\n HR: 78 (66 - 80) bpm\n BP: 105/52(61) {105/52(61) - 138/78(88)} mmHg\n RR: 12 (9 - 13) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 237 mL\n PO:\n Tube feeding:\n IV Fluid:\n 237 mL\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 237 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 98%\n ABG: ///28/\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, No(t) Trace)\n Right Extremities: (Edema: Absent)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 234 K/uL\n 13.5 g/dL\n 89 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 3.8 mEq/L\n 20 mg/dL\n 102 mEq/L\n 139 mEq/L\n 37.5 %\n 11.2 K/uL\n [image002.jpg]\n 01:06 AM\n WBC\n 11.2\n Hct\n 37.5\n Plt\n 234\n Creatinine\n 0.9\n Troponin T\n <0.01\n Glucose\n 89\n Other labs: PT / PTT / INR:14.7/25.1/1.3, CK / CK-MB / Troponin\n T:134/1/<0.01, ALT / AST:40/28, Alk-Phos / T bili:72/0.7, Amylase /\n Lipase:148/129, Albumin:4.3 g/dL, Ca:9.3 mg/dL, Mg:2.1 mg/dL, PO4:3.7\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan:\n Neurologic: tight SBP <140, nicardipine gtt if needed, nimodipine,\n dilantin loaded, repeat CT head in AM, CIWA scale, banana bag, SW\n consult, angio in AM with , q1h neuro check\n Cardiovascular: neg enzymes\n Pulmonary: intubate if needed for mental status, currenly doing well on\n NC\n Gastrointestinal / Abdomen: elevated lipase and amylase, keep NPO and\n gentle hydration (although with a careful balance due to possible\n increased ICP given his bleeding), follow LFTs, lipase and amylase\n Nutrition: NPO, banana bag at 50ml/hr\n Renal: no urine output yet, no foley\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: no issues\n Lines / Tubes / Drains: PIV\n Wounds:\n Imaging: none\n Fluids: banana bag at 50ml/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 12:48 AM\n 22 Gauge - 12:49 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status:\n Disposition: ICU\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2150-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439226, "text": ",\n Patient transferred from with left lateral\n ventricle bleed. Patient? Head trauma 5-6days ago. Patient is unclear\n to exact events, but has complained of headaches for days.\n Patient has history of pancreatitis, and risk of etoh withdrawal.\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n No withdrawal noted. Patient alert orient x2 no tremors, delirium\n noted.\n Action:\n Ciwa scale used to monitor for withdrawal, iv banana bag started.\n Response:\n No active withdrawal noted at this time.\n Plan:\n Will continue to monitor for withdrawal, if patient has signs of\n withdrawal, ativan is ordered to treat.\n Altered mental status (not Delirium)\n Assessment:\n Patient is alert orientated x2, with some confused speech noted.\n Follows commands. Perral. Denies numbness tingling. Mae equal strength\n noted. Continue to have headache po Tylenol given, with little effect.\n Action:\n Neuro checks monitored Q1,\n Response:\n No change in neuro status at time of report\n Plan:\n Patient to have ct scan of head in am, and cta\n" }, { "category": "Nursing", "chartdate": "2150-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439223, "text": "Patient admitted via Ed with left ventricular bleed. Patient\n transferred from ,\n .H/O alcohol withdrawal (including delirium tremens, DTs, seizures)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 439740, "text": "Altered mental status (not Delirium)\n Assessment:\n Continues to be confused. Alert and disoriented. Continually\n forgetting where he is, however remembers with reinforcement. Able to\n report being in a hospital. Does not know why or for how long he has\n been here. Complaining of headache this afternoon.\n Action:\n Gave oxycodone 10 mg prn once this afternoon.\n Response:\n Patient appearing more comfortable after oxycodone, sleeping\n comfortably.\n Plan:\n Continue to assess neuro status Q 2 hours, alert team to any changes.\n Treat headache with oxycodone when appropriate. Embolization on\n Monday.\n" }, { "category": "Physician ", "chartdate": "2150-01-12 00:00:00.000", "description": "Intensivist Note", "row_id": 439881, "text": "SICU\n HPI:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Chief complaint:\n Head bleed\n PMHx:\n polysubstance abuse (cocaine/IVDA)? on suboxone, EtOH abuse /day,\n +tob\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Acetaminophen-Caff-Butalbital 5.\n Famotidine 6. Influenza Virus Vaccine\n 7. Lorazepam 8. Nitroprusside Sodium 9. OxycoDONE (Immediate Release)\n 10. Sodium Chloride 0.9% Flush\n 24 Hour Events:\n FEVER - 101.2\nF - 04:00 PM\n No acute events overnight\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 06:37 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: 81 (56 - 88) bpm\n BP: 122/81(89) {100/57(69) - 149/90(104)} mmHg\n RR: 25 (9 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 68 Inch\n Total In:\n 620 mL\n PO:\n 620 mL\n Tube feeding:\n IV Fluid:\n Blood products:\n Total out:\n 1,300 mL\n 450 mL\n Urine:\n 1,300 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -680 mL\n -450 mL\n Respiratory support\n SPO2: 97%\n ABG: ///23/\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli, Tactile stimuli), Moves all extremities\n Labs / Radiology\n 305 K/uL\n 14.3 g/dL\n 95 mg/dL\n 0.8 mg/dL\n 23 mEq/L\n 3.7 mEq/L\n 16 mg/dL\n 102 mEq/L\n 136 mEq/L\n 39.2 %\n 10.0 K/uL\n [image002.jpg]\n 01:06 AM\n 04:52 AM\n 01:00 AM\n 02:18 AM\n WBC\n 11.2\n 9.6\n 10.1\n 10.0\n Hct\n 37.5\n 35.8\n 36.2\n 39.2\n Plt\n 05\n Creatinine\n 0.9\n 0.7\n 0.7\n 0.8\n Troponin T\n <0.01\n <0.01\n Glucose\n 89\n 85\n 100\n 95\n Other labs: PT / PTT / INR:14.4/26.3/1.3, CK / CK-MB / Troponin\n T:97/1/<0.01, ALT / AST:25/22, Alk-Phos / T bili:69/0.6, Amylase /\n Lipase:142/109, Albumin:4.3 g/dL, Ca:9.3 mg/dL, Mg:2.3 mg/dL, PO4:3.2\n mg/dL\n Assessment and Plan\n .H/O ALCOHOL WITHDRAWAL (INCLUDING DELIRIUM TREMENS, DTS, SEIZURES),\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n Assessment and Plan: 51 y/o with likely AVM of the lateral ventricle\n Neuro: no change in neuro status, nimodipine, dilantin loaded, embo\n planned for today. Pain control with fioricet, oxycodone\n CV: HD stable, nicardipine prn HTN, SBP <160\n Resp:no issues\n GI: regular diet, NPO after midnight for embolization today\n FEN: NS at 70 cc/hr\n Renal:follow UOP, no issues\n Heme:Hct stable\n Endo:RISS\n ID:no issues\n TLD:PIV\n Wound:none\n Prophylaxis: H2B and boots\n Consults: neurosurgery, neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 09:58 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n" }, { "category": "General", "chartdate": "2150-01-12 00:00:00.000", "description": "Generic Note", "row_id": 440045, "text": "TITLE:\n Altered mental status (not Delirium)\n Assessment:\n S/p angio today for attempted emobolization of AV malformation. Pt\n arrived to unit extubated, moving all extremities, cooperative,\n following commands, pupils equal and reactive, oriented x\ns 1, more\n confused than prior to procedure\n sicu team is aware. Angio site\n intact, pulses palpable. Sbp goal verbally verified with neuro .\n P.a. < 160. Sbp 130\ns-150s.\n Action:\n q 2 hour neuro checks, angio site monitored.\n Response:\n Neuro status unchanged\n Plan:\n Transfer to step down when bed available, continue to monitor neuro\n status, check angio site and pulses, maintain safety.\n" }, { "category": "General", "chartdate": "2150-01-12 00:00:00.000", "description": "Generic Note", "row_id": 440046, "text": "TITLE:\n 51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Altered mental status (not Delirium)\n Assessment:\n S/p angio today for attempted emobolization of AV malformation. Pt\n arrived to unit extubated, moving all extremities, cooperative,\n following commands, pupils equal and reactive, oriented x\ns 1, more\n confused than prior to procedure\n sicu team is aware. Angio site\n intact, pulses palpable. Sbp goal verbally verified with neuro .\n P.a. < 160. Sbp 130\ns-150s.\n Action:\n q 2 hour neuro checks, angio site monitored.\n Response:\n Neuro status unchanged\n Plan:\n Transfer to step down when bed available, continue to monitor neuro\n status, check angio site and pulses, maintain safety.\n" }, { "category": "Nursing", "chartdate": "2150-01-12 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 440053, "text": "51 yo M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was\n found to have a large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well\n likely from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase\n Altered mental status (not Delirium)\n Assessment:\n S/p angio today for attempted emobolization of AV malformation. Pt\n arrived to unit extubated, moving all extremities, cooperative,\n following commands, pupils equal and reactive, oriented x\ns 1, more\n confused than prior to procedure\n sicu team is aware. Angio site\n intact, pulses palpable. Sbp goal verbally verified with neuro .\n P.a. < 160. Sbp 130\ns-150s.\n Action:\n q 2 hour neuro checks, angio site monitored.\n Response:\n Neuro status unchanged\n Plan:\n Transfer to step down when bed available, continue to monitor neuro\n status, check angio site and pulses, maintain safety.\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 441847, "text": "Pt is a 51yo who presented to OSH on with confusion and lethargy.\n Ct showed ICH and transferred to where further studies showed ICH\n caused from AVM. Angio done but not candidate for intervention. Pt was\n on floor for monitoring and after several days not showing much\n improvement. Bifrontal Craniotomy with excision of AVM done and\n pt to PACU post-op. Doing well initially, extubated, alert, orientated\n x 1, FC\ns, eating breakfast. Had MS changes, reintubated for CT scan\n which showed no changed, extubated then admitted evening to ICU\n for monitoring.\n Transfers, Impaired\n Assessment:\n Pt OOB to chair today with minimal assist of 1. Back to bed with\n supervision. Did c/o some dizziness. Not orthostatic.\n Action:\n Pt in chair most of morning. PT assessed/worked with pt late morning.\n Response:\n Transfers with supervision mostly for safety r/t monitoring leads and\n foley.\n Plan:\n Acivity as tolerated with supervision.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n Afebrile this am.\n Action:\n This afternoon pt having occasional tremors and c/o feeling cold. HR\n 100-110s. Temp 101.2. Given Tylenol.\n Response:\n Remains tachycardic in 110s. Tem remains elevated.\n Plan:\n Cont Tylenol as needed. Follow-up with cultures currently pending.\n Delirium / confusion\n Assessment:\n Pt easily arousable to voice. Eyes swollen but does open to command.\n Orientated x 1, person only. Verbal responses consistly mainly of\n yes/no. Able to communicate needs this way. Calm and cooperative.\n Action:\n Restraints d/c\nd this am. OOB to chair. Remains orientated to person\n only but FCs well. MAEs. Has not received any haldol since early am.\n Response:\n Calm cooperative, FCs.\n Plan:\n Cont frequent neuro checks. Maintain safe environment.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n INTRACRANIAL HEMORRHAGE\n Code status:\n Height:\n Admission weight:\n 75 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Pancreatitis, Smoker\n CV-PMH:\n Additional history: ETOH drinks per day\n Smoker 1PPD\n chronic pancreatitis\n IVDA\n Acid reflux\n migraines\n Surgery / Procedure and date: Angio for embolization of AVM\n specific to corpus callosum\n bifrontal craniotomy and excision of AVM\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:120\n D:68\n Temperature:\n 101.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 29 insp/min\n Heart Rate:\n 108 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 96% %\n O2 flow:\n 3 L/min\n FiO2 set:\n 24h total in:\n 1,795 mL\n 24h total out:\n 2,100 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 02:41 AM\n Potassium:\n 3.5 mEq/L\n 02:41 AM\n Chloride:\n 104 mEq/L\n 02:41 AM\n CO2:\n 24 mEq/L\n 02:41 AM\n BUN:\n 4 mg/dL\n 02:41 AM\n Creatinine:\n 0.6 mg/dL\n 02:41 AM\n Glucose:\n 127 mg/dL\n 02:41 AM\n Hematocrit:\n 31.8 %\n 02:41 AM\n Finger Stick Glucose:\n 133\n 09:00 AM\n Valuables / Signature\n Patient valuables:\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: 1114\n Date & time of Transfer: at 1600\n" }, { "category": "Nutrition", "chartdate": "2150-01-22 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 441846, "text": "Subjective\n Pt reports good appetite, eating chicken fingers in room\n Objective\n Pertinent medications: KCl, pepcid, heparin, colace, RISS, others noted\n Labs:\n Value\n Date\n Glucose\n 127 mg/dL\n 02:41 AM\n Glucose Finger Stick\n 133\n 09:00 AM\n BUN\n 4 mg/dL\n 02:41 AM\n Creatinine\n 0.6 mg/dL\n 02:41 AM\n Sodium\n 140 mEq/L\n 02:41 AM\n Potassium\n 3.5 mEq/L\n 02:41 AM\n Chloride\n 104 mEq/L\n 02:41 AM\n TCO2\n 24 mEq/L\n 02:41 AM\n pH (urine)\n 8.0 units\n 02:13 AM\n Calcium non-ionized\n 9.4 mg/dL\n 02:41 AM\n Phosphorus\n 3.2 mg/dL\n 02:41 AM\n Magnesium\n 1.9 mg/dL\n 02:41 AM\n WBC\n 14.7 K/uL\n 02:41 AM\n Hgb\n 11.5 g/dL\n 02:41 AM\n Hematocrit\n 31.8 %\n 02:41 AM\n Current diet order / nutrition support: regular\n Assessment of Nutritional Status\n Specifics: 51year old male S/P bifrontal craniotomy and excision of\n arterivenous malformation on . SLP saw pt today and recommended\n regular diet with thin liquids. Pt with fair po intake, will add\n supplements to increase caloric intake post-op. Pt tolerating diet no\n N/V.\n Medical Nutrition Therapy Plan - Recommend the Following\n Current diet / nutrition support is appropiate:\n Oral supplements: ensure TID\n Multivitamin / Mineral supplement: via po\n Check chemistry 10 panel daily\n Encourage po intake and supplements\n Page with questions\n" }, { "category": "Rehab Services", "chartdate": "2150-01-22 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 441832, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: IPH/Crani / 431\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 51 y.o. male found\n by friend to have altered mental status and admitted to OSH ED. Found\n to have extensive intraventricular hemorrhage due to AVM. Transferred\n and admitted on . Profound encephalopathy continued and pt went\n to OR for bifrontal craniotomy and excision of AVM of corpus\n callosum, in pt was agitated and required haldol, was transferred\n to TSICU for monitoring\n Past Medical / Surgical History: See IE\n Medications: Acetaminophen, hydromorphone, oxycodine, levetiracetam,\n metoprolol tartrate, samotidine, diphrahydramine, heparin\n Radiology: CT : Apparent small nidus of an arteriovenous\n malformation with a draining vein that drains into the right septal\n vein. No evidence of new hemorrhage. :Expected evolution of the\n corpus callosum and intraventricular hemorrhage without evidence of new\n hemorrhage. Subtle increase in pericallosal hypo attenuation which is\n suspicious for ischemia.\n Labs:\n 31.8\n 11.5\n 417\n 14.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist qid\n Social / Occupational History: See IE\n Living Environment: See IE\n Prior Functional Status / Activity Level: See IE\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt. was drowsy.\n Oriented x1 to name. Able to follow 90% of simple 1 step verbal\n commands. Answered question but incorrectly. Unable to recall name of\n hospital or year after reorientation\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 119/71\n 23\n 99% on RA\n Sit\n /\n Activity\n 89\n 132/81\n 28\n 95% on RA\n Stand\n /\n Recovery\n 97\n 120/72\n 24\n 97% on RA\n Total distance walked:\n Minutes:\n Pulmonary Status: No abnormal breathing patterns noted\n Integumentary / Vascular: Foley, Large craniotomy incision across head\n with staples intact and without drainage., PIV\n Sensory Integrity: Intact\n Pain / Limiting Symptoms: Pt. denied pain\n Posture: unremarkable\n Range of Motion\n Muscle Performance\n B UE WNL\n B LE WNL\n Able to perform seated therex: Marching, LAQ, standing marching\n B shoulder flexion \n Motor Function: Able to move all extremities against gravity\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was seated at the beginning of tx. Was able to\n perform sit <->stand with . Maintain standing with CG. Re-eval\n limited by pt\ns mental confusion.\n Rolling:\n NT\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n NT\n\n\n\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: with standing marching and to maintain standing during\n perturbation to prevent LOB.\n Education / Communication: Spoke with RN prior to tx. Pt educated on\n role of PT\n Intervention: transfer training, balance training, therex\n Other: Re-evaluation and tx was limited by pt\ns mental confusion.\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Transfers, Impaired\n 4.\n Impaired Mobility\n 5.\n Impaired Balance\n Clinical impression / Prognosis: Pt is a 51 y.o. male s/p bifrontal\n craniotomy for AVM excision who presents with above mentioned\n impairments consistent with Non progressive CNS dysfunction. Pt.\n continues to mobilize well below baseline limited by mental status. Pt\n has potential to make gains with functional mobility, however cognition\n may continue to impair safety. OT consult would be beneficial in\n determining d/c plan. Rehab may be necessary in order to optimize\n safety.\n Goals\n Time frame: 1 week\n 1.\n Follow verbal commands 100% of the time\n 2.\n Transfer from sit to stand I\n 3.\n Cg for amb >150ft and Min VCs for safety\n 4.\n I with bed mobility\n 5.\n I prevent LOB in standing with perturbations\n 6.\n safe transfer technique\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n Therex, mobility training, gait training, balance training, pt.\n education on safe transfer technique.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Note written by PT/S\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 441835, "text": "Transfers, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 441837, "text": "Transfers, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Delirium / confusion\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2150-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 441744, "text": "TITLE:\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n Assessment:\n Pt confused and non-coop with care, remains lethargic though has\n improved overnoc. Oriented x1 at times, answers\n to most questions.\n Normal strength in all extremites, which he frequently flails in bed.\n PERRLA 3-5mm, briskly react, +corneals, brief tracking to speaker.\n Difficult to assess sensation in extremities-pt appearing to be\n hypersensitive to tactile stimuli and yells out. Cough and gag appear\n to be normal. Tremulous throughout night but has lessened as his fever\n ha subsided. Denies pain.\n Action:\n Psych consult obtained. Keppra continued. Q1 neuro exam monitored.\n Response:\n Psych recommending Haldol instead of Ativan. Haldol given x1 overnight\n with little effect.\n Plan:\n Consider changing neuro exams to Q2-4 as his exam is stable, ? repeat\n head CT, continue Keppra.\n Fever (Hyperthermia, Pyrexia, not Fever of Unknown Origin)\n Assessment:\n T-max 103\n Action:\n Cooling blanket, PRN tylenol, and fan provided. Blood and urine cx\n obtained.\n Response:\n Pt continuously pulling off cooling blanket (despite soft wrist\n restraints), temp briefly down to 99.8, though is beginning to rise\n again.\n Plan:\n f/u cx results, continue anti-pyretic measures.\n" }, { "category": "Rehab Services", "chartdate": "2150-01-22 00:00:00.000", "description": "Bedside Swallow Evaluation", "row_id": 441828, "text": "TITLE: Bedside Swallow Evaluation\n Patient was seen for bedside swallow evaluation. Please see full\n evaluation in OMR or paper chart for details and recommendations.\n" }, { "category": "Rehab Services", "chartdate": "2150-01-22 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 441829, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: IPH/Crani / 431\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 51 y.o. male found\n by friend to have altered mental status and admitted to OSH ED. Found\n to have extensive intraventricular hemorrhage due to AVM. Transferred\n and admitted on . Profound encephalopathy continued and increased\n mental confusion so went to OR. Is now s/p bifrontal craniotomy and\n excision of AVM of corpus callosum on .\n Past Medical / Surgical History: See IE\n Medications: Acetaminophen, hydromorphone, oxycodine, levetiracetam,\n metoprolol tartrate, samotidine, diphrahydramine, heparin\n Radiology: CT : Apparent small nidus of an arteriovenous\n malformation with a draining vein that drains into the right septal\n vein. No evidence of new hemorrhage. :Expected evolution of the\n corpus callosum and intraventricular hemorrhage without evidence of new\n hemorrhage. Subtle increase in pericallosal hypo attenuation which is\n suspicious for ischemia.\n Labs:\n 31.8\n 11.5\n 417\n 14.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with asist qid\n Social / Occupational History: See IE\n Living Environment: See IE\n Prior Functional Status / Activity Level: See IE\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt. was drowsy.\n Oriented x1 to name. Able to follow 90% of verbal commands. Answered\n question but incorrectly.\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 119/71\n 23\n 99% on RA\n Sit\n /\n Activity\n 89\n 132/81\n 28\n 95% on RA\n Stand\n /\n Recovery\n 97\n 120/72\n 24\n 97% on RA\n Total distance walked:\n Minutes:\n Pulmonary Status: No abnormal breathing patterns noted\n Integumentary / Vascular: Foley, Large incision across head with\n staples intact and without drainage.\n Sensory Integrity: Intact\n Pain / Limiting Symptoms: Pt. denied pain\n Posture:\n Range of Motion\n Muscle Performance\n B UE WNL\n B LE WML\n Able to perform seated therex: Marching, LAQ, standing marching\n B shoulder flexion \n Motor Function: Able to move all extremities against gravity\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was seated at the begining of tx. Was able to\n perform sit <->stand with . Maintain standing with CG. Re-eval\n limited by pt\ns mental confusion.\n Rolling:\n NT\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n NT\n\n\n\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: with standing marching and to maintain standing during\n perturbation to prevent LOB.\n Education / Communication: Spoke with RN prior to tx.\n Intervention: transfer training, balance training, therex\n Other: Re-evaluation and tx was limited by pt\ns mental confusion.\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Transfers, Impaired\n 4.\n Impaired Mobility\n 5.\n Impaired Balance\n Clinical impression / Prognosis: Pt is a 51 y.o. male s/p bifrontal\n craniotomy who presents with above mentioned impairments consistent\n with Non progressive CNA. Pt. continues to mobilize well below\n baseline limited by mental confusion and would benefit from rehab to\n optimize return to baseline. Good potential to return to functional\n baseline. Progress may be slow due to mental confusion.\n Goals\n Time frame: 1 week\n 1.\n Follow verbal commands 100% of the time\n 2.\n Transfer from sit to stand I\n 3.\n for amb >50ft and Min VCs for safety\n 4.\n I with bed mobility\n 5.\n I prevent LOB in standing with perturbations\n 6.\n safe transfer technique\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n Therex, mobility training, gait training, balance training, pt.\n education on safe transfer technique.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Note written by PT/S\n" }, { "category": "Rehab Services", "chartdate": "2150-01-22 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 441830, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: IPH/Crani / 431\n Reason of referral: Eval and Tx\n History of Present Illness / Subjective Complaint: 51 y.o. male found\n by friend to have altered mental status and admitted to OSH ED. Found\n to have extensive intraventricular hemorrhage due to AVM. Transferred\n and admitted on . Profound encephalopathy continued and increased\n mental confusion so went to OR. Is now s/p bifrontal craniotomy and\n excision of AVM of corpus callosum on .\n Past Medical / Surgical History: See IE\n Medications: Acetaminophen, hydromorphone, oxycodine, levetiracetam,\n metoprolol tartrate, samotidine, diphrahydramine, heparin\n Radiology: CT : Apparent small nidus of an arteriovenous\n malformation with a draining vein that drains into the right septal\n vein. No evidence of new hemorrhage. :Expected evolution of the\n corpus callosum and intraventricular hemorrhage without evidence of new\n hemorrhage. Subtle increase in pericallosal hypo attenuation which is\n suspicious for ischemia.\n Labs:\n 31.8\n 11.5\n 417\n 14.7\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with asist qid\n Social / Occupational History: See IE\n Living Environment: See IE\n Prior Functional Status / Activity Level: See IE\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt. was drowsy.\n Oriented x1 to name. Able to follow 90% of verbal commands. Answered\n question but incorrectly.\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 119/71\n 23\n 99% on RA\n Sit\n /\n Activity\n 89\n 132/81\n 28\n 95% on RA\n Stand\n /\n Recovery\n 97\n 120/72\n 24\n 97% on RA\n Total distance walked:\n Minutes:\n Pulmonary Status: No abnormal breathing patterns noted\n Integumentary / Vascular: Foley, Large incision across head with\n staples intact and without drainage.\n Sensory Integrity: Intact\n Pain / Limiting Symptoms: Pt. denied pain\n Posture:\n Range of Motion\n Muscle Performance\n B UE WNL\n B LE WML\n Able to perform seated therex: Marching, LAQ, standing marching\n B shoulder flexion \n Motor Function: Able to move all extremities against gravity\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was seated at the begining of tx. Was able to\n perform sit <->stand with . Maintain standing with CG. Re-eval\n limited by pt\ns mental confusion.\n Rolling:\n NT\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n NT\n\n\n\n\n\n\n Transfer:\n NT\n\n\n\n\n\n\n Sit to Stand:\n\n\n T\n\n\n Ambulation:\n NT\n\n\n\n\n\n\n Stairs:\n NT\n\n\n\n\n\n\n Balance: with standing marching and to maintain standing during\n perturbation to prevent LOB.\n Education / Communication: Spoke with RN prior to tx.\n Intervention: transfer training, balance training, therex\n Other: Re-evaluation and tx was limited by pt\ns mental confusion.\n Diagnosis:\n 1.\n Arousal, Attention, and Cognition, Impaired\n 2.\n Knowledge, Impaired\n 3.\n Transfers, Impaired\n 4.\n Impaired Mobility\n 5.\n Impaired Balance\n Clinical impression / Prognosis: Pt is a 51 y.o. male s/p bifrontal\n craniotomy who presents with above mentioned impairments consistent\n with Non progressive CNA. Pt. continues to mobilize well below\n baseline limited by mental confusion and would benefit from rehab to\n optimize return to baseline. Good potential to return to functional\n baseline. Progress may be slow due to mental confusion.\n Goals\n Time frame: 1 week\n 1.\n Follow verbal commands 100% of the time\n 2.\n Transfer from sit to stand I\n 3.\n for amb >50ft and Min VCs for safety\n 4.\n I with bed mobility\n 5.\n I prevent LOB in standing with perturbations\n 6.\n safe transfer technique\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n Therex, mobility training, gait training, balance training, pt.\n education on safe transfer technique.\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Note written by PT/S\n" }, { "category": "Physician ", "chartdate": "2150-01-22 00:00:00.000", "description": "Intensivist Note", "row_id": 441820, "text": "TSICU\n HPI: 51M PMH polysubstance abuse/EtOH and ? recent head trauma. Not\n oriented and no contact. Presented to after a\n period of 5 days reportedly where no one had seen him? and he was found\n to have a large amount of blood in the LEFT lateral ventricle extending\n to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm (anterior cerebral artery RIGHT). Profound\n encephalopathy but no focality. His screening labs were otherwise\n remarkable for elevated lipase and amylase.\n .\n ISSUES:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n - aggitation\n - persistant mental status changes\n - Fever of unknown origin\n .\n CHIEF COMPLAINT:\n - s/p bifrontal craniotomy and excision of arteriovenous malformation\n .\n 24 HOUR EVENTS:\n : admitted to TICU s/p bifrontal craniotomy and excision of\n arteriovenous malformation; fever -> pan cultured; seen by endo and\n psych\n .\n 24 Hour Events:\n BLOOD CULTURED - At 08:28 PM\n URINE CULTURE - At 08:28 PM\n FEVER - 102.8\nF - 09:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Haloperidol (Haldol) - 09:45 PM\n Famotidine (Pepcid) - 10:31 PM\n Metoprolol - 04:09 AM\n Other medications:\n Haloperidol 1 mg IV ONCE, LeVETiracetam 1500 mg IV BID,\n Acetaminophen-Caff-Butalbital TAB PO Q6H:PRN, Acetaminophen 650 mg\n PO Q6H:PRN, Bisacodyl 10 mg PO/PR, Lopressor 5 mg IV Q4H,\n DiphenhydrAMINE 12.5 mg PO Q6H:PRN, OxycoDONE (Immediate Release) 10\n mg PO Q4H:PRN, Docusate Sodium (Liquid) 100 mg PO BID, Senna 1 TAB PO\n BID:PRN, Famotidine 20 mg IV Q12H, HYDROmorphone (Dilaudid) 0.25 mg IV\n Q3H:PRN\n Flowsheet Data as of 07:02 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.3\nC (102.8\n T current: 37.4\nC (99.3\n HR: 83 (83 - 107) bpm\n BP: 149/92(105) {123/69(85) - 167/98(134)} mmHg\n RR: 33 (20 - 33) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,550 mL\n 978 mL\n PO:\n Tube feeding:\n IV Fluid:\n 590 mL\n 978 mL\n Blood products:\n Total out:\n 5,625 mL\n 1,320 mL\n Urine:\n 1,190 mL\n 1,320 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,075 mL\n -342 mL\n Respiratory support\n O2 Delivery Device: None\n SPO2: 96%\n ABG: ///24/\n Physical Examination\n General Appearance: No acute distress, Well nourished, moving quite a\n bit in bed\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 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, (Responds to: Verbal stimuli),\n Moves all extremities, occasionally will say his name - not answering\n questions reliably\n Labs / Radiology\n 417 K/uL\n 11.5 g/dL\n 127 mg/dL\n 0.6 mg/dL\n 24 mEq/L\n 3.5 mEq/L\n 4 mg/dL\n 104 mEq/L\n 140 mEq/L\n 31.8 %\n 14.7 K/uL\n [image002.jpg]\n 08:15 PM\n 12:03 AM\n 02:41 AM\n WBC\n 14.7\n Hct\n 31.8\n Plt\n 417\n Creatinine\n 0.6\n 0.6\n 0.6\n Glucose\n 127\n Other labs: PT / PTT / INR:13.9/26.5/1.2, Ca:9.4 mg/dL, Mg:1.9 mg/dL,\n PO4:3.2 mg/dL\n Assessment and Plan\n ANEURYSM, OTHER, DELIRIUM / CONFUSION, FEVER (HYPERTHERMIA, PYREXIA,\n NOT FEVER OF UNKNOWN ORIGIN), INTRAVENOUS DRUG ABUSE (IVDU, IVDA),\n ALCOHOL ABUSE\n .\n ASSESSMENT AND PLAN: 51M s/p bifrontal craniotomy and excision of\n arteriovenous malformation with persistant mental status changes and\n fevers.\n .\n NEUROLOGIC: Pt. s/p crani with persistant mental status changes -\n possibly secondary to withdrawl from suboxone v. etoh v. other\n substances v. changes related to bleed from AVM; will continue Haldol\n as first line med for aggitation - appreciate recs from psych; will\n consider benzos if aggitation non-responsive to haldol and accompanied\n with other symptoms of etoh withdrawl; on keppra for seizure prophy;\n goal SBP<140\n Neuro checks Q:4 hour\n Pain: dilaudid prn\n CARDIOVASCULAR: unknown if h/o HTN -> will continue on lopressor 5 IV\n q4 for goal SBP<140 and adjust as needed; will transition to PO when\n mental status safe for PO intake\n PULMONARY: continue aggressive pulmonary toilet -> OOB and deep\n breathing as tolerated; follow-up final read of CXR tonight\n GI / ABD: mental status not quite amenable to PO intake at this time;\n consider speech and swallow eval\n NUTRITION: written for a diet but not taking much po; see above\n RENAL: Cr normal and stable; making large volumes of urine > 200cc/hr;\n urine osms>serum osms -> pt. able to concentrate so at this time the\n diuresis appears to be secondary to fluid mobilization post-OR rather\n than DI; appreciate Endo recs - UOP steady through the night with\n stable serum sodium and osms -> unlikely DI; currently getting 1/2NS at\n 100cc/hr\n HEMATOLOGY: INR normal and no history of anticoagulation; Hct stable ->\n will follow daily hct\n ENDOCRINE: RISS; see renal section as well\n ID: pt. spiking fevers overnight and pan cultured -> given tylenol and\n cooling blanket; no abx at present - will follow cultures\n LINES/TUBES/DRAINS: PIV and foley\n WOUNDS: crani wound -> dressing C/D/I\n IMAGING: f/u final read from CXR from last evening -> no obvious\n infiltrate per my eval\n FLUIDS: 1/2NS @ 100cc/hr\n CONSULTS: Neurosurg, Endocrinology, Psych\n BILLING DIAGNOSIS:\n ICU CARE:\n GLYCEMIC CONTROL: RISS\n PROPHYLAXIS:\n DVT - , discuss with NSurg when hep sq can start\n STRESS ULCER - famotidine\n VAP BUNDLE -\n COMMUNICATIONS: () (c)/ (h)\n ICU Consent: yes\n CODE STATUS: Full\n DISPOSITION: to the floor\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 20 Gauge - 06:45 PM\n 16 Gauge - 06:46 PM\n Prophylaxis:\n DVT: \n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\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:\n Patient is critically ill\n" }, { "category": "Radiology", "chartdate": "2150-01-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059785, "text": " 11:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? PNA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with ICH\n REASON FOR THIS EXAMINATION:\n ? PNA\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Single portal AP chest radiograph.\n\n INDICATION: Intracranial hemorrhage, question pneumonia.\n\n COMPARISON: None available.\n\n FINDINGS: The cardiomediastinal silhouette is within normal limits. The\n lungs are clear. No effusion or pneumothorax is detected. However, the\n extreme right costophrenic angle not included. No evidence of free\n intraperitoneal or displaced rib fracture.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-20 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1061852, "text": " 7:06 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: STAT! PLEASE DO A \"CT / CTA\" AT 5 AM ON WITH BRAIN L\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with AVM\n REASON FOR THIS EXAMINATION:\n STAT! PLEASE DO A \"CT / CTA\" AT 5 AM ON WITH BRAIN LAB PROTOCOL......PT\n WILL NEED FADUCIALS PLACED / PLEASE ASK MRI TECH TO PLACE FADUCIALS / ALSO\n PLEASE PUSH IMAGES THROUGH TO BE UPLOADED TO OR IMAGE GUIDED BRAIN-LAB SYSTEM.\n (MRI TECH SHOULD BE ABLE TO ASSIST IN THIS ALSO).... IF QUESTIONS PLEASE SPEAK\n TO YOUR DIRECT SUPERVISOR....IF YOU HAVE NEUROSURGICAL QUESTIONS PLEASE CALL\n BEEPER . THANKS SO MUCH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg TUE 3:18 PM\n PFI: No evidence of new hemorrhage, hydrocephalus, or mass effect.\n Persistent but evolving anterior corpus callosum and intraventricular\n hemorrhage with mild vasogenic edema. Right inferior pericallosal AVM and\n absent A1 segment on the right, otherwise unremarkable CTA of the head.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male with AVM.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n contrast material. Subsequently, rapid axial imaging was performed from the\n base of skull through the brain during infusion of intravenous contrast.\n Images were processed on a separate workstation with display of Circle of\n reformats.\n\n COMPARISON: CT of , angiogram, .\n\n FINDINGS:\n\n CT HEAD: There is persistent but evolving hemorrhage of the anterior corpus\n callosum and intraventricular hemorrhage within the frontal ventricular horns.\n There is no evidence of acute hemorrhage, mass, mass effect, or major vascular\n territory infarction. There is persistent low attenuation of the frontal\n periventricular white matter consistent with edema. There is no evidence of\n hydrocephalus.\n\n CTA HEAD: There is nonvisualization of the right A1 segment and apparent\n supply of the right A2 segment by the left ACA. A small collection of faintly\n enhancing vessels is noted in the right pericallosual region with an\n abnormally enlarged draining vein which is a tributary of the septal vein.\n This finding is consistent with the previously noted AVM in the inferior\n pericallosal region. The remainder of the carotid and vertebral arteries and\n their major branches are patent without evidence of stenoses or other vascular\n abnormality.\n\n IMPRESSION:\n 1. No evidence of new hemorrhage.\n (Over)\n\n 7:06 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: STAT! PLEASE DO A \"CT / CTA\" AT 5 AM ON WITH BRAIN L\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2. Persistent but evolving corpus callosum and intraventricular hemorrhage.\n\n 3. AVM in the pericallosal region on the right and nonvisualization of right\n A1, otherwise normal CTA of the head.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-20 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1061853, "text": ", J. NSURG FA11 7:06 AM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: STAT! PLEASE DO A \"CT / CTA\" AT 5 AM ON WITH BRAIN L\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with AVM\n REASON FOR THIS EXAMINATION:\n STAT! PLEASE DO A \"CT / CTA\" AT 5 AM ON WITH BRAIN LAB PROTOCOL......PT\n WILL NEED FADUCIALS PLACED / PLEASE ASK MRI TECH TO PLACE FADUCIALS / ALSO\n PLEASE PUSH IMAGES THROUGH TO BE UPLOADED TO OR IMAGE GUIDED BRAIN-LAB SYSTEM.\n (MRI TECH SHOULD BE ABLE TO ASSIST IN THIS ALSO).... IF QUESTIONS PLEASE SPEAK\n TO YOUR DIRECT SUPERVISOR....IF YOU HAVE NEUROSURGICAL QUESTIONS PLEASE CALL\n BEEPER . THANKS SO MUCH\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of new hemorrhage, hydrocephalus, or mass effect.\n Persistent but evolving anterior corpus callosum and intraventricular\n hemorrhage with mild vasogenic edema. Right inferior pericallosal AVM and\n absent A1 segment on the right, otherwise unremarkable CTA of the head.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-17 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1061452, "text": ", J. NSURG FA11 7:41 PM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: PLEASE PERFORM EXAM PT IS \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Incomplete study with patient unable to continue and only sagittal and axial\n T1 images obtained. Hemorrhage is identified in the corpus callosum and the\n lateral ventricles without hydrocephalus.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062037, "text": " 7:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Postop - PERFORM AT 1830\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p craniotomy/angioplasty\n REASON FOR THIS EXAMINATION:\n Postop - PERFORM AT 1830\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AGLc TUE 10:49 PM\n Status post left frontal craniotomy, with small amount of high-density\n layering along the frontal region and along the anterior falx likely\n representing small amount of postoperative blood. Otherwise, extent of\n anterior corpus callosum and frontal intraventricular hemorrhage is not\n substantially changed from 12 hours prior.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male status post craniotomy and angioplasty; for\n post-operative evaluation.\n\n COMPARISON: CTA head of and CT head of as well as MR head of\n .\n\n TECHNIQUE: MDCT axial imaging was performed through the brain without\n administration of IV contrast.\n\n NON-CONTRAST HEAD CT: The patient is newly status post frontal craniotomy\n with expected postoperative changes including subcutaneous swelling and\n emphysema, as well as pneumocephalus. Linear extra-axial high density along\n the frontal region likely represents a small amount of postoperative blood\n layering along the dural surface. Small amount of high density in the\n interhemispheric fissure, layering along the anterior falx (2:19) likely\n represents a small amount of subdural or subarachnoid blood.\n\n Otherwise, appearance of the brain is not substantially changed compared to\n the most recent prior head CT performed at 7:12 a.m., with no increase in\n extent of left rostrum of the corpus callosal and frontal \n intraventricular hemorrhage. No new hydrocephalus, mass effect, or large\n vascular territory infarction is seen. The visualized paranasal sinuses and\n mastoid air cells remain well aerated. Minimal cavernous carotid artery\n calcifications are noted.\n\n IMPRESSION:\n\n Status post frontal craniotomy, with small amount of high-density material\n layering along the frontal region and also the anterior falx, consistent with\n a small amount of postoperative extra-axial blood. Otherwise, extent of\n left rostral corpus callosum and frontal intraventricular hemorrhage is\n not substantially changed. Continued postoperative followup recommended.\n (Over)\n\n 7:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Postop - PERFORM AT 1830\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2150-01-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062038, "text": ", J. NSURG PACU 7:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Postop - PERFORM AT 1830\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man s/p craniotomy/angioplasty\n REASON FOR THIS EXAMINATION:\n Postop - PERFORM AT 1830\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Status post left frontal craniotomy, with small amount of high-density\n layering along the frontal region and along the anterior falx likely\n representing small amount of postoperative blood. Otherwise, extent of\n anterior corpus callosum and frontal intraventricular hemorrhage is not\n substantially changed from 12 hours prior.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-17 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1061451, "text": " 7:41 PM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: PLEASE PERFORM EXAM PT IS \n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AFSN SUN 12:23 PM\n Incomplete study with patient unable to continue and only sagittal and axial\n T1 images obtained. Hemorrhage is identified in the corpus callosum and the\n lateral ventricles without hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRI of the brain.\n\n CLINICAL INFORMATION: Patient with intracranial hemorrhage, for further\n evaluation.\n\n TECHNIQUE: T1 sagittal and axial images of the brain were obtained. The\n examination could not be completed as patient was unable to continue.\n\n FINDINGS: As seen on the previous CT examination, there is subacute\n hemorrhage identified in the anterior of the both lateral ventricles\n extending to the left lateral ventricle and also in the genu of corpus\n callosum. There is no hydrocephalus seen. No midline shift.\n\n IMPRESSION: Limited study with hemorrhage visualized in the ventricles and in\n the corpus callosum without hydrocephalus.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060661, "text": " 8:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for PNA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with IVH and AVM with temp to 101.2\n REASON FOR THIS EXAMINATION:\n evaluate for PNA\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n INDICATION: 51-year-old man with IVH and AVM with temperature to 101,\n evaluate for pneumonia.\n\n CHEST PORTABLE: Comparison is made to prior examination of . The\n heart is normal in size. The mediastinal and hilar contours are unremarkable.\n The pulmonary vasculature is normal. The lungs are clear. There are no\n pleural effusions.\n\n IMPRESSION: No evidence of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062503, "text": " 9:56 PM\n CHEST (PORTABLE AP) Clip # \n Reason: PNA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with new onset fever\n REASON FOR THIS EXAMINATION:\n PNA\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male with new fever.\n\n COMPARISON: .\n\n AP PORTABLE CHEST: Heart size and mediastinal contours are normal. Lungs are\n clear. No pleural fluid. Skeletal structures are unremarkable.\n\n IMPRESSION: No pneumonia.\n\n\n" }, { "category": "ECG", "chartdate": "2150-01-12 00:00:00.000", "description": "Report", "row_id": 240440, "text": "Artifact is present. Sinus rhythm. Probably normal tracing. No previous\ntracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-09 00:00:00.000", "description": "ADD'L 2ND/3RD ORDER", "row_id": 1059842, "text": " 9:04 AM\n CAROT/CEREB Clip # \n Reason: evaluate for AVM, aneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 231\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * 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 ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with large large amount of blood in the LEFT lateral ventricle\n extending to the third and 4th as well as slightly on the RIGHT as well likely\n from AVM or aneurysm\n REASON FOR THIS EXAMINATION:\n evaluate for AVM, aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n CEREBRAL ANGIOGRAM PERFORMED ON \n\n Correlation is made with recent head CT dated .\n\n Attending:\n INDICATION: 51-year-old male with a large amount of blood in the left lateral\n ventricle extending to the third and fourth as well as slightly on the right.\n Evaluate for AVM, aneurysm.\n\n TECHNIQUE: After the risks, benefits, and alternative of the procedure were\n explained to the patient and his brother, informed written consent was\n obtained. The patient was brought to the angiography suite and both groins\n were prepped and draped in the usual sterile fashion. Access was gained to\n the right common femoral artery using the Seldinger technique and a 6 Fr\n vascular sheath was placed in the right common femoral artery. Following\n this, the vascular sheath was connected to continuous saline. We then\n catheterized the right vertebral artery, right internal carotid artery, right\n common carotid artery, right external carotid artery, left internal carotid\n artery, left common carotid artery, left external carotid artery, the left\n vertebral artery, and the right common femoral artery. AP, lateral and 3D\n angiography were performed.\n\n FINDINGS: The right vertebral artery arteriogram shows normal course and\n caliber of the vessel. No areas of stenosis, aneurysmal dilatation, or\n occlusion are identified. No evidence of AV malformation is noted. Both\n (Over)\n\n 9:04 AM\n CAROT/CEREB Clip # \n Reason: evaluate for AVM, aneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 231\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n superior cerebellar arteries and posterior cerebral arteries are noted. No\n significant reflux was noted on the left vertebral artery.\n\n The right common carotid arteriogram shows no evidence of significant stenosis\n at the carotid bifurcations. Both the take-off of the right external and\n internal carotid artery are normal.\n\n The right internal carotid arteriogram shows a normal cervical, petrous,\n precavernous, cavernous and paraclinoid segment. The right A1 segment is\n hypoplastic. There is no evidence of aneurysm, critical stenosis, or AV\n malformation identified. The left common carotid arteriogram shows a normal\n bifurcation without evidence of stenosis.\n\n The right external carotid arteriogram and the left external carotid artery\n arteriogram show normal external branches. No evidence of aneurysm, AV\n malformation or dural AV fistula is identified.\n\n The left internal carotid arteriogram shows normal cervical, petrous,\n cavernous, and paraclinoid segments. A small arteriovenous malformation is\n noted n the inferior paracallosal region. The AVM appears to have multiple\n small feeders, presumably left frontal polar, left lenticulostriate and\n recurrent artery of Heubner feeders. Drainage appears to occur into the\n internal cerebral veins. Branches from perforators from the left A1/A2\n junction are also noted.\n\n The left vertebral artery arteriogram shows no evidence of stenosis. The\n course and caliber of the vertebral artery are patent. Again both superior\n cerebellar and posterior cerebral arteries are noted. No aneurysm, stenosis,\n or AV malformation is identified.\n\n IMPRESSION:\n\n is a 51-year-old male who had a large intraventricular\n hemorrhage, left greater than right. A small amount of hemorrhage is also\n noted in the region of the genu of the corpus callosum. Today's arteriogram\n demonstrates a small arteriovenous malformation in the inferior aspect of\n pericallosal region. There appears to be multiple feeders from the left\n frontal polar, left ventriculostriate branches. The recurrent artery of\n Heubner also appears to be feeder. No aneurysms are identified.\n\n Mr. the procedure well without immediate complication. Divided\n doses for a total of 100 mcg of Fentanyl and 2 mg of Versed were given as\n conscious sedation during the procedure for a total intraservice time of 1\n hour and 50 minute with continuous hemodynamic monitoring.\n\n (Over)\n\n 9:04 AM\n CAROT/CEREB Clip # \n Reason: evaluate for AVM, aneurysm\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 231\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-10 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 1060097, "text": " 3:27 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: please eval for worsening head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with head bleed, ? AVM, now with worsening headache\n REASON FOR THIS EXAMINATION:\n please eval for worsening head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): RSRc SAT 9:38 PM\n Unchanged extensive intraventricular hemorrhage. No interval development of\n hydrocephalus.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male with AVM and intraventricular hemorrhage with\n headache.\n\n COMPARISON: Head CT without IV contrast .\n\n TECHNIQUE: Axial imaging was performed from the cranial vertex to the foramen\n magnum without IV contrast.\n\n HEAD CT WITHOUT IV CONTRAST: The configuration and degree of intraventricular\n hemorrhage is unchanged. There is extensive hemorrhage involving both lateral\n ventricles, left greater than right, the third ventricle, and the fourth\n ventricle. There has been no evident interval development of hydrocephalus or\n new site of hemorrhage. There is no shift of normally midline structures.\n There is no evidence of major vascular territorial infarction or cerebral\n edema. Osseous structures and paranasal sinuses are unremarkable. An\n arteriovenous malformation seen on CTA head two days prior is not evaluated on\n non-contrast head CT technique.\n\n IMPRESSION: Unchanged extensive intraventricular hemorrhage due to AVM\n visualized on CTA head from two days prior. No interval development of\n hydrocephalus.\n\n NOTE ON ATTENDING REVIEW:\n There is interval development of some degree of loss of -white matter\n differentiation and effacement of the cerebral sulci concerning for cerebral\n edema. Close f/u as clinically indicated.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062185, "text": " 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for frontal bleed/ fluid collection and or changes refl\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p AVM resection #1 - now with increasing mental\n status changes...\n REASON FOR THIS EXAMINATION:\n eval for frontal bleed/ fluid collection and or changes reflecting infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): EAGg WED 6:55 PM\n Expected evolution of the corpus callosum and intraventricular hemorrhage\n without evidence of new hemorrhage. Subtle increase in pericallosal\n hypoattenuation which is suspicious for ischemia. If clinically indicated and\n there are no contraindications, MRI is more sensitive for the detection of\n acute ischemia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 51-year-old male status post AVM resection, postop day 1, with\n increasing mental status change. Evaluate for frontal bleed, fluid\n collection, or acute infarct.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered.\n\n COMPARISON: Multiple studies including most recent CT of /9.\n\n FINDINGS: The patient is status post bifrontal craniotomy with expected\n pneumocephalus and post-surgical changes in the soft tissues. Persistent\n hemorrhage of the anterior corpus callosum and frontal ventricular horns is\n again noted with expected evolution. There is subtle increase in hypodensity\n in the deep white matter of the cingulate gyri overlying the corpus callosum,\n which could be related to edema, but infarct related to intraoperative injury\n (not a territorial distribution) cannot be excluded.\n\n No new hemorrhage, mass, or mass effect is seen. There is no evidence of\n hydrocephalus. The visualized portion of the paranasal sinuses and mastoid air\n cells are well aerated.\n\n IMPRESSION:\n 1. Subtle increase in pericallosal hypoattenuation which may represent\n infarction and could relate to intraoperative injury, as this is not a typical\n vascular territorial distribution. If there is clinical suscpicion and there\n is no contraindication, MRI may be considered to evaluate for acute ischemia.\n\n 2. Stable corpus callosal and intraventricular hemorrhage.\n\n 3. Status post bifrontal craniotomy with expected post-surgical changes.\n\n Findings were discussed with (Neurosurgery PA) at 2:40 p.m. on\n .\n (Over)\n\n 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for frontal bleed/ fluid collection and or changes refl\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2150-01-21 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1062186, "text": ", J. NSURG FA11 2:00 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for frontal bleed/ fluid collection and or changes refl\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with s/p AVM resection #1 - now with increasing mental\n status changes...\n REASON FOR THIS EXAMINATION:\n eval for frontal bleed/ fluid collection and or changes reflecting infarct\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Expected evolution of the corpus callosum and intraventricular hemorrhage\n without evidence of new hemorrhage. Subtle increase in pericallosal\n hypoattenuation which is suspicious for ischemia. If clinically indicated and\n there are no contraindications, MRI is more sensitive for the detection of\n acute ischemia.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1062257, "text": " 8:30 PM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infiltrate\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with fever\n REASON FOR THIS EXAMINATION:\n please eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for pneumonia.\n\n COMPARISON: .\n\n FINDINGS: In comparison to the previous radiograph, the size of the cardiac\n silhouette has minimally increased. Signs of overhydration are not seen. No\n pleural effusions, no focal parenchymal opacity suggestive of pneumonia. The\n hilar and mediastinal structures are unremarkable.\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-10 00:00:00.000", "description": "CT HEAD W/ & W/O CONTRAST", "row_id": 1060098, "text": ", J. NSURG SICU-A 3:27 PM\n CT HEAD W/ & W/O CONTRAST Clip # \n Reason: please eval for worsening head bleed\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with head bleed, ? AVM, now with worsening headache\n REASON FOR THIS EXAMINATION:\n please eval for worsening head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Unchanged extensive intraventricular hemorrhage. No interval development of\n hydrocephalus.\n\n" }, { "category": "Radiology", "chartdate": "2150-01-12 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 1060319, "text": " 12:30 PM\n CAROT/CEREB Clip # \n Reason: Embolization of AVMAnesthesia has been book but pt is on the\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 125\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 3RD ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE CAROTID/CEREBRAL BILAT *\n * SEL EA ADD'L *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with aneurysm\n REASON FOR THIS EXAMINATION:\n Embolization of AVMAnesthesia has been book but pt is on the Add-on list.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 51-year-old male patient with intraventricular and subarachnoid\n hemorrhage and subsequently found to have an AVM.\n\n ATTENDING:\n FELLOW: , MD\n\n TECHNIQUE: Informed consent was obtained from the patient and the patient's\n family after explaining the risks, indications and alternative management.\n Risks explained included stroke, loss of vision and speech, temporary or\n permanent, with possible treatment with stent and coils if needed.\n\n The patient was brought to the Interventional Neuroradiology Theater and\n placed on the biplane table in supine position. Both groins were prepped and\n draped in the usual sterile fashion. Access to the right common femoral artery\n was obtained using a 19-gauge single wall needle, under local anesthesia using\n 1% lidocaine mixed with sodium bicarbonate and with aseptic precautions.\n Through the needle, a 0.35 wire was introduced and the needle taken\n out. Over the wire, a 5 Fr vascular sheath was placed and connected to a\n saline infusion (mixed with heparin 500 units in 500 cc of saline) with a\n continuous drip. Through the sheath, a 4 Fr was introduced\n and connected to continuous saline infusion (with mixture of 1000 unitsof\n heparin in 1000 cc of saline).\n\n We selectively catheterized and injected:\n Left internal carotid artery\n\n Using a coaxial microcatheter system , we selectively catheterized and hand\n injected:\n Left A1 segment of the ACA\n Right A1/A2 segments of the ACA\n\n FINDINGS:\n\n LEFT INTERNAL CAROTID ARTERY:\n An abnormal conglomeration of vessels is seen with feeding arteries which\n (Over)\n\n 12:30 PM\n CAROT/CEREB Clip # \n Reason: Embolization of AVMAnesthesia has been book but pt is on the\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 125\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n appear to arise from some of the branches of the A2 segment of the left ACA.\n The drainage is via the internal cerebral vein. There is some crossover of\n contrast opacification via the ACOM to the contralateral right ACA. e.\n\n LEFT A1 SEGMENT OF ACA: There is visualization of the AVM nidus via some of\n the branches of the left A2 segment of the ACA.\n\n RIGHT A2 SEGMENTS OF ACA: There is no supply from the right A2 segment.\n\n IMPRESSION:\n\n Arteriovenous malformation fed by branches of the A2 segment of the left ACA\n and drainage via the internal cerebral veins.\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2150-01-20 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 1061964, "text": " 1:36 PM\n CAROT/CEREB Clip # \n Reason: please evaluate for any aneurysm or vascular malformation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 50\n ********************************* CPT Codes ********************************\n * SEL CATH 2ND ORDER CAROTID/CEREBRAL UNILAT *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with AVM s/p crani for resection\n REASON FOR THIS EXAMINATION:\n please evaluate for any aneurysm or vascular malformation\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 51-year-old male with AVM status post craniotomy for\n resection. Please evaluate for any aneurysm or residual vascular\n malformation.\n\n PROCEDURE PERFORMED: Carotid angiogram.\n\n OPERATORS: Dr. , Dr. . The attending radiologist, Dr. ,\n was present and supervised throughout the entire procedure.\n\n PROCEDURE: The risks, benefits, and alternatives of the procedure were\n explained to the patient, and informed consent was obtained and placed on the\n chart. The patient was subsequently transported to the neuroangiography\n suite. The patient was placed in the supine position. Both groins were\n prepped and draped in the standard sterile fashion. A 4 French vascular\n sheath was exchanged over a 0.38 Glidewire in the right common femoral artery.\n catheter was subsequently positioned through the vascular sheath.\n\n COMPARISON: Cerebral angiogram from .\n\n FINDINGS: The following vessels were evaluated using angiography: Left\n internal carotid artery.\n\n LEFT INTERNAL CAROTID ARTERY: There is no evidence of residual arteriovenous\n malformation. There are no draining veins identified. There are nonspecific\n prominent vessels identified in the region of the A2 segment. However, there\n is no definite arteriovenous malformation. There is mild vasospasm in the\n supraclinoid portion of the internal carotid artery.\n\n Angio-Seal was used for closure of the right common femoral artery puncture\n site. The femoral vessel was patent on angiography.\n\n IMPRESSION:\n\n No evidence of residual arteriovenous malformation.\n\n (Over)\n\n 1:36 PM\n CAROT/CEREB Clip # \n Reason: please evaluate for any aneurysm or vascular malformation\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n Contrast: OPTIRAY Amt: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2150-01-08 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1059769, "text": " 9:12 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: eval for intraparenchymal hemorrhage\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51yo male hx of IVDA c/o h/a x 1 week s/p assault with visual changes. Seen at\n OSH with ICH in 3rd/4th ventricles. ? incoherent at home per report.\n REASON FOR THIS EXAMINATION:\n eval for intraparenchymal hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 11:27 PM\n C-: Extensive intraventricular blood in lateral, 3rd and 4th ventricles.\n Parenchymal hemorrhage of genu of corpus callosum.\n CTA: small cluster of vessels inferior right frontal lobe (2G:57, 300b:16)\n with prominent draining vein may be vascular malformation.\n WET READ VERSION #1 9:54 PM\n - hemorrhage of anterior of corpus callosum w/ extensive intraventricular\n hemorrhage of third and fourth ventricles\n ______________________________________________________________________________\n FINAL REPORT\n CTA HEAD WITHOUT AND WITH CONTRAST, \n\n HISTORY: Intraventricular hemorrhage.\n\n Contiguous axial images were obtained through the brain before administration\n of intravenous contrast. Subsequently, contiguous axial images were obtained\n during rapid infusion of 80 cc of Optiray contrast. Comparison to a head CT\n performed at on . The CTA examination was\n processed on a separate workstation.\n\n FINDINGS: The pre-contrast head CT demonstrates an identical pattern of\n corpus callosum and intraventricular hemorrhage to that of the earlier CT from\n . There is no evidence of new hemorrhage.\n\n The CTA examination demonstrates no evidence of aneurysm formation. However,\n there is a prominent vein just to the right of midline in the right frontal\n lobe. Although this could represent a developmental venous anomaly, it is\n suspicious for a vein draining a small arteriovenous malformation. The axial\n images demonstrate an apparent nidus on image 56 of series 2G.\n\n The remainder of the cerebral vasculature appears normal.\n\n CONCLUSION: Apparent small nidus of an arteriovenous malformation with a\n draining vein that drains into the right septal vein. No evidence of new\n hemorrhage since the study performed at on .\n\n" }, { "category": "Radiology", "chartdate": "2150-01-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1060633, "text": " 4:35 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for new bleed - pt with dizzyness and altered mental st\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 51 year old man with AVM with IVH\n REASON FOR THIS EXAMINATION:\n eval for new bleed - pt with dizzyness and altered mental status / AVM with\n bleed / AVM not embolized at this point / eval for HCP\n contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JVg TUE 5:06 PM\n No new hemorrhage. Decreased ventricular blood. No hydrocephalus. No cerebral\n edema.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the head without contrast.\n\n CLINICAL INDICATION: 51-year-old man with history of AVM with\n intraventricular hemorrhage. Evaluate for new bleed. Patient with dizziness\n and altered mental status change.\n\n COMPARISON: Prior CT of the head dated .\n\n TECHNIQUE: Contiguous axial images were obtained through the brain. No\n contrast was administered. The images were reviewed using soft tissue and bone\n window algorithms.\n\n FINDINGS: In comparison with the prior examination again there is evidence of\n hemorrhage in the anterior corpus callosum and intraventricular hemorrhage\n involving the frontal ventricular horns, which is slightly decreased since the\n prior study. There is no noteworthy mass effect or midline shift. Persistent\n areas of low attenuation in the frontal periventricular white matter are\n consistent with edema. There is no evidence of hydrocephalus or shift of\n normally midline structures. There are no new areas of hemorrhage.\n\n IMPRESSION:\n\n 1. No evidence of new hemorrhage.\n 2. Decreased ventricular blood.\n 3. No evidence of hydrocephalus.\n 4. Mild vasogenic edema surrounding the hemorrhage.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2154-03-31 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 758483, "text": " 10:06 AM\n CHEST (PA & LAT) Clip # \n Reason: 80 yo F with bronchiectasis and h/ here with hypoxia an\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hx of MAC, bronchiectasis, recent bronch.\n REASON FOR THIS EXAMINATION:\n 80 yo F with bronchiectasis and h/ here with hypoxia and SOB, BAL with\n strep pneumo.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Hypoxia and shortness of breath.\n\n Comparison to prior chest X-ray of shows no appreciable change in the\n patchy densities in the right upper lobe and left lower lobes. Hilar and\n mediastinal contours are normal. A vague ill-defined density overlying the\n anterior left second rib is again noted.\n\n IMPRESSION: There is no significant change in the chest over the past 4 days.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2154-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758094, "text": " 3:02 PM\n CHEST (PORTABLE AP) Clip # \n Reason: hypoxia post bronch\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with tachypnea and low sats arrives in moderate resp.\n distress. f/u pulmonary nodules and infiltrates in this woman with pulmonary\n mac rx'd one year ago. now recurrent symptoms\n REASON FOR THIS EXAMINATION:\n hypoxia post bronch\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia following bronchoscopy procedure. MAC infection.\n\n There is an unusual curvilinear opacity along the lateral aspect of the right\n chest. It is uncertain whether this represents an atypical manifestation of\n pneumothorax or structure external to the patient.\n\n The heart size is normal. The aorta is unfolded. The lungs reveal multiple\n ill-defined nodular opacities as well as new areas of confluent air space\n opacification in the lower lobes. There are also small bilateral pleural\n effusions, which were not seen previously.\n\n Note is also made of a dense rounded contour in the right hilar region, likely\n corresponding to previously noted lymphadenopathy on prior chest CT\n examination.\n\n IMPRESSION:\n 1. Curvilinear opacity in periphery of right lung, which may reflect atypical\n presentation of pneumothorax vs. structure external to the patient. As\n discussed with the clinical service caring for the patient, immediate repeat\n film following removal of external structures is advised. If persistent, this\n may reflect a loculated pneumothorax.\n\n 2. New bilateral confluent alveolar opacities, concerning for acute aspiration\n event.\n\n 3. New small bilateral pleural effusions.\n\n 4. Background pattern of multifocal patchy opacities as well as underlying\n bronchiectasis, likely due to known MAC infection.\n\n" }, { "category": "Radiology", "chartdate": "2154-03-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758105, "text": " 5:34 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p bronch, resp distress, hypoxemia, Previous CXR with ? R\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with , s/p bronch with hypoxemia, SOB.\n Pleae page with wet read. Thanks.\n REASON FOR THIS EXAMINATION:\n s/p bronch, resp distress, hypoxemia\n Previous CXR with ? R PTX. Please repeat. Thanks.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 80 year old woman with bronchiectasis, status post bronch with\n hypoxemia. Question of pneumothorax on prior exam.\n\n PORTABLE AP CHEST: Portable AP upright view of the chest performed at\n 17:32 hours: Comparison is made with prior study performed the same day at\n 15:12 hours. The curvilinear opacity in the periphery of the right lung is no\n longer identified suggesting that it was outside of the patient. No evidence\n of pneumothorax is now seen. There is no other significant change from prior\n study. Bilateral pulmonary opacities are again noted as described previously.\n\n IMPRESSION: No evidence of pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2154-03-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 758140, "text": " 10:12 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for resolution of opacities with diuresis\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 80 year old woman with bronchiectasis, s/p bronch with hypoxemia, SOB.\n REASON FOR THIS EXAMINATION:\n assess for resolution of opacities with diuresis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess multifocal pulmonary opacification s/p diuresis.\n\n AP CHEST: In the interval since the prior study, there is considerable\n reduction in the size and intensity of the previously described bilateral\n lower lobe confluent opacifications. Given the rapidity of resolution after\n diuresis, this most likely represents resolving heart failure. The partial\n resolution of these opacifications further reveals the underlying\n bronchiectatic changes diffusely. The nodular appearance in the right upper\n lobe is stable over time. The cardiac silhouette is slightly decreased since\n the prior study. There are no pleural effusions.\n\n IMPRESSION: Partial interval resolution of bibasilar confluent opacifications\n suggesting resolving heart failure.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 1510230, "text": "ccu progress note 7p-7a\nuneventful nite. slept in naps.\n\nRESP: LS I/E wheezes, rec'ing albuterol neb tx q4h. Bilat crackles noted thruout lobes. rec'd Lasix 20mg IVP (for low u/o + crackles) w/ good effect this evening. O2 4L n/c + Cool Aerosol 40% shovel mask w/ sats 90-94%. RR 30s-40s. pt stating her breathing feels much improved over the afternoon.\n\nVSS. no other c/o.\n\nPLAN: monitor u/o. keep pt comfortable. ?c/o today if unable to wean off O2 -?discharge home after weaning off O2.\n" }, { "category": "Nursing/other", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 1510231, "text": "RESP CARE\nPt given 2.5mg alb . via microneb. BS scattered coarse wheeze with bil crackles. Cough nonprod. Pt states her breathing is much improved. Will follow as needed.\n" }, { "category": "Nursing/other", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 1510232, "text": "NO CP .DOE.OOB TO CHAIR ,AMBULATING IN RM\n\nSR NO ECT.BP STABLE.CK FLAT\n\nSA 84 RM AIR.92 OPEN FACE MASK 40%.CRACKLES,WHEEZES .10 MG IV LASIX GIVEN.\n\nVOMITED P OJ, BUT ABLE TO TAKE WATER, NO NAUSEA .HAD SOFT BR STOOL.\n\nFOLEY DRAIN BLD TINGED\n\nSTABLE FOR TRANSFER.\n\n" }, { "category": "Nursing/other", "chartdate": "2154-03-25 00:00:00.000", "description": "Report", "row_id": 1510229, "text": "HYPOXIA POST BRONHCOSCOPY\n\n80 YR OLD WOMEN C 5 YR HX MYCOBACTERIUM LUNG INFECTION SP 4 COURSES OF ANTIBX THERAPY .SHE WAS HOSPITALYZED ONE MONTH AGO C PNEUMONIA . TODAY SHE UNDERWENT OUTPT BRONCH,BECAME DYPNEIC AND VOMITED,ABG O253/PCO255/TCO230/7.36. NEW Q WAVES INDICATE SILENT MI ,SHE HAVE FLASHED.SHE HAS DIURESED 1500CC C LASIX .SHE ALSO HAS HAD 5 ALBUTEROL RXS AND IS MORE COMFORTABLE ON 4LNP,NONREBREATHER C SAT 97.PURULENT MUCOUS SEEN.BAL TAKEN.\n\nSR NO ECTOPY.BP 126/43.\n\nWHEEZES CRACKLES THROUGHOUT.RR 36\n\nNO NAUSEA ,BS PRESENT, ABD SOFT.\n\nDIURESING VIA FOLEY .\n\nALERT,ORIENTED,COOPERATIVE ,DENIES PAIN,ASKING FOR WATER\n\nLIVES C SISTER\n\nSTABLIZING\n\nWEAN O2\nFOLLOW CK\n\n" }, { "category": "Echo", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 96565, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Chronic lung disease.\nHeight: (in) 66\nWeight (lb): 145\nBSA (m2): 1.75 m2\nBP (mm Hg): 119/54\nStatus: Inpatient\nDate/Time: at 10:21\nTest: Portable TTE(Complete)\nDoppler: Complete pulse and color flow\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: The left atrium is normal in size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The right atrium is normal in size.\n\nLEFT VENTRICLE: Left ventricular wall thickness, cavity size, and systolic\nfunction are normal (LVEF>55%). Regional left ventricular wall motion is\nnormal.\n\nRIGHT VENTRICLE: Right ventricular chamber size is normal.\n\nAORTA: The aortic root is normal in diameter. The ascending aorta is\nmoderately dilated.\n\nAORTIC VALVE: The aortic valve leaflets (3) are mildly thickened. Mild (1+)\naortic regurgitation is seen.\n\nMITRAL VALVE: The mitral valve leaflets are mildly thickened.\n\nTRICUSPID VALVE: The tricuspid valve appears structurally normal with trivial\ntricuspid regurgitation. There is mild pulmonary artery systolic hypertension.\n\nPERICARDIUM: There is 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 ascending aorta is moderately dilated.\n3. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic\nregurgitation is seen.\n4. The mitral valve leaflets are mildly thickened.\n5. There is mild pulmonary artery systolic hypertension.\n\n\n" }, { "category": "Echo", "chartdate": "2154-04-01 00:00:00.000", "description": "Report", "row_id": 96509, "text": "PATIENT/TEST INFORMATION:\nIndication: Shortness of breath.\nHeight: (in) 66\nWeight (lb): 145\nBSA (m2): 1.75 m2\nStatus: Inpatient\nDate/Time: at 15:16\nTest: Stress Echo(Treadmill)\nDoppler: No Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\n\n\nConclusions:\nThe patient received intravenous dobutamine beginning at 15 mcg/kg/min,\nincreasing to 30mcg/kg/min and 45 mcg/kg/min in 3 minute stages. The test was\nstopped because the target heart rate was achieved. In response to stress, the\nECG showed no ST-T wave changes (see exercise report for details). There were\nnormal blood pressure and heart rate responses to stress.\nResting images were acquired at a heart rate of 77 bpm and a blood pressure of\n112/60 mmHg. These demonstrated normal regional and global left ventricular\nsystolic function. Focused Doppler demonstrated mild aortic regurgitation with\nno significant mitral regurgitation or LVOT gradient. At peak dobutamine\nstress 45 mcg/kg/min and no atropine; heart rate 120 bpm, blood pressure\n136/50 mmHg), there was appropriate augmentation of systolic function of all\nsegments\n\nIMPRESSION: No 2D echocardiographic evidence of inducible ischemia to achieved\nworkload.\n\n\n" }, { "category": "ECG", "chartdate": "2154-03-27 00:00:00.000", "description": "Report", "row_id": 266052, "text": "Sinus rhythm\nPossible left atrial abnormality\nLow QRS voltages in limb leads\nPossible old inferior myocardial infarction\nSince previous tracing, , no significant change\n\n" }, { "category": "ECG", "chartdate": "2154-03-26 00:00:00.000", "description": "Report", "row_id": 266053, "text": "Sinus rhythm. Compared to tracing #1 no significant change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2154-03-25 00:00:00.000", "description": "Report", "row_id": 266054, "text": "Sinus tachycardia. Left atrial abnormality. Borderline left axis deviation.\nQ waves in leads II, III and aVF consistent with old inferior myocardial\ninfarction. Poor R wave progression. Low limb lead voltage. Compared to the\nprevious tracing of no significant diagnostic change.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2154-03-27 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 758219, "text": " 9:23 AM\n CHEST (PA & LAT) Clip # \n Reason: **********************************************, *** please d\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 79 year old woman with hx of MAC, bronchiectasis, recent bronch.\n REASON FOR THIS EXAMINATION:\n **********************************************\n *** please do on Wednesday, morning ***\n **********************************************\n\n eval for change in infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Chest two views.\n\n INDICATION: History of MAC and bronchiectasis. Please evaluate for change in\n infiltrates.\n\n COMPARISON STUDIES: , as well as .\n\n CHEST TWO VIEWS: The cardiomediastinal silhouette is stable in appearance.\n Again seen in the right apical region is ill-defined rounded opacity that has\n not significantly changed considering technique over the multiple comparison\n studies. This is felt to represent the patient's MAC. At the lung bases,\n bibasilar alveolar infiltrate felt to represent acute pneumonia superimposed\n on known bronchiectasis is not significantly changed since the \n examination.\n\n IMPRESSION:\n\n 1) Stable bibasilar opacity felt to represent acute bacterial pneumonia.\n\n 2) Stable rounded alveolar opacity at the right lung apex as well as diffuse\n scattered heterogenous lung opacities and bronchiectasis, felt to represent\n the patient's known chronic MAC infection.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2111-06-13 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 969637, "text": " 8:12 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: please assess for ischemic changes in brain\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: MAGNEVIST Amt: 24\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with head and neck SCC s/p XRT to neck thursday, friday\n REASON FOR THIS EXAMINATION:\n please assess for ischemic changes in brain\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Head and neck cancer, status post radiation. Assess for ischemic\n damage in the brain.\n\n Comparison is made with prior studies from and .\n\n TECHNIQUE: Routine MRI of the neck without gadolinium. Routine MRA of the\n brain without gadolinium. Routine MRA of the neck without and with\n gadolinium.\n\n\n\n The study is motion degraded. On the diffusion-weighted images of the brain,\n there is no evidence for acute ischemia. There are mild small vessel ischemic\n sequela in the brain parenchyma.\n\n There is no hydrocephalus.\n\n MRA of the brain demonstrates patency of the anterior and posterior\n circulation, without hemodynamically significant stenosis or aneurysm within\n limits of this examination.\n\n There is poor visualization of the right V3 segment of the vertebral artery,\n which is likely on a technical basis since there is good flow beyond this\n segment. MRA of the neck otherwise demonstrates no hemodynamically\n significant stenosis.\n\n There is extensive sinus and mastoid opacification and fluid levels.\n\n There is a right frontal scalp fluid collection, extending to the right\n periorbital region, which is new. Incompletely evaluated, there appear to be\n bilateral large necrotic lymph nodes, which were also seen on the MRI of the\n neck from yesterday.\n\n IMPRESSION: No acute ischemia in the brain.\n\n New right frontal scalp fluid collection extending to the periorbital region.\n Infection of this fluid collection cannot be excluded.\n\n Unremarkable MRA of the brain and neck.\n\n (Over)\n\n 8:12 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n MRA NECK W&W/O CONTRAST\n Reason: please assess for ischemic changes in brain\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: MAGNEVIST Amt: 24\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Massive cervical adenopathy.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969029, "text": " 7:08 PM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls evaluate consolidation\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n REASON FOR THIS EXAMINATION:\n Pls evaluate consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old man with supraglottic SCC with bilateral IJ clots,\n right greater than left, pneumonia and status post trach. Evaluate for\n consolidations.\n\n COMPARISONS: None.\n\n AP CHEST: The tracheostomy tube is in appropriate position. There is a left\n upper lobe consolidation. Additional, more patchy opacities are seen in the\n right mid and lower lung field which also could represent pneumonic\n infiltrates or asymmetric pulmonary edema. There are bilateral small pleural\n effusions, right greater than left. The extreme right chest is not included\n in this study. The heart is difficult to assess. The right heart border is\n obscured by the pulmonary opacities.\n\n IMPRESSION:\n 1. Multifocal opacities consistent with pneumonia.\n 2. Bilateral pleural effusions, right greater than left.\n 3. Tracheostomy tube in appropriate position.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969237, "text": " 5:08 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression of pneumonia\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n Progression of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with large supraglottic SCC, internal jugular clots,\n necrotic lymphadenopathy, pseudomonas pneumonia. For evaluation.\n\n TECHNIQUE: Frontal chest radiograph was obtained.\n\n COMPARISON: CT from , the patient's tracheostomy tube appears in\n similar position. There has been some interval improvement in the degree of\n biapical airspace consolidation. There is continued right-sided pleural\n effusion, although the left lower lobe effusion is somewhat improved. There\n is a right paramediastinal stripe, which may represent a degree of upper lobe\n collapse.\n\n CONCLUSION:\n\n 1. Interval improvement in pneumonia.\n\n 2. Persistent pleural effusions, larger on the right.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-09 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 969047, "text": " 10:27 PM\n CT CHEST W/CONTRAST Clip # \n Reason: pls evaluate for tumor/clot burden, PNA and ?loculated pluer\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Field of view: 40 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with large supraglottic SCC s/p trach, IJ clots R>L, necrotic\n neck LAD, pseudomonal PNA\n REASON FOR THIS EXAMINATION:\n pls evaluate for tumor/clot burden, PNA and ?loculated plueral effusions\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Large supraglottic squamous cell carcinoma, status post\n tracheostomy and internal jugular clots, necrotic lymphadenopathy and\n pseudomonal pneumonia.\n\n There are no prior studies for comparison.\n\n TECHNIQUE: Contiguous axial images through the chest were obtained following\n the administration of 80 mL of Optiray contrast, and displayed at 5 and 1.25\n mm collimation. Coronal reformatted images were generated.\n\n CT OF THE CHEST WITH CONTRAST: There are large conglomerates of necrotic\n lymph nodes in the supraclavicular regions bilaterally, of fluid attenuation\n centrally and enhancing peripherally. The imaged portion of the right\n supraclavicular conglomerate measures up to 8.1 x 4.9 cm in greatest axial\n dimensions, the left 10.1 x 5.1 cm. Both internal jugular veins are occluded.\n The subclavian veins are not identified. The left brachiocephalic vein\n opacifies with contrast as it crosses the aortic arch, but cannot be\n identified cephalad to this point. The right brachiocephalic vein is not well\n visualized. There are extensive collateral vessels within the posterior and\n anterior chest.\n\n A moderate-to-large right pleural effusion is simple in attenuation, with a\n significant component located within the lower major fissure. The left\n pleural effusion is small and simple in attenuation. Atelectasis is seen\n adjacent to both pleural effusions; the right lower lobe has completely\n collapsed. Lung windows demonstrate marked parenchymal opacification within\n the upper lobes, that could, given the appropriate historn, be due to\n radiation. Ground-glass opacities are seen throughout the lungs more\n inferiorly, with more confluent opacity within the inferior right upper lobe.\n All the ground- glass opacities are nonspecific and may represent edema or\n infection, the confluent opacity of the inferior right upper lobe, likely\n represents pneumonia. The central airways remain patent, with a tracheostomy\n tube at the thoracic inlet.\n\n The heart size is normal, and there is no pericardial effusion. There are\n atherosclerotic calcifications of the aortic arch. Several enlarged axillary\n nodes are seen bilaterally measuring up to 1.6 cm in the short axis dimension.\n Several borderline mediastinal nodes are seen, measuring 8-10 mm in the short\n axis in the paratracheal station, and 12 mm in short axis in the subcarinal\n (Over)\n\n 10:27 PM\n CT CHEST W/CONTRAST Clip # \n Reason: pls evaluate for tumor/clot burden, PNA and ?loculated pluer\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Field of view: 40 Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n station.\n\n The exam was not tailored for subdiaphragmatic evaluation. A tiny hypodensity\n of the right lobe of the liver is too small to characterize. Subcutaneous\n edema is evident in the chest and upper abdomen.\n\n There are no definite bone lesions suspicious for malignancy.\n\n IMPRESSION:\n 1. Extensive necrotic lymphadenopathy of the supraclavicular region, with\n apparent occlusion of both internal jugular and subclavian veins.\n 2. Moderate-to-large right pleural effusion and small left pleural effusion,\n with associated atelectasis involving the entire right lower lobe.\n 3. Biapical opacities may reflect radiation treatment if there is such a\n history.\n 4. Ground-glass opacities throughout the remainder of the lungs are\n nonspecific, possibly reflecting edema or infection. A more focal opacity in\n the lower right upper lobe suggests pneumonia.\n 5. Axillary lymphadenopathy and borderline mediastinal nodes.\n 6. Extensive subcutaneous edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-09 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 969048, "text": " 10:28 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: pls evaluate mass and extent of clot burden\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with large supraglottic SCC, IJ clots R>L, necrotic neck LAD\n REASON FOR THIS EXAMINATION:\n pls evaluate mass and extent of clot burden\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with large supraglottic squamous cell carcinoma,\n internal jugular clots greater on the right than the left, and necrotic neck\n lymphadenopathy. Please evaluate mass and extent of clot burden.\n\n COMPARISON: Chest radiograph from same day.\n\n TECHNIQUE: MDCT-acquired axial imaging of the neck after administration of 80\n cc Optiray intravenous contrast.\n\n FINDINGS: There is massive cervical lymphadenopathy throughout the neck\n bilaterally, displacing and distorting normal tissue planes. Majority of the\n lymphadenopathy demonstrates low-attenuation center, consistent with necrosis.\n Large conglomerate lymph nodes have completely occluded the right internal\n jugular vein, and narrow and likely occlude the left internal jugular vein at\n the level of the thyroid cartilage.\n\n There is a large amount of retropharyngeal fluid, which could possibly relate\n to lymphatic obstruction due to lymphadenopathy.\n\n Evaluation of the lung apices demonstrates bilateral pleural effusion, and\n parenchymal opacities, which are more completely evaluated and described on\n concurrently performed CT of the chest.\n\n IMPRESSION:\n 1. Massive bilateral cervical lymphadenopathy, with low-attenuation centers\n consistent with necrosis.\n 2. Complete occlusion of the right internal jugular vein, secondary to\n compression from lymphadenopathy, and at least partial, and possibly complete\n occlusion of the left internal jugular vein at the level of the thyroid\n cartilage from similar compression.\n 3. Retropharyngeal fluid collection, possibly secondary to lymphatic\n obstruction, v. inflammatory process.\n 4. Biapical pleural fluid, and parenchymal opacity, described in detail on\n separate chest CT report.\n\n\n (Over)\n\n 10:28 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: pls evaluate mass and extent of clot burden\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2111-06-09 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 969046, "text": " 10:26 PM\n CT HEAD W/ CONTRAST Clip # \n Reason: pls evaluate extent of tumor/clot burden\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with large supraglottic SCC s/p trach, IJ clots R>L, SVC\n syndrome, necrotic neck LAD, pseudomonal PNA\n REASON FOR THIS EXAMINATION:\n pls evaluate extent of tumor/clot burden\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: 61-year-old man with large supraglottic cancer, please evaluate\n the extent of tumor clot.\n\n TECHNIQUE: Axial contrast-enhanced images of the head were obtained.\n\n No comparison is available.\n\n No mass effect, shift of normally midline structures or hydrocephalus is\n noted. No major or minor vascular territorial infarct is detected. No\n abnormal enhancing mass or intracranial hemorrhage is noted.\n\n Bone windows do not demonstrate a fracture. There is prominent mucosal\n thickening of the ethmoidal sinuses, with probable fluid in the right\n maxillary and sphenoid sinuses, likely inflammatory in origin.\n\n Partial imaging of what appear to be huge bilateral posterior cervical\n triangle masses, likely necrotic lymph nodes, is seen.\n\n\n IMPRESSION:\n 1. No acute intracranial hemorrhage or masses is seen.\n 2. Large bilateral posterior cervical triangle masses, likely metastatic,\n necrotic lymph nodes.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969706, "text": " 1:47 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PICC eval\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach, now\n neutropenic\n REASON FOR THIS EXAMINATION:\n PICC eval\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: PICC evaluation.\n\n FINDINGS: The PICC catheter is again seen in similar location compared to the\n earlier films from the same day. A large right effusion, right lower lobe\n volume loss, bilateral alveolar infiltrates are unchanged. Dense retrocardiac\n opacity is again visualized. The tracheostomy tube is unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969671, "text": " 6:56 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: Rt PICC 20 cm\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n Rt PICC 20 cm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON AT 6:15.\n\n HISTORY: Right PICC.\n\n FINDINGS: There is a new right PICC with tip just past the axilla and the\n subclavian vein although it is pointed downward. This finding was called to a\n house staff at the time of dictating this report on at 8:45. The\n right-sided effusion has markedly decreased with improved aeration on the\n right and continued alveolar infiltrate bilaterally that has increased on the\n left. It is unclear if this is all due to pulmonary edema or an underlying\n infectious infiltrate. There continues to be a moderate right effusion that\n is layering posteriorly. However, this is much smaller than on the prior\n study.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969943, "text": " 5:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of pna, tubes, lines\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy PNA, s/p Trach, now neutropenic\n REASON FOR THIS EXAMINATION:\n progression of pna, tubes, lines\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:16 A.M., .\n\n HISTORY: Supraglottic carcinoma, cervical adenopathy, pneumonia, and\n neutropenia.\n\n IMPRESSION: AP chest compared to through 16:\n\n Large right pleural effusion continues to increase at the expense of aeration\n in the right lung and mediastinal shift to the left. Moderately-severe\n pulmonary edema has worsened. Mild cardiomegaly is new. Mediastinal vascular\n engorgement and/or adenopathy produce stable mediastinal widening in the\n region of the aorta and right paratracheal stations. Tracheostomy tube in\n standard placement. No pneumothorax. Right PIC catheter ends in right\n axilla.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-17 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 970121, "text": " 8:20 AM\n HUMERUS (AP & LAT) RIGHT Clip # \n Reason: Please locate PICC/Midline\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic squamous cell carcinoma with trach\n REASON FOR THIS EXAMINATION:\n Please locate PICC/Midline\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Subglottic squamous cell carcinoma. Apparent pain humerus.\n\n Internal and external rotation radiographs of the right humerus are limited by\n bedside technique. No osseous abnormality identified and no fracture or bone\n destruction in the humerus. There is an apparent large right pleural\n effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 969684, "text": " 10:04 AM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: PICC line eval, progression of pna, please eval/include line\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n PICC line eval, progression of pna, please eval/include line in the right arm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE VIEW ON \n\n HISTORY: Check location of PICC line. Check progression of disease.\n\n FINDINGS: Again seen is the PICC line that extends just past the axilla into\n the subclavian vein and then goes downward. Again seen is a large right\n pleural effusion and bilateral alveolar infiltrates, right greater than left\n with volume loss in both lower lobes. An underlying infectious infiltrate\n cannot be excluded, although many of these changes are likely due to fluid\n overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970056, "text": " 6:10 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: acut cadio pulmonary process?\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, now neutropenic had to be put on vent\n again b/o sudden resp failure\n REASON FOR THIS EXAMINATION:\n acut cadio pulmonary process?\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with supraglottic squamous cell carcinoma, with\n bilateral internal jugular vein compression, cervical adenopathy, now with\n sudden respiratory failure. Please evaluate for acute cardiopulmonary\n process.\n\n FINDINGS: Single portable upright chest radiograph is reviewed and compared\n to same day, 5:16 a.m.\n\n Tracheostomy tube is unchanged in position, tip approximately 7.9 cm above the\n carina. Heart size is unchanged, and there remains some leftward shift of\n mediastinal structures, displaced by right pleural effusion, which is slightly\n decreased in size in the interval. There remains moderate pulmonary edema,\n which is slightly improved since prior exam, particularly on the left. There\n is no pneumothorax. Right PICC is unchanged, with tip projecting over the\n axilla.\n\n IMPRESSION: Slight improvement in moderate pulmonary edema, and slight\n interval decrease in size of right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969541, "text": " 5:28 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression of PNA\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n Progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate for progression of pneumonia.\n\n COMPARISON: Upright AP view from at 22:46.\n\n SEMI-UPRIGHT AP VIEW OF THE CHEST: The right lower hemithorax is not included\n in the examination. Tracheostomy tube remains in standard position. Diffuse\n opacification of the right lung remains relatively unchanged as is the large\n right pleural effusion. Continued opacity involving the left upper and mid\n lung is unchanged. No pneumothorax is identified on this limited examination.\n\n IMPRESSION: No significant change in diffuse opacification of the right lung\n and ill-defined opacities in the left upper and mid lung, likely representing\n multifocal pneumonia. Large right pleural effusion, unchanged.\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2111-06-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970105, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression of pna, pulmonary edema, pleural effusion\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, now neutropenic\n REASON FOR THIS EXAMINATION:\n Progression of pna, pulmonary edema, pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 12:51 a.m. .\n\n HISTORY: Supraglottic small cell carcinoma. Possible pneumonia.\n Neutropenia.\n\n IMPRESSION: AP chest compared to through 17:\n\n Mild pulmonary edema has recurred in the left perihilar lung, with increased\n mediastinal vascular engorgement suggesting recurrence of volume overload.\n Right heart border is obscured by the elevated right hemidiaphragm and middle\n lobe atelectasis but the heart size appears stable, probably mildly enlarged.\n Small-to-moderate right pleural effusion persists. Tracheostomy tube in\n standard placement. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969669, "text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess trach, airspace\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n assess trach, airspace\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON \n\n HISTORY: Supraglottic SCC with IJ clots and pneumonia status post trach.\n\n REFERENCE EXAM: \n\n FINDINGS: There continues to be a large right effusion but it is slightly\n decreased in size and there is better aeration of the right lung. There are\n alveolar opacities in the right lung that could be due to incomplete re-\n expansion versus some alveolar infiltrates. There is hazy vasculature on the\n left suggesting an element of fluid overload. There continues to be widening\n of the paratracheal stripe on the right which is felt to be secondary to fluid\n and volume loss. Tracheostomy tube is in good location.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 969693, "text": " 11:14 AM\n HUMERUS (AP & LAT) RIGHT Clip # \n Reason: find picc line\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with s/p picc\n REASON FOR THIS EXAMINATION:\n find picc line\n ______________________________________________________________________________\n FINAL REPORT\n HUMERUS FILM AT 10:29.\n\n HISTORY: Find PICC line.\n\n FINDINGS: Frontal film of the humerus. The PICC line is seen extending from\n the arm into the chest.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970259, "text": " 5:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of pna, tubes & lines\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, now neutropenic had to be put on vent\n again b/o sudden resp failure\n REASON FOR THIS EXAMINATION:\n progression of pna, tubes & lines\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Supraglottic squamous cell carcinoma with neutropenia and\n pneumonia.\n\n COMPARISON: .\n\n SUPINE AP CHEST: A tracheostomy is in place, with the tip 7.3 cm from the\n carina. Right pleural fluid is increasing in volume compared to recent\n preceding exams noted particularly at the apex and lateral right chest.\n Increased density within the right hemithorax is related to the increasing\n effusion as well. Diffuse pulmonary vascular congestion is persistent.\n Cardiac and mediastinal contours are stable, with evidence of mediastinal\n lymphadenopathy. No pneumothorax is evident. There is persistent elevation\n of the right hemidiaphragm.\n\n IMPRESSION: Increasing right pleural fluid. Persistent pulmonary vascular\n congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-12 00:00:00.000", "description": "MRA NECK W&W/O CONTRAST", "row_id": 969497, "text": " 7:47 PM\n MRA NECK W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please do MRV to evaluate both presence of thrombus and poss\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic locally advanced SCC s/p first radiation\n therapy with right sided neck, arm and facial edema.\n REASON FOR THIS EXAMINATION:\n Please do MRV to evaluate both presence of thrombus and possibility of R SVC\n obstruction from lymph node/tumor mass.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: MRA of the neck.\n\n CLINICAL INFORMATION: Rule out superior vena caval occlusion.\n\n TECHNIQUE: 2D time-of-flight MRA of the neck vessels acquired. Following\n this, gadolinium-enhanced 3D time-of-flight MRA of the neck was obtained with\n both arterial and venous phases.\n\n FINDINGS: Both carotid and vertebral arteries demonstrate normal flow signal\n without evidence of occlusion or stenosis. Given the patient's large\n lymphadenopathy in the neck with necrotic masses and known locally invasive\n squamous cell carcinoma, evaluation was made for any arterial invasion. No\n evidence of irregularity of the vascular structures is seen to indicate\n arterial invasion.\n\n The venous phase of the MRA demonstrates superior vena cava to be patent\n within the thorax. The left jugular vein is visualized in its upper portion.\n The lower portion of left jugular vein is not visualized, appears to be\n compressed and occluded by the large necrotic mass. A small component of the\n left jugular vein is visualized at its junction with partially visualized left\n subclavian vein. Faint visualization of the left innominate vein is seen.\n\n The right jugular vein is not visualized throughout its length from below the\n level of skull base. A large mass is seen occluding the vein. Small venous\n collaterals are seen in this region. The right subclavian vein is partially\n visualized with indentation at the area appropriate for its junction with the\n right internal jugular vein. It is unclear whether the right internal jugular\n vein has been invaded by the mass with tumor extending through the venous\n lumen to the nunction with subclavian vein.\n\n IMPRESSION:\n 1. No evidence of arterial occlusion or invasion identified by large masses\n in the neck.\n 2. There is no evidence of occlusion of the superior vena cava seen.\n 3. Both jugular veins are occluded, the left vein is occluded in the upper\n third, while the right vein is occluded by tumor near the skull base.\n 4. Partial visualization of both subclavian veins with findings suspicious\n for invasion and extension of tumor through the right internal jugular vein to\n (Over)\n\n 7:47 PM\n MRA NECK W&W/O CONTRAST; MR 3D RENDERING W/POST PROCESSING ON INDEPENDENT WSClip # \n Reason: Please do MRV to evaluate both presence of thrombus and poss\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n the junction of right subclavian vein.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-12 00:00:00.000", "description": "MRI SOFT TISSUE NECK, W/O & W/CONTRAST", "row_id": 969498, "text": " 7:49 PM\n MRI SOFT TISSUE NECK, W/O & W/CONTRAST Clip # \n Reason: please evaluate soft tissue of head/face thanks\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic locally advanced SCC s/p first radiotherapy\n now with significant right facial and neck edema\n REASON FOR THIS EXAMINATION:\n please evaluate soft tissue of head/face thanks\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE NECK.\n\n CLINICAL INFORMATION: Patient with supraglottic locally advanced squamous\n cell carcinoma with radiation therapy and right-sided neck and arm and facial\n edema, for further evaluation.\n\n TECHNIQUE: T1 and inversion recovery axial images of the neck were acquired.\n Following gadolinium, T1 axial and coronal images of the neck were obtained.\n The examination is limited by motion.\n\n FINDINGS: As seen on the previous CT of , bilateral massive necrotic\n lymphadenopathy is identified extending from level II inferiorly to level IV\n level and also involving the supraclavicular regions. The overall size of the\n lymphadenopathy has not changed compared to the prior study. Diffuse edema is\n seen in the supraglottic region with obliteration of the airway in this\n region. A tracheostomy is in position. These findings have not significantly\n changed from the previous CT. Although evaluation is limited, the flow voids\n of the jugular veins are not visualized on the current study. This is also not\n changed from the previous CT examination. Diffuse soft tissue swelling is\n present involving the subcutaneous tissues bilaterally.\n\n At the lung apex pleural changes are visualized on the right side. No\n abnormalities are seen at the skull base.\n\n IMPRESSION: Bilateral extensive necrotic lymphadenopathy as seen on the CT of\n . Soft tissue edema involving right sides of the neck involving the\n subcutaneous soft tissues. These findings have not significantly changed from\n the CT. Internal jugular vein flow voids are not visualized. Please\n correlate with the same day MRA of the neck.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969394, "text": " 6:40 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progression of pneumonia\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n Progression of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:50 a.m. \n\n HISTORY: Supraglottic carcinoma.\n\n IMPRESSION: AP chest compared to through 12:\n\n Consolidation and effusion at the base of the right chest have worsened over\n the past two days, while moderately severe pulmonary edema, particularly in\n the suprahilar lungs has improved. Small left pleural effusion is stable.\n Heart is normal size. Mediastinal widening is unchanged. Tracheostomy tube\n is in standard placement. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-10 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 969118, "text": " 10:53 AM\n BILAT UP EXT VEINS US Clip # \n Reason: Please eval bilateral IJ clots.\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with large supraglottic squamous cancer, bilateral IJ clots.\n REASON FOR THIS EXAMINATION:\n Please eval bilateral IJ clots.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Supraglottic squamous cell cancer, bilateral IJ clot by report\n from outside hospital. Please evaluate.\n\n COMPARISON: None.\n\n FINDINGS: -scale and Doppler son of the right subclavian, axillary,\n brachial, cephalic, and basilic veins was performed. Normal flow and\n waveforms are identified within these vessels. Compression was not able to be\n performed secondary to patient body habitus. Evaluation of the internal\n jugular veins was not possible secondary to a large amount of overlying soft\n tissue within the neck. Multiple large rounded hypoechoic lesions consistent\n with enlarged lymphadenopathy seen throughout the neck. Soft tissues appear\n edematous.\n\n IMPRESSION:\n\n 1. Internal jugular veins not assessed secondary to overlying soft tissue.\n Enlarged cervical lymphadenopathy seen throughout the neck.\n\n 2. No evidence of DVT identified within the right or left subclavian,\n axillary, brachial, basilic and cephalic veins.\n\n Findings were discussed with the clinical team following completion of the\n study.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-17 00:00:00.000", "description": "PICC W/O PORT", "row_id": 970151, "text": " 11:02 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Please place PICC line, pt now without access\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\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 61 year old man with supraglottic SCC, pseudomonal PNA; also with Trach\n REASON FOR THIS EXAMINATION:\n Please place PICC line, pt now without access\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION FOR THE EXAM: This is a 61-year-old man with supraglottic SCC. IV\n access needed for medications. The procedure was explained to the patient. A\n timeout was performed.\n\n RADIOLOGISTS: Drs. and performed the procedure. Dr.\n , the attending radiologist, was present and supervised the entire\n procedure.\n\n Using sterile technique and local anesthesia, various attempts to puncture the\n vein were done under direct ultrasound guidance. Basilic vein was first\n attempted unsuccessfully due to stenosis distally confirmed after a venogram\n was obtained. Some collateral veins were also attempted unsuccessfully. The\n cephalic vein was also punctured and after unseuccesful advancement of\n guidewire, a venogram was performed and showed distal stenosis with collateral\n veins and without visualization of the central venous system. Peelaway sheath\n was then placed over the guidewire and a 10-cm double lumen PICC line was\n placed through the peelaway sheath. Unfortunately, flushing was possible but\n aspiration was not possible from either of the lumen. The PICC line was then\n exchanged to a single lumen, again measuring 10 cm in length with its tip\n positioned in midline position of the cephalic vein using flouroscopic\n guidance. The position of the catheter was confirmed by fluoroscopic spot film\n of the chest. The peelaway sheath and guidewire were then removed. The\n catheter was secured to the skin, flushed, and a sterile dressing applied. The\n patient tolerated the procedure well. There were no immediate complications.\n Hard copy ultrasound images were obtained before and after venous access\n documenting vessel patency.\n\n IMPRESSION: Ultrasound and fluoroscopically guided single-lumen line\n placement via the left cephalic venous approach. Final internal length is 10\n cm, with the tip positioned midline in cephalic vein, due to venous occlusion.\n The line is ready to use.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969777, "text": " 5:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please assess lung fields, tubes, lines\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p\n Trach, now neutropenic\n REASON FOR THIS EXAMINATION:\n please assess lung fields, tubes, lines\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:44 A.M. \n\n HISTORY: Supraglottic carcinoma. Tracheostomy. Neutropenic.\n\n IMPRESSION: AP chest compared to through 15:\n\n Mild pulmonary edema has improved since . Moderate-to-large right\n pleural abnormality, probably largely due to effusion, is unchanged.\n Mediastinal widening due to adenopathy and fat deposition is stable.\n Tracheostomy tube is in standard placement. Heart is not enlarged. There is\n no pneumothorax. There is a suggestion of at least one lung nodule in the\n right upper lung.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 969512, "text": " 11:36 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: trach tube placement, after removal by pt\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach\n\n REASON FOR THIS EXAMINATION:\n trach tube placement, after removal by pt\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Supraglottic squamous cell carcinoma, pneumonia, status post\n trach tube placement after removal by patient.\n\n COMPARISON: AP semi-upright view of the chest from 5:50, the same day.\n\n UPRIGHT AP VIEW OF THE CHEST: Tracheostomy tube is present with tip in\n standard position, 7.3 cm from the carina. Study is limited by\n respiratory motion artifact. Allowing for this, the diffuse opacity involving\n the right lung has progressed, appearing more consolidative in nature,\n with increased loss of aeration. A large right pleural effusion has also\n increased in the interval. Continued heterogeneous opacity primarily involving\n the left upper and mid lung is not significantly changed in the interval.\n Small left pleural effusion is likely present. Cardiac and mediastinal\n contours are unchanged. There is no pneumothorax.\n\n IMPRESSION:\n\n 1. Standard positioning of tracheostomy tube.\n\n 2. Worsening diffuse opacification of the right lung with increased size of\n large right pleural effusion.\n\n 3. Unchanged heterogeneous opacity in the left upper and mid lung and small\n left pleural effusion.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2111-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970549, "text": " 5:16 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess lung fields, effusion\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, now neutropenic had to be put on vent\n again b/o sudden resp failure\n REASON FOR THIS EXAMINATION:\n Please assess lung fields, effusion\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: AP chest.\n\n INDICATION: Respiratory distress.\n\n A single AP view of the chest is obtained at 0545 hours and is\n compared with the prior radiograph performed at 0449 hours. Allowing\n for technical differences, there has likely been no significant change in the\n appearances of the chest with moderate-to-large right pleural effusion,\n bilateral pulmonary vascular congestion. Tracheostomy is in place. The\n apical areas are not included on the current examination.\n\n IMPRESSION:\n\n No significant change allowing for technical differences.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970629, "text": " 5:17 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please assess lung fields, pleural effusion progression\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, currently off vent\n REASON FOR THIS EXAMINATION:\n Please assess lung fields, pleural effusion progression\n ______________________________________________________________________________\n FINAL REPORT\n Supraglottic cancer with nodal enlargement.\n\n CHEST\n\n Position of the tracheostomy tube is satisfactory. Widening of the upper\n mediastinum is again noted consistent with known nodal enlargement\n\n Consolidation and volume loss in the right lower lobe are present, more marked\n on the prior chest x-ray. Right effusion is still again noted.\n\n IMPRESSION: Increasing consolidation in right lower lobe.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-14 00:00:00.000", "description": "R HUMERUS (AP & LAT) RIGHT", "row_id": 969709, "text": " 2:11 PM\n HUMERUS (AP & LAT) RIGHT; -76 BY SAME PHYSICIAN # \n Reason: PICC line eval, previously coiled in arm\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ clots R>L, PNA, s/p Trach, now\n neutropenic\n REASON FOR THIS EXAMINATION:\n PICC line eval, previously coiled in arm\n ______________________________________________________________________________\n FINAL REPORT\n HUMERUS FILM.\n\n HISTORY: Neutropenic, PICC line previously coiled in arm.\n\n FINDINGS: AP view of the humerus demonstrates the PICC line extending into\n the chest. There is a right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-24 00:00:00.000", "description": "BILAT UP EXT VEINS US", "row_id": 971073, "text": " 10:37 AM\n BILAT UP EXT VEINS US Clip # \n Reason: R>L upper extremity, ?DVT\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with Supraglottic SCC, with XRT\n REASON FOR THIS EXAMINATION:\n R>L upper extremity, ?DVT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 61-year-old male with supraglottic squamous cell cancer, and\n right greater than left upper extremity swelling. Please evaluate for DVT.\n\n FINDINGS: The grayscale, color and pulse wave Doppler son were\n performed on the bilateral internal jugular, subclavian, axillary, brachial,\n basilic, and cephalic veins.\n\n The internal jugular veins are not identified bilaterally, consistent with\n compression/occlusion to large necrotic lymphadenopathy, better demonstrated\n on neck CT from .\n\n On the right, there is non-compressible thrombus extending from one of the\n paired brachial veins, into the axillary vein, and extending into the right\n subclavian vein. No color flow is seen within these vessels. Note is made of\n a PICC within the right basilic vein, without associated thrombus.\n\n On the left, there is thrombus seen within the left cephalic and basilic\n veins. Other veins in the left upper extremity demonstrate normal flow,\n compressibility, and waveforms.\n\n IMPRESSION:\n\n 1. DVT in the right upper extremity, extending from one of the paired\n brachial veins, into the axillary vein and right subclavian vein.\n\n 2. Thrombus in the left cephalic and basilic veins.\n\n 3. Non-visualization of the bilateral internal jugular veins secondary to\n chronic compression/occlusion from large necrotic neck lymphadenopathy, better\n detailed on neck CT from .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970712, "text": " 5:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval tubes, lines, pleural effusion, pseudomonal pna\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, currently off vent\n REASON FOR THIS EXAMINATION:\n Pls eval tubes, lines, pleural effusion, pseudomonal pna\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:36 AM, \n\n HISTORY: Small cell carcinoma, cervical adenopathy, pleural effusions.\n\n IMPRESSION: AP chest compared to through 21:\n\n Mild pulmonary edema, moderate right pleural effusion, and atelectasis or\n consolidation at the base of the right lung are unchanged over at least five\n days. Heart size is top normal, increased slightly in the interim which could\n be due to some cardiac enlargement or pericardial effusion. Tracheostomy in\n standard placement. Upper mediastinal widening is longstanding due to\n combination of adenopathy and fat deposition. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 971929, "text": " 5:35 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please evaluate for interval changes\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, currently off vent, diminished breath\n sound today\n REASON FOR THIS EXAMINATION:\n please evaluate for interval changes\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM.\n\n History of tracheostomy in patient with supraglottic carcinoma and pneumonia\n with diminished breath sounds.\n\n Tracheostomy tube is 5 cm above carina. Heart size is within normal limits\n for technique. There is elevation of the right hemidiaphragm with persistent\n linear/discoid atelectases at the right lung base. No new lung lesions. Tip\n of PICC line remains in region of right axilla. No new lung lesions. No\n pneumothorax. Mild gaseous distension of colon.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 970413, "text": " 5:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Pls eval. tubes, lines & progression of PNA\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, now neutropenic had to be put on vent\n again b/o sudden resp failure\n REASON FOR THIS EXAMINATION:\n Pls eval. tubes, lines & progression of PNA\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:49 A.M., .\n\n HISTORY: Supraglottic carcinoma. Severe adenopathy. Neutropenic, in sudden\n respiratory failure.\n\n IMPRESSION: AP chest compared to through 19:\n\n Moderate to large right pleural effusion slightly smaller since .\n Pulmonary vascular congestion persists. Heart size normal. Mediastinal\n widening due to combination of adenopathy and vascular congestion, stable.\n Tracheostomy tube in standard placement. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 971780, "text": " 5:55 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusion\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, currently off vent, diminished breath\n sound today\n REASON FOR THIS EXAMINATION:\n pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Supraglottic SCC, cervical adenopathy, status post trach,\n currently off vent, query pleural effusion.\n\n COMPARISON: .\n\n CHEST, ONE VIEW: A tracheostomy tube in unchanged position. Cardiac size\n again top normal; mediastinal and hilar contours are unchanged. Mediastinal\n mild widening is longstanding due to a combination of adenopathy and\n mediastinal fat. Persistent elevation of the right hemidiaphragm. The\n costophrenic angles are clear. There is plate-like atelectasis at the right\n base. There is a decrease in the vascular markings relative to prior. No\n focal lung parenchymal abnormality. No pneumothorax.\n\n IMPRESSION: Interval improvement in edema and right pleural effusion;\n persistent right basal discoid atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2111-06-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 971036, "text": " 5:29 AM\n CHEST (PORTABLE AP) Clip # \n Reason: progression of pseudomonal pna, b/l pleural effusion\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 61 year old man with supraglottic SCC w/b/l IJ compression R>L by tumor,\n cervival adenopathy, PNA, s/p Trach, currently off vent\n REASON FOR THIS EXAMINATION:\n progression of pseudomonal pna, b/l pleural effusion\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 5:01, \n\n HISTORY: Severe adenopathy. Pseudomonas pneumonia and pleural effusions.\n\n IMPRESSION: AP chest compared to through 23:\n\n Pulmonary edema has largely cleared and previous small right pleural effusion\n continues to decrease. Right middle lobe is still collapsed. Heart size is\n top normal. Mediastinal widening due to combination of adenopathy and\n vascular engorgement has improved since . Tracheostomy tube in\n standard placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-06-22 00:00:00.000", "description": "PICC W/O PORT", "row_id": 970765, "text": " 11:38 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: SUPRAGLOTTIC SCC\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\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 61 year old man with supraglottic SCC, pseudomonal PNA; also with Trach\n\n REASON FOR THIS EXAMINATION:\n Okay to have midline.\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE NAME: PICC line placement.\n\n INDICATION FOR EXAM: 61-year-old man with SCC needs PICC for chemotherapy.\n\n RADIOLOGISTS: , and performed the procedure. Dr.\n , the Attending Radiologist, was present and supervised the entire\n procedure.\n\n TECHNIQUE: Using sterile technique and local anesthesia, the right basilic\n vein was punctured under direct ultrasound guidance using a micropuncture set.\n Hard copies of ultrasound images were obtained before and immediately after\n establishing intravenous access. A guidewire was now advanced over the right\n subclavian vein and venogram with injection of a contrast was obtained.\n Venogram demonstrated occlusion of right subclavian vein with multiple\n collateral veins. A peel-away sheath was then placed over a guidewire and 5\n French single lumen PICC line measuring 19 cm in length was then placed\n through the peel-away sheath with its tip in the mid axillary vein under\n fluoroscopic guidance. The position of catheter was confirmed by a\n fluoroscopic film over the chest. The peel- away sheath and the guidewire\n were then removed. The catheter was secured to the skin, flushed and a\n sterile dressing applied. The patient tolerated the procedure well. There\n were no immediate complications.\n\n IMPRESSION:\n 1. Limited venogram of the right upper extremity shows complete occlusion of\n the right subclavian vein with multiple collaterals.\n 2. Uncomplicated ultrasound and fluoroscopic guided 5 French single lumen\n PICC line placement by right basilic venous approach. Final internal length is\n 19 cm, with the tip positioned in right mid axillary vein. The line is ready\n to use.\n\n (Over)\n\n 11:38 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: SUPRAGLOTTIC SCC\n Admitting Diagnosis: STAGE IV SUBGLOTTIC CANCER\n Contrast: OPTIRAY Amt: 5\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Echo", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 83741, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 68\nWeight (lb): 196\nBSA (m2): 2.03 m2\nBP (mm Hg): 121/64\nHR (bpm): 66\nStatus: Inpatient\nDate/Time: at 10:00\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: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Transmitral Doppler E>A and TDI E/e' <8\nsuggesting normal diastolic function, and normal LV filling pressure\n(PCWP<12mmHg). 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 tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor subcostal views.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%) Transmitral\nand tissue Doppler imaging suggests normal diastolic function, and a normal\nleft ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber\nsize and free wall motion are normal. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. There is no mitral valve prolapse. The estimated pulmonary\nartery systolic pressure is normal. There is no pericardial effusion.\n\nIMPRESSION: Normal study. Preserved biventricular cavity sizes with normal\nglobal and regional 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": "Nursing/other", "chartdate": "2111-06-13 00:00:00.000", "description": "Report", "row_id": 1662452, "text": "Respiratory care\nPt with increased , increased confession, rr elevated to 40 placed on vent without compliants. Pt started on lidocaine 1% nebs for\nrelief of cough secondary radation with good subjective results. Plan for family meeting, possible cat-scan, will continue support as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-14 00:00:00.000", "description": "Report", "row_id": 1662453, "text": "NPN 1900-0700:\nEvents: MRI of head, brain and neck done, hasn't yet being read, pt switched to AC, given propofol for the MRI, then Ativan for .\n\nROS:\nNeuro: alert, unable to assess orientation due to trach, opens eyes spontaneously, follows commands by nodding head to yes/no questions, squeezes hands, denied any pain or discomfort, though he gets agitated occasionally, responded well to Ativan PRN, PERRLA.\n\nResp: trached, on vent AC 10, 600, 60%, PEEP 5, suctioned with moderate thick yellowish secretions, has a strong cough, LS CTA, Sat 99-100%.\n\nCV: SB-NSR, HR 48-75, bradycardiac due to propofol most likely as pt reverted to NSR after propofol stopped, BP 107-156/66-84, with 2 PIV lines, still on Heparin drip @ 1600 units/hr, on Vanco, gentamycin and meropenam IV from multilobar PNA and bilateral pleaural effusion, and on flagyl PO for C-Diff, palpable peripheral pulses, with enlarged head and neck with erythema, neck swollen and swollen BUE, elevated over pillows.\n\nGI/GU: with PEG tube in place, TF at goal 55 cc/hr, abdomen obese, passed many brown soft BMs, with foley cath drained adequate U/O, received lasix 20 mg IV to improve resp. pattern with good effect, FS was 181 covered with 2 units Humalogue as per sliding scale.\n\nInteg: with enlarged swelling on neck and face, T max 98, on contact precautions for .\n\nSocial: full code, family visited and updated on POC.\n\nPlan: wean O2 and mechanical ventilation as tolerated, continue heparin drip, monitor PTT (heparin not changed over night, morning PTT pending), follow up on MRI result, control /pain with PRN meds as indicated.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-14 00:00:00.000", "description": "Report", "row_id": 1662454, "text": "Resp Care\nTrached, ventilated on a/c 600 x10 60% +5peep. Switched from pressure support due to need for increased propafol overnight. Transported to and from mri last evening without incident. Suctioning thick white/yellow sputum. Inhalers given as ordered. Did not require any lidocaine overnight due to sedation, no episodes of coughing.\n" }, { "category": "Nursing/other", "chartdate": "2111-07-01 00:00:00.000", "description": "Report", "row_id": 1662525, "text": "Nursing progress note:\n\n Please see flowsheet for more details\n\nNeuro: Remains confused/restless/squirming in chair most of the day/picking at things/only oriented to self. At ~ 17:45 pt. fell asleep in chair and assisted back to bed.\n\nPulm: Trached on 0.35% humified trach mask. RR regular and unlabored. Min. amount of suctioned needed. Maintained stable svo2 95-100%. Passy muir in place.\n\nCV: NSR-ST w/o ectopy. HR 97-119. T. max 98.9. BP stable. + dvt to R brachial and on heparin gtt (600unit/hr) and now, transitioning to coumadin day 2.\n\nGI/GU: + BS noted. Abd is nt, soft, nd. Probalance TF'ing via PEG at goal rate of 55cc/hr. Incont of small amt of loose brown stool while in chair. Foley w/ uo > 30cc/hr.\n\nINTEG: Dry and noted pt. scratching arms many times today. Otherwise, intact.\n\nACCESS: R cephalic SL PICC.\n\nID: Started on cipro today for gram - rods in sputum.\n\nPLAN: Monitor per protocol. Called out to floor and awaiting bed availability. Address delirium if worsens. Cont. haldol prn.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-15 00:00:00.000", "description": "Report", "row_id": 1662461, "text": "(Continued)\nolerated, monitor sats; pulmonary toilet as needed\n\nprovide emotional support to patient ( pallative care following with patient )\n\nreplete lytes as needed\n\ncontinue broad spectrum antibiotics, maintain on neutropenic and contact precaution\n\ndilaudid for pain management\n\nnext XRT schedule will follow-up with radiation dept, hold chemo till G-CSF level is > 2000mcg\n" }, { "category": "Nursing/other", "chartdate": "2111-06-15 00:00:00.000", "description": "Report", "row_id": 1662462, "text": "Respiratory Care\nPt placed on trach collar today. Pt freg. requesting I want to go home today! Pt suctioned for white frofty secrections. will keep vent s/b .\n" }, { "category": "Nursing/other", "chartdate": "2111-06-17 00:00:00.000", "description": "Report", "row_id": 1662468, "text": "Nsg.notes 1900-0700hrs\n\nshift uneventful.\n\nNeuro:Alert and oriented ,confused at times,more awake by am than at the begining of shift.c/o neck pain at 12mn,given 2mg iv dilaudid with good effect.\n\nResp:trached,on trache mask O2 10lit/min,Fio2 50%suctioned small to moderate white thick secretions.coughed out too.sats 93-96% .lungs coarse on auscultation.talking with speaking tube.\n\nCVS:HR 70-100/min,NSR,No ectopics noted.BP 110-140/60-70 mm of hg.Both hands and nect swollen.weeping through Rt.hand,small collection bag connected for drainage on Rt hand.PICC on Rt.hand no blood back flow when tried to aspitate blood sample.CXR taken am,to check PICC position with CXR.PICC dressing changed.when opened dressing extra length was coiled and dressing was done ,same repeated .\n\nGU/GI:PEG in place,on feed neutran pulmonary 55 ml/hr,tolerated well.abdomen soft and bowel sounds present.had moderate loose stool during this shift.on foley cath,received 40mg lasix iv at 12mn,with good effect,clear yellow urine.\n\nIntegu:edematous both hands and neck.T max 98.bath given and position changed.on multiple antibiotics for c diff and staph,Bactrim started yesterday,and on genta,vanco,meropenam,fluconazole,and flagyl.\n\nIV access:PIV 2 on Lt hand ,one on Rt hand ,PICC line on Rt hand.\n\nSocial:visisted by wife and brother early shift and updated with MD.Full code,on contact precautions.\n\nEndo:Blood sugar Q6h,AND COVERED.\n\nPlan:airway management and wean off.check PICC For patency.ICU care.\n\nPlan:\n" }, { "category": "Nursing/other", "chartdate": "2111-06-13 00:00:00.000", "description": "Report", "row_id": 1662450, "text": "Nursing Progress Note:\nPt increasing hypertensive, agitated and confused t/o shift. - See flowsheet for trends. During am rounds pt wrote \"hearing bad,\" pt's last note reads, \"Mr. said on of wholed deer to bear care.\" When asked where he is mouths word \"school.\" Restlessness worsens w/ HOB up. Per Dr. previous jugular/corotid US was unable to idenfity blood flow r/t known compression of these vessels.\n\nDr. in to assess pt's changes and discussed w/ heme/onc. Pt continues on heparin gtt. HOB down 15 degrees to increase cerebral perfusion. Dr. to discuss pt status and address goals w/ pt's brother today. Continues ativan for restlessness, dilaudid for pain as ordered. 1:1 sitter requested. Soft wrist restraints remain in place as ordered for safety. Pt in view from nurses station, Frequent checks and 1:1 w/ RN during periods of agitation for now.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-13 00:00:00.000", "description": "Report", "row_id": 1662451, "text": "Shift Note: 0700-1900\nPlease see previous nursing progress note. See flow sheet for all objective data.\n\nROS:\n\nNeuro: Pt remains trached, alert, follows commands. MS changes w/ increasing restless and per previous note and flow sheet. Reveiving ativan and dilaudid as ordered. Also given haldol 2.5mg and will repeat as ordered if no improvement. Plan for CT if no improvement in VS or MS after these interventions.\n\nResp: Pt on 80% FiO2 via t-piece or trach mask t/o most of shift. Continues to desat to 70's quickly if O2 falls off, or w/ snx and recovers quickly. Increasing secretions today, now blood tinged s/p trach reinserted previous shift per notes. Pt continues w/ intermittent periods of distress, w/ increase use of accessory muscles, and cynosis w/ bronchospastic episodes. Started on lidocaine nebs. Ultimately has been put back on the vent given worsening respiratory distress in the setting of increasing - Current settings CPAP/PS 12/5 FiO2 60%. Pt remains afebrile. Continues abx coverage, now on vanc/zosyn/meropenem and gentamycin.\n\nCV: HR 60's to 1teens - sinus w/ no appreciable ectopy. Facial edema greatly improved from yesterday morning, slightly improved from last noc. LUE edema greatly improved though RUE continues w/ extensive edeam. Pt continues on decadron as ordered. BLE remain very pale, cool, no edema, PP easily palpable. As per previous note known compression of SVC, jugular and corotid vessles per Dr. . MS seems to worsen w/ increased htn and tachycardia when HOB elevated as ? decreased cerebral perfussion. Dr. has been in to assess and plan as above w/ likely CT for tonight. Continues heparin gtt at 1600ml/hr. AM PTT subtherapeutic though drip had been off per report. Repeat trending up and afternoon PTT therapeutic. Recheck PTT tonight.\n\nFEN: Abd obese, non-tender, BS present. Tolerating TF now at goal rate 55ml/hr. Residuals remain minimal this shift. Foley catheter patent and draining clear yellow urine 40-100ml/hr. Fluid status approximately even today w/ goal fluid status even - plan per team for lasix if UOP drops.\n\nSocial: brother due in today. Team to discuss pt's status and goals of care w/ brother given today's changes. Also - case management notified of borthers concerns yesterday RE: FML paperwork that was started at hospital though not present in chart. Case management to follow up.\n\nPlan: Continue to monitor VS and labs. Continue abx as ordered. Rest on vent and wean as tolerated. Continue dilaudid for pain, ativan for . Anticipate CT tonight. Team to discuss goals of care/code status w/ pt's brother tonight. 1:1 has been requested. Pt continues under continuous 1:1 supervision w/ the RN from 1400 until present for safety. Also, continue bilat soft-wrist restraints for safety.\n" }, { "category": "Nursing/other", "chartdate": "2111-07-01 00:00:00.000", "description": "Report", "row_id": 1662526, "text": "Respiratory Care:\nPt trached and on PMV most of the day. Seems confused sometimes\nand says things totally out of context as though he thinks he is elsewhere...Secretions are mininal.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-16 00:00:00.000", "description": "Report", "row_id": 1662463, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 119/50-154/68. SB/SR WITH HR RANGING FROM 48-67, NO ECTOPY NOTED. PPP BILAT. NECK EDEMA REMAINS UNCHANGED.\n\nRESP: PT HAS REMAINED ON TRACH COLLAR AT 50% WITH FREQUENT SX OF LG AMTS OF FROTHY CLEAR SPUTUM WHICH IS THICK. PT HAS GOOD COUGH, IS ABLE TO RAISE SOME SECRETIONS ON HIS OWN. PT DOES HAVE PLEURAL EFFUSIONS BY CXR.\n\nNEURO: PT HAS HEAD APPROPRIATELY IN RESPONSE TO QUESTIONS AND IS ABLE TO WRITE TO MAKE NEEDS KNOWN. PT CLEARLY MOUTHED THAT HE WANTED TO GO HOME. EXPLAINED TO PT THAT ONCE THE EVAL OF HOW WELL THE XRY/CHEMO HAS WORKED THE TEAM WILL BE BETTER ABLE TO PRESENT OPTIONS. PT THAT HE UNDERSTOOD. PT HAS BEEN MED X3 SO FAR WITH DILAUDID 2MG IV.\n\nGI: TOL TF WELL WITH MINIMAL RESIDUALS NOTED. CURRENTLY THE RATE IS 35CC WITH A GOAL OF 55. NO BILI DRAINAGE THIS SHIFT. NO STOOLS NOTED WITH POS BS.\n\nGU: FOLEY REMAINS PATENT WITH ADEQUATE U/O. NO LASIX THIS SHIFT.\n\nENDO: SSIC NOT NEEDED AT MIDNIGT FOR FSBS OF 123.\n\nSKIN: WEEPING CONT ON R ARM WITH PEDIA COLLECTION BAG.\n\nSOCIAL: BROTHER WAS IN AND UPDATED BY TEAM. CURRENTLY THE BROTHER FEELS IT IS APPROPRIATE TO TAKE THINGS ONE DAY AT A TIME.\n\nPLAN CONT TO PROVIDE RESP ASSIST AS NEEDED. MONITOR LABS AND CONT WITH NEUPOGEN FOR NEUTROPENIC. REMAINS ON CONTACT AND NEUTROPENIC PRECAUTIONS.REPLETE LYTES AS NEEDED AND PROVIDE EMOTIONAL SUPPORT TO PT AND FAMILY. CONT WITH ANTIBIOTICS\n" }, { "category": "Nursing/other", "chartdate": "2111-06-16 00:00:00.000", "description": "Report", "row_id": 1662464, "text": "RESPIRATORY CARE:\n\nFollowing for trache care protocol. Vent remains stand-by in room, for pt tiring. Pt remained off vent all night shift. Frequently sxing for moderate to large amts thick white secretions. Administered MDI's via trache/spacer. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-16 00:00:00.000", "description": "Report", "row_id": 1662465, "text": "Respiratory care\nPt recieved on trach mask after radiation pt placed on cpap/psv for c/o of sob. Plan to place back on trach collar this evening.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-16 00:00:00.000", "description": "Report", "row_id": 1662466, "text": "Neuro: Pleasantly confuse early of shift, able to stand with 2 assist. transferred to chair, gait fairly steady. More confused after coming back from XRT, compained of choking, keeps on pulling off trache collar; uncooperative. trying to get out of bed. restraints applied at 1800, recieved 1mg of Ativan x1 and Dilaudid 2mgs x 2 for pain with good relief.\n\nrespi: on trache collar the whole day, able to cough out clear-white frotty secretions; Passy-muer valve placed after speech and swallow evaluation. able to communicate well after encouraged to speak. lung sounds coarse throughout; suctioned q2-3 hrs when passy-muer valve in place. CXR showed worsening R pleural effusion. ? plan to tap patient gets worse clinically; cultures shows pseudomonas on secretions ? paln to start on bactrim. place back on ventilator PS 5/5 50% FiO2 after desatting while takingoff trache mask in setting of increased confusion. ABG and CXR done.\n\nCV: hemodynamically stable, SR-ST 80's-110's denies denies any chest pain. increased swelling of neck noted after XRT, Bilateral upper extremities edema noted, R > L; PICC line dressing changed, serosanguinous drainage noted. Collection bag in place at R LFA for weeping edema.\n\nGI: tube feeds goal up 55cc/hr, residuals 10cc/4 hrs; bowel sounds present, G-tube in place, dressing changed. G-tube site with serous drainage noted when dressing change. Scant amount Soft golden brown BM x 1 at start of shift, started on bowel regimen. on flagyl PO for c-diff.\n\nGU: received 40mgs of Lasix, put out 1L one hour after meds was given; urine output adequate. received Calcium and potassium repletion today.\n\nID: ? start on bactrim; continues on vancomycin, gentamycin and meropemen; gentamycin peak and trough done. 1 set of Blood culture sent with T max 100.8; neupogen dc'd with G-CSF > mcg today.\n\nEndo: on RISS, coverage given\n\nSkin: weeping edema RUE\n\nSocial: no calls from family today.\n\nplan:\n\nmonitor respiratory status, pulmonary toilet;\ndilaudid for pain, avoid ativan per team since patient gets more confused with med; remains on contact and neutropenia precaution; ? start on bactrim; follow - up ABG, the specimen sent this pm is not enough.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-17 00:00:00.000", "description": "Report", "row_id": 1662467, "text": "Resp: pt on psv . Pt has #8 portex trach. BS are coarse to clear. Ambu @ hob. Suctioned for small to moderate amounts of thick secretions. RSBI=38, then placed back on T/C @ 50% with cuff deflated and pmv in place. Family in room. Removed pmv by 12:00, left cuff deflated with 02 sats @ 99%. Pt has a strong cough and is able to expectorate some secretions. Pt is expected to have another treatment for cancerous mass in throat in am,and as in past has ^ wob and requires a duration on the vent. Vent in room. Will continue to monitor and treat accordingly.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-17 00:00:00.000", "description": "Report", "row_id": 1662469, "text": "patient went for radiation on T_mask.Placed on vent to rest for 4hours upon his return from radiation.needs to go back o T-mask around 8PM then to rest on PSv for a few hours.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-18 00:00:00.000", "description": "Report", "row_id": 1662470, "text": "Nsg.notes 1900-0700hrs\n\nNeuro:alert and oriented x2 ,confused and agitated at times, restrained four limbs.denies any pain.had 5th radiation yasterday.\n\nResp:trache collar,fio2 50% ,O2 12 lit/min.sutioned thick secretions.lungs coarse.sats 93-97%\n\nCVS:HR 68-90/min,NSR,NO ECTOPICS NOTED.60 meq K repleted,calcium gluconate 1gm in 100ml D5 repleted.Both hands and neck incresing swelling.weeping from both hands.Rt hand small collection bag present.Lt hand mid line,site looks clean,no blood draw.\n\nGU/GI:Abdomen soft bowel sounds present,PEG ,ON feed neutran pulmonary with benoprotein 55 ml/hr.tolerated well.no BM this shift.no pain.20f urinary cath,urine turns to yellow clear from pink in early shift.slight bleeding from catheter site nted..urine output adequate,draing more from 1am.prophylaxis on PPI,heparin and pneumo boots.\n\nIntegu:skin intact other than edema and weeping.bath given and positioned.T max 98.3\n\nEndo:on sliding scale insulin q6h\n\nIV access:Lt midline,site looks clean,infusing well.no blood draw as by previous shift.weeeping from hands.sheets underneath hands are wet.\n\nsocial:family visisted early shift and updated.pt slept in beteween .\n\nPlan:care of IV line.? may need central line.care of skin as edematous.watach for urethral bleeding.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-26 00:00:00.000", "description": "Report", "row_id": 1662507, "text": "Addendum 1600-1900\nDNR/DNI\n\nFamily meeting with Dr and MSW. Family wishes to continue care with goal of pt going home but pt is now DNR. Family states that they will reassess pt's situation daily. Encouraged to seek support prn from nursing/SW/palliative staff.\n\nNeuro: pt sleeping but responded to request to squeeze this RN's hand. intact. Haldol prn d/c'd. Continue to monitor.\n\nCV: Hct now 20.4, Dr paged. PTT still pending.\n\nGU: Urology placed 3way catheter. 1800 cc initial u/o of dark gold, clear urine. No clots observed.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-27 00:00:00.000", "description": "Report", "row_id": 1662508, "text": "Nsg.notes 1900-0700hrs\n\nshift uneventful.had good night.\n\nNeuro:Alert and obey commands,not trying to talk,looks lethargic,slept well during the night.no specific c/o pain.\n\nResp:on trache collar 35%,sats 99% .suctioned large thick secretions.trache site cleaned and allevyn dressing inract.\n\nCVS:HR 80-90/min,NSR, no ectopics noted.BP Stable.received 1 unit red cells for low crit.no active bleeding from foleys cath noted.heparin adjusted as per PTT report protocol.At 1am PTT REPORT 115,reduced infusion to 100unit/hr.sent crit post transfusion\n\nGU/GI:abdomen firm,bowel sounds present,PEG in place,on tube feed 55 ml/hr,tolerating well.no BM this shift.UO adequate on 3 way folwys cath.clear yellow urine.\n\nSocial:no family contact during night.calm and co operatine DNR /DNI.on contact precautions.\n\nIV access:PICC on Rt hand and 22G PIV rt.hand.patent,site looks clean.\n\nPlan: ? call out if secretions are low.airway management.neuro assessment.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-27 00:00:00.000", "description": "Report", "row_id": 1662509, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Portex 8.0 DIC. Airway patent. BLBS are coarse. SXN for copious amounts thick white secretions. No PMV this shift d/t secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2111-06-27 00:00:00.000", "description": "Report", "row_id": 1662510, "text": "resp. care\npt. remains trached and on 35% trach mask. sx'd many times\nfor thick white sputum. mdi's given. pt pulled out trach and\n# 7.0 cuffless portex was placed without incident. continue\nto keep in unit due to secretions.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-20 00:00:00.000", "description": "Report", "row_id": 1662478, "text": "Respiratory Care:\n\nPt followed for routine trach care/ bronchodilator therapy. He remain on 50% TC cool mist/ patent Inner cannula. He slept all night. He clear his secretions most times, thick yel secretions, occ sution with with RN/RRT active . All essential eq @ bedside, Ambu resus & supplies. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-20 00:00:00.000", "description": "Report", "row_id": 1662479, "text": "Respiratory Care: Pt seen fro outine airway care. Pt on 50% FiO2 via trach mask. Lung sounds coarse. Suctioned for moderate thcik white secretions. Pt has a strong able to clear own secretions at times. Inner cannual clean and patent, cuff down. MDIs given per order. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-20 00:00:00.000", "description": "Report", "row_id": 1662480, "text": "Shift Note: 0700-1900\nNeuro: Pt A+OX3, MAE, receiving dilaudid 2mg X2 via PEG tube as ordered for report of pain, and otherwise denies pain t/o shift. Pt trached though mouthing words, shaking and nodding head appropriately and able to make needs known. Dr. in to discuss code status w/ pt. Pt verbalizes understanding of discussion though writes \"you are the doctors,\" and has not identified specific wishes. brother and sister-in-law in presently, updated on pt status and POC, verbalize understanding, and verbalize understanding of tx plan including side-effects per their discussion w/ Dr. . Family updated re; discussion between MD and pt about code status. brother reports that they have not talked about advanced directives in past, though brother also reports, \"these issues have been on my mind,\" and reports that he will talk with the patient about his wishes.\n\nResp: Remains trached on FiO2 70% via TM. SpO2 Remains 98-100% BBS w/ rhonchi to diminshed at bases. Pt w/ frequent strong, loose , productive for amounts of thick white sputum. Snx q3-4hr for additional moderate to copius amounts of thick white secretions. Pt continues on gentamycin and meropenem as ordered. Remains afebrile. Midline not functioning this morning and D/C'd IV RN. PIV access #22 in L wrist placed by IV RN. Plan for PICC line placement in IR on monday. Plan to resume XRT for 8 more treatments and plan to start low-dose chemo on monday per oncology fellow note.\n\nCV: HR 60's to 80's, SR w/ no appreciable ectopy. BP stable. Continues w/ upper body edema, though improved from last week. Facial swelling and neck swelling greatly improved w/ neck softer.\n\nFEN: Receiving TF at goal rate w/ minimal residuals. Abd soft, non-tender w/ BS present. FSBS covered w/ SSI. Foley catheter patent and draining clear yellow urine ~100-200ml/hr. Mushroom rectal tube draining small amount loose/liquid green stool.\n\nSocial: Brother and sister-in-law in to visit, updated on pt status and POC as above.\n\nPlan: Continue to monitor VS, MS, resp status and labs. Resume XRT and chemo on monday. Continue pulmonary toilet. Continue ABX as ordered. Increase activity as tolerated. Continue support for patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-21 00:00:00.000", "description": "Report", "row_id": 1662481, "text": "MICU NPN\nNEURO: ALERT AND ORIENTATED X3. ANSWERS QUESTIONS APPROP. BY NODDING YES/NO. MED. X1 WITH PRN HALDOL DUE TO PT. TRYING TO GET OOB, LEGS OVER SIDERAILS. WRISTS LOOSELY RESTRAINED FOR PT. COMFORT.\n\nRESP: CONTINUES TO HAVE COPIOUS AMTS. OF THICK WHITE SECREATIONS, SX. FREQ. TRACHED WITH O2 VIA TRACH MASK AT 50% SATS HAVE BEEN FINE. STRONG HE IS ABLE TO UP SECREATIONS ON YOUR OWN.\n\nCV: HR AND BP STABLE SEE CAREVUE FOR MOST RECENT VITAS SIGNS.\n\nSKIN: NECK CONTINUES TO BE VERY RED AND SWOLLEN, TO CONTINUE WITH XRT TREATMENTS ON MON.\n\nGI: TUBE FEEDS AT GOAL, MUSHROOM CATH IN PLACE DRAINING LIQ. BROWN STOOL.\n\nGU: SEE CAREVUE FOR URINE OUTPUT, FOLEY DRAINING WELL URINE IS CLEAR.\n\nACCESS: PT. HAS VERY POOR PERIPHERAL ACCESS AND IS TO HAVE A PICC LINE PLACED ON MONDAY, I WAS NOT ABLE TO DRAW LABS THIS AM DUE TO HIS POOR ACCESS, RIGHT NOW HE HAS ONLY 1 #22G PIV IN HIS LEFT WRIST.\n\nSOCIAL: NO PHONE CALLS OVER NIGHT.\n\nPLAN: CONTINUE WITH XRT, LOW DOSE CHEMO, PULMONARY TOILET. CONTINUE IV ABX. SUPPORT FOR FAMILY AND PT.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-21 00:00:00.000", "description": "Report", "row_id": 1662482, "text": "Respiratory Care:\n\nPt followd for rutine trach care & bronchodilator therapy. He remain on 50% TC with cuff defated, IC patent. We sxtn twice for small amt of thick tel secretions, active strong , also clears secretions himself. Plan: continue present care.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-21 00:00:00.000", "description": "Report", "row_id": 1662483, "text": "Respiratory Care:Pt seen for routine airway care. Pt refusing to be suctioned. Able to expectorate at times, thick white secretions. Pt also refused MDIs only recieved one tx this shift. Lung sounds slightly coarse.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-21 00:00:00.000", "description": "Report", "row_id": 1662484, "text": "Shift Note: 0700-1900\nNeuro: Pt A+OX3, vague and confused at times w/ poor short-term memory. Pt also withdrawn, refusing OOB to chair X 2 attempts today, pushing away nurses. Also refusing snx from RT X 1 today. MAE, mouthing words, shaking and nodding head appropriately and able to make needs known. Denied pain t/o shift until 1800 and was given dilaudid 2mg via PEG tube as ordered.\n\nResp: Remains on trach mask w/ FiO2 weaned to 35%. BBS remain course at times and diminshed at bilat bases. Pt w/ strong productive for thick white secretions and continues w/ copious amounts of secretions requiring additional tracheal snx ~q2hr. Remains afebrile and continues abx as ordered. Plan to resume XRT tomorrow and chemo early this week. SpO2 remains 97-100%.\n\nCV: HR 70's to 80's, SR w/ no appreciable ectopy. BP remains stable. K increasing now to 5.1. EKG obtained and shows no changes per Dr. . Dextrose 12.5gm and regular insulin 10 units given as ordered. Continues w/ upper body edema, slightly improved today. No significant changes in neck edema as compared with yesterday.\n\nFEN: Abdomen soft, non-tender w/ BS present. Receiving TF at goal rate 55ml/hr and residuals remain minimal. Foley catheter patent and draining clear yellow urine, >100ml/hr. Fluid status ~<1L> this shift. Na+ 126-128 today w/ increasing K. Urine lytes sent as ordered. Serum osmo and cortisol added to afternoon lab sample and results are pending.\n\nSkin: Areas of skin breakdown noted directly below trach site. Wound base yellow and draining purulent drainaing. Area cleansed w/ 1/2 strength peroxide, rinsed w/ NS and drain sponge applied. Area was visualized by team and Dr. on am rounds.\n\nSocial: Pt's fiance is HCP per pt's brother. Social services in on consult and spoke w/ pt and family. Social services reports will consult w/ palliative care, and plan for family meeting early this week w/ team, oncology, social services and palliative care. Dr. spoke w/ family at length, updated on pt status, POC and plan for family meeting. Family denies any further questions and agrees to plan.\n\nPlan: Continue to monitor VS and labs. Monitor fluid status and lytes w/ plan for Na correction pending lab results. Will need repeat serum lytes at ~2100 as well as routine EKG in am per Dr. . Resume XRT and chemo this week as above. Will need PICC or Midline placement in IR tomorrow. Continue skin care measures. Continue diluadid as ordered and needed for pain. Family meeting to take place early this week as above. Continue support for patient and family.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 1662485, "text": "NPN 1900-0700:\nNeuro: pt is alert, oriented x3, mouthing words and talking at times, making his needs very clear, he was very aggressive, agitated and withdrawn, refused treatments, holding and pulling the nurse most often, though he remained oriented x3 and answered appropriately when asked orientation questions, he kept on asking that he is tied up here and he wanted to go home or outside this unit, this nurse untied his hands for long periods of time when pt was directly observed, and loosely tied hands when unobserved (this nurse has another patient too), pt pulled the mushroom catheter 2x, was witnessed pulling at the Foley catheter and tracheostomy and once pulled the PEG tube, given Haldol 0.5 mg, then 1 mg, then another 4 mg with no effect, as HO assessed pt to be more agitated she recommended giving him Dilaudid and ordered Ativan, given Dilaudid 1 mg, later pt was observed to be more restless and pulling on tubes and tried to get out of bed many times although side rails were up, HO ordered 1-5 mg Ativan Q 4 hrs PRN, given 2 mg IV and he calmed down a little bit. Pt denied any pain.\n\nResp: trached, breathing regularly on Tracheal mask 35 %, coughing strongly with copious thick whitish secretions, deep tracheal suctining done 3x by this nurse with excessive thick yellowish to whitish secretions, SPO2 94-100%, was pulling the oxygen occasionally, LS coarse on upper lobes and diminished on lower lobes.\n\nCV: NSR-ST HR 78-129, SBP 113-144, Na was 129 at 2100, received 1 L NS at 100 cc/hr, K 4.8, FS 75, peripheral pulses palpable, with only one PIV line and is not easy to stick, with edema on upper body parts though the neck edema is apparently less compared to last week, on .\n\nGI/GU: abdomen soft, BS present, with PEG tube in place, on TF at goal @ 55 cc/hr well tolerated, very minimal residue flushed with 50 cc Q 6 hrs, BS present, with mushroom catheter drained about 400 cc golden color liquidy stool, with Foley cath draining adequate U/O.\n\nInteg: On contact precautions, T max 99.4.\n\nSocial: family members visited early during the shift before pt got so agitated and updated on POC, both hands restrained with soft restrained for safety of tubes, the purpose of the restrains explained and frequent psychological support and explanation about procedures and POC offered by this nurse.\n\nPlan: continue antibiotics, monitor FS and cover with insulin/dextrose as per SS, radiotherapy and chemotherapy this week, family meeting with ICU team, oncology team, social worker, and ? psych today to plan for the upcoming treatment regimen and ? readdress code status and transfer from ICU and/or hospital.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 1662486, "text": "Respiratory Care Note:\n\nPt followed for routine trach care & brochodiulator therapy. He s a # 8 trach in place on 50% Cool mist, cuff deflated with PMV at bedise, IC patent. Pt was agitated o/n, pulling on trach mask and asking to go home. We are wsxtn as needed for small amt of thick yel-whitish secretions, active present. Plan: keep confortable.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-26 00:00:00.000", "description": "Report", "row_id": 1662503, "text": "Nsg.Notes 1900-0700hrs\n\nshift uneventful.see care vue for more details.\n\nNeuro:OOB to chair last evening and back to bed at 2000hrs,tolerated well.steady gait.alert and oriented x2.confused and trying to remove lines and bed sheets at times,received 2mg halodol at 00.00hrs and slept well after that.denies any pain.\n\nResp:on trache collar 3%, sats 100%.suctioned moderate secertions.LS clear.\n\nCVS:HR 90-110/MIN,NSR-ST,on lopressor 12.5mg for rate control.BP 110-120/60-70 MM OF HG.PTT report at 2200hrs 54 secs,heparin 1200units iv bolus and increased infusion 75units per hr,ie:850unit/hr.repeat PTT at 0400hrs.\n\nGU/GI:PEG in place,dressing intact,site looks clean,on feed 55ml/hr and water 30ml q8h.on fluid restriction 1500ml.abdomen firm and distended,bowel sounds present.no BM this shift.voids often incontinent,put on diaper during night time. clear yellow urine.\n\nIntegu:all hygenic needs attended and positioned,turns in bed self.afebrile.DSD on PEG site.\n\nEndo:on sliding scale insulin and covered.\n\nIV Access:Rt hand PICC ,and Lt.hand 20g PIV,site looks clean,dressing intact.\n\nSocial:no family contact during the shift.full code.\n\nPlan:call out ? when bed available.airway management,emotional support to pt and family.heparin infusion as per PTT.ambulate as tolerated.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-26 00:00:00.000", "description": "Report", "row_id": 1662504, "text": "RESPIRATORY CARE NOTE\n\nPatient remains on 35% Trach mask at this time. Tolerating well. Has Portex 8.0 DIC trach tube in place and patent. Inner cannula changed. Sxn for copious amount thick white-pale yellow secretions. Albuterol and atrovent mdi's given. Plan to use PMV as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662446, "text": "Shift Note: 0700-1900\nPlease see careview for all objective data:\n\nNeuro: Pt alert, trached, MAE and follows commands consistently. Receiving dilaudid 2mg PRN as ordered for pain w/ good effect.\n\nResp: Received pt on CPAP/PS which was weaned to t-piece 70% FiO2. BBS Course to diminshed at bases, and clear somewhat w/ snx. Snx q2-3hr for mod amounts thick white secretions. pt to XRT today for 2nd tx. Episode desating to 70's, hypertensive SBP to 180's, tachypneic to 40's, though recovered w/ titration of FiO2 and has otherwise remained free of distress this shift. Abx changed now on vanc/flagyl, gentamycin coverage.\n\nCV: HR 70's to low 100's - sinus w/ no appreciable ectopy. BP stable, SBP 120's to 140's except breif episode as noted above. Continues on heparin gtt at 1600 units/hr. PTT therapeutic X 3. Pt initially w/ severe R facial swelling. Now recieving decadron w/ benadryl PRN. Facial swelling greatly improved. General edema noted from waste up with skin pink to slightly reddened, + BUE edema. LE pale w/ no edema present, skin warm, capillary refill <3 sec. Plan for pt to go for MRI head/neck to evaluate SVC syndrome and Dr. reports no need for abd/thoracic MRI. MRI checklist completed by MD.\n\nFEN: Abd soft, non-tender, BS hypoactive. No stool this shift. Receiving TF - residuals elevated this afernoon and held for several hours. Now at 15ml/hr w/ goal rate 45ml/hr. K, mag and ca+ have been repleated. Foley catheter patent and draining clear yellow urine. UA/ CS sent as ordered.\n\nSocial: No contact from family this shift.\n\nPlan: Continue to monitor VS and resp status. Continue pulmonary toilet. MRI this evening. Continue abx as ordered. Pt to continue XRT as ordered. Monitor labs. Continue heparin gtt as ordered and per protocol.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662447, "text": "Respiratory Care\nPt remains on t-piece traveled to radiation was anxious resolved with medication. Plan for possible mri this evening. MDI as ordered increased secrections post radiation.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-13 00:00:00.000", "description": "Report", "row_id": 1662448, "text": "neuro: follows commands restless at times. mouths he wants to go home.\nmedicated several times through the night for paiin with dilaudid and for anxiety with ativan. Good effect.\n\ncv/resp nsr no ectopy BP stable. Please see carevue flow sheet for aprox. time: Pt found with Trach out and sitting on his chest. Trach tube gentley replaced immediatetly and Ambu bag used to generate sat>90. Pt. stabilized and returned to t-piece at 80% fio2. CXR done.\nWrist restraints placed on pt since pt. was touching trach frequently prior to this incident. suctioned for copious secretions now some blood tinged.\n\ngi/gu tube feeds slowly increased progressing towards goal rate.\nfoley with q.s. uop. small stool/mucous passed.\n\ninteg skin no issues\n\nmisc: MRI of neck completed at 8:30 pm. last eve. Pt. tol procedure well. results pending.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-13 00:00:00.000", "description": "Report", "row_id": 1662449, "text": "Resp CAre\nFollowed pt overnight with mdis, trach care. #8 Portex, cuff inflated with 4cc air, inner cannula in. Suctioned for large amounts of thick white, blood tinged sputum. Trach became dislodged last evening but was easily put back in. CXR confirms placement. O2 sats 95-97 on 80% trach collar, but has frequent episodes of desaturation down to low 80s when coughing .\n" }, { "category": "Nursing/other", "chartdate": "2111-06-26 00:00:00.000", "description": "Report", "row_id": 1662505, "text": "NPN 0700-1900\nFull code NKDA Stage IV subglottic Ca\n\nNeuro: Pt lethargic, dozing off and on but arousable throughout shift. Responds appropriately to yes/no questions w/ nonverbal cues. MAE, weaker today, remains strong. Afebrile.\n\nCV:NSR high 70's to low 90's. BPs 105-126/55-69. Hct redrawn at 0900, 22.4. Guaiac will be done on next stool. PTT 58.4 @ 1000, bolused with 1200 units heparin and drip increased to 925 units/hr @ 1100. PTT will be redrawn @ 1700. +PPP's b/l, denies CP, skin warm/dry.\n\nResp: Trach collar with cool neb @ 35%, RRR, sats 98-100% even when off O2 for any time. Considerably increased secretions so medical team decided pt should remain in ICU.. Pt coughing out moderate amts regularly, deep sxn'd x 5 for white thick secretions.\n\nGI/Endo/GU: TF continue @ goal of 55cc/hr and on RISS with minimal coverage needed. +BS, abd firm/distended despite consistent urine output; bladder scan performed and pt had retained liter +. Urology resident attempted to placed catheter but unsuccessful, will perform cystoscopy later today. Frank blood draining from penis in small to moderate amt, monitoring closely. Also, loose stool in small amt x3. Will send C Diff w/next stool.\n\nID: Gentamycin d/c'd today.\n\nLines: PICC patent, new #22 placed in LL forearm\n\nSocial: Fiance, friend and brother in to visit.\n\nPlan: monitor/manage secretions\n urology to remove retained urine\n Lopressor \n abx and RISS as ordered\n encourage t/c/db, emotional support\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-26 00:00:00.000", "description": "Report", "row_id": 1662506, "text": "resp. care\npt. remains trached on 35% tm. tolerating well.\nsx'd many times for cop. thick white sputum. mdi's\ngiven. no pmv today. to rad. therapy.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-30 00:00:00.000", "description": "Report", "row_id": 1662521, "text": "Resp care note\n\nPt getting albuterol and atrovent Q 6 hrs. Sx several times for mod to copious amts of thk yellow secretions. IC for #7 Protex trach replaced. Pt has fairly strong but but still needs sx.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-30 00:00:00.000", "description": "Report", "row_id": 1662522, "text": "7A-7PM P-MICU Nsg Progress Note\n61 y.o. with Stage IV Subglottic Squamour Cell Ca\nDNR~ NKDA\n\n\nONC: XRT today, pt receiving Taxol and Carboplatin today, premedicated with 25 mg IV Benadryl, 10 mg IV Dexamethasone, and 20 mg IV Famotidine. tolerating chemo, VSS (oncology RN - infusing)\nfollow Hct 25.4 WBC 9.7\n\nNEURO: awake, alert, watching TV, oriented to person only, thought he was at the , confusion waxes and wanes. Attempts to get OOB, pulls at lines. hands restrained for safety. SR up x 4, bed in low position. MAE, pt OOB to chair (2 assists) for 2 hrs. tolerated well.\n\nCV: bp stable 130-150/80-90 HR 90's SR, no vea noted. +pedal pulses. remains on IV Heparin gtt @ 950 u/hr. PTT 70 on Coumadin 5 mg, INR~1.1\n\nRESP: pt on 35% trach collar, rr~20, O2 Sats 100% lungs with coarse breath sounds, suctioning decreased. passy-Muir valve in place most of the day. receiving Albuterol/atrovent MDI's\n\nGI/GU: tube feeds Nutren Pulmonary FS @ 55 cc/hr via G-tube. pt passed loose stool x 2.\n\nID: afebrile, on po Flagyl 500 tid awaiting sensitivities regarding sputum cx. (growing pseudomonas)\n\nSKIN: wound at trach, dressed with Alleyn trach dsg. Stage 1 pressure ulcer on back Aloe Vesta reapplied, frequent turning.\n\nLINES: patent PICC in right antecubital, flushed well, no redness, dsg intact, peripheral will be d'cd after chemo.\n\nPLAN: aggressive pulmonary toilet, Flagyl for C-Diff, on Coumdadin, follow INR, continue Heparin gtt till INR therapeutic. follow counts, called out to floor tomorrow~ hem/onc.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-07-01 00:00:00.000", "description": "Report", "row_id": 1662523, "text": "MICU/SICU NPN ICU Day #21\nEvents: pt continues to be confused and restless, climbing out of bed and pulling at PICC line, O2, etc.\n\nS: \" da new uniform.\"\n\nO:\n\nNeruo: pt is oriented to self only, MAEW, denies pain, restless, climbing OOB and pulling at PICC line, monitoring equipment, pt transfers bed to commode/chair with one to two min assist, gait and balance are poor\n\nPulm: Spo2 96-100% on 35% trach mask, pt has not required suctioning this shift, pt has been expectorating and swallowing secretions\n\nCV: AVSS, please see flowsheet for data\n\nInteg: C/W/D/I\n\nGI/GU: abd soft, NT/ND, BS present, tolerating Probalance at goal rate of 55cc/h, pt moved bowels x3 overnight, Foley patent for clear yellow urine in adequate amts\n\nAccess: left cephalic PICC\n\nA:\n\nacute /confusion r/t prolonged hospitalization, acute illness\nhigh risk for injury, trauma r/t restlessness, confusion, \nrisk for aspiration\n\n\nP:\n\ncontinue to monitor hemodynamic/repiratory status, continue chemo/XRT as planned, transfer to med/onc bed when available\n" }, { "category": "Nursing/other", "chartdate": "2111-07-01 00:00:00.000", "description": "Report", "row_id": 1662524, "text": "Resp Care note\n\nPt has strong which usually will clear secretions. He wears trach mask at all times. Pt gets alb/atrv MDI Q 4-6 hrs. He is is confused but was cooperative last night.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-19 00:00:00.000", "description": "Report", "row_id": 1662475, "text": "Nursing Note: 0700-1900 pt full code\n\nNeuro: pt remains oriented to person and place, dozing intermitently during shift, pt noted to be attempting to pull at foley and verbally redirected but unable to remember, wrist restraints remain for safety. received 4mg PO dilaudid prn for pain, non verbal communication difficult, passy muir valve attempted today but pts voice to garbled to communicate. able to move all extremities well.\n\nCV: NBP stable throughout shift (see careview), HR 70's NSR no ectopy, tmax 98.8. continues generalized weeping edema, facial edema noted to be unchanged from prior assessments. pos distal pulses.\n\nResp: trach intact, remains on 0.50 trach collar, sats 97-100. lungs clear and diminished. able to expectorate thick white/yellow secretions, suctioned x1. trach care done by RRT.\n\n\nGI: TF cont at goal of 55/hr via PEG. mushroom cath remains lg amts green loose stool, cdiff spec sent. pos bowel sounds. no insulin coverage needed today.\n\nGU: foley cath intact, urine output adequate (see careview).\n\nOncology: pt had radiation tx today at 1400, pt stable during procedure. Plan to have 7 more doses per oncology.\n\nIV: left single lumen midline cathether remains WNL, difficult blood return, IV therapy assessed and no way to increase blood return. dressing to be changed today.\n\nSocial: no contact from pts family this shift.\n\nPlan: cont to monitor and assess resp status, trach care, vitals, urine output. I/O's.\n\nplan to increase activity level. ambulate pt OOB to chair, PT consult ordered.\n\ncont to assess pain level and provide emotional support to pt and family.\n\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-19 00:00:00.000", "description": "Report", "row_id": 1662476, "text": "resp care\nfollowed for trach care, bronchodilator therapy. resp status stable. pmv placed briefly, speech garbled,pt unable to clear. pmv removed. cuff remains deflated with patent inner cannula. expectorating mostly on own with strong cough. 50% trach collar with stable spo2s. trach supplies,ambu at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-20 00:00:00.000", "description": "Report", "row_id": 1662477, "text": "NPN 1900-0700:\nNeuro: Pt is trached, mouthing words, alert, oriented x3 as he answered appropriately to name, place and date questions, at times looks confused and pulling at tubes, mushroom cath reinserted, opens eyes spontaneously, follows commands but inconsistently.\n\nResp: with tracheal collar mask80%, 12 LPM, strong cough with copious thick yellowish secretions, needed suctioned twice per shift as he is able to cough all secretions out by himself, Sat 98-100%, LS CTA and diminished at bases, on Alb/Atr tx.\n\nCV: NSR HR 68-99, BP 108-163/50-71, with a midline, on IV antibiotics, palpable peripheral pulses, FS 149.\n\nGI/GU: abdomen soft distended, BS present, passing liquidy greenish stool second specimen sent for C-Diff, TF at goal at 55 cc/hr via J tube well tolerated with 100 cc free water Q 6 hrs, with Foley draining adequately after 80 mg Lasix IV, he is about 100 cc negative.\n\nInteg: T max 98.7, on contact precautions, restrained for tubes safety.\n\nPlan: continue antibiotics, pulmonary toileting, FS and cover with insulin as per SS, follow up on C Diff results, reorient frequently and keep restrained for safety of trach and tubes.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662443, "text": "Nursing Note: 1900-0700\n\nNeuro: pt alert, confused. able to answer simple questions. able to follow commands but unable to remember directions.\n\nResp: on 70% trach collar until 0145 (see above note). currently remains back on vent support CPAP 12/5, FIO2 0.60. RR 20-30. sats 95-100. suction moderate white thick. lungs coarse/diminished bases.\n\nCV: HR 80-110 SR no ectopy, BP stable (see careview). remains on heparin gtt increased to 1600units/hr overnight. pos distal pulses. pos distal pulses. noted to have incresed facial edema and swelling overnight.\n\nGU: foley cath changed overnight r/t pos yeast culture. bloody urine and clots noted after insertion, foley flused and draining appropriatly.\n\nGI: pos bowel sounds, TF @ 45/hr via PEG. no BM overnight.\n\nSkin: PEG dsg changed overnight. intact. repositioned in bed.\n\nIV: PIV x2\n\nSocial: pts fiance and brother in to visit during evening.\n\nPlan: cont to monitor resp status, vitals. labs.\nnext ptt @ 0800\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662444, "text": "Nursing Note:\n\nat 0430 pt noted to have increased facial edema and swelling, especially in right eye over period of several hours. intern and resident paged and are presently assessing pt, tube feeds off, pt presently more somnolent and less responsive.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-25 00:00:00.000", "description": "Report", "row_id": 1662499, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. REMAINS ON HEPARIN GTT FOR R UPPER EXTREMITY DVT. PT. MORE ALERT AND ORIENTED WITH EACH DAY. NO WRISTS REQUIRED. PT. VERY PLEASANT AND COOERATIVE WITH POC.\n\nNEURO: ALERT AND ORIENTED X3. MAE. DANGLED ON SIDE OF BED THIS SHIFT FOR 15 MINUTES. TOLERATED WELL. PT. DID C/O SOME NECK PAIN WHERE RECEIVING HIS RADIATION. MEDICATED WITH HYDROMORPHONE WITH GOOD EFFECT.\n\nRESP: PT. ON ATC 35% WITH SATS 99-100%. BREATH SOUNDS CTA. PT. REQUIRED NO SUCTIONING THIS SHIFT. VERY STRONG . CLEARING SECRETIONS ON OWN. NO C/O SOB.\n\nCV: NSR. NO ECTOPY NOTED. BP WNL. + PULSES. GENERALIZED EDEMA. AFEBRILE. REMAINS ON HEPARIN GTT. NEXT PTT DUE AT NOON.\n\nGI: PT WITH PEG. TFEEDS AT GOAL RATE OF 55CC/HR. ABD. SOFT. BS+. NO BM T HIS SHIFT.\n\nGU: PT. ATTEMPTING TO VOID IN URINAL, HOWEVER, OUTPUT INACCURATE AS URINE FOUND IN BED AFTER URINAL USE.\n\nPLAN: ? C/O TO FLOOR TODAY. ? SPEECH AND SWALLOW EVAL IN NEAR FUTURE. MONITOR HEMODYNAMIC/RESP STATUS CLOSELY. PT.'S BROTHER IN LAST EVENING. REMAINS FULL CODE. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-25 00:00:00.000", "description": "Report", "row_id": 1662500, "text": "RESPIRATORY CARE NOTE\n\nPatient remains trached with Portex 8.0 DIC trach tube. Wears PMV with good vocalization. PMV off for the night. Sxn for moderate amount thick pale yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2111-06-25 00:00:00.000", "description": "Report", "row_id": 1662501, "text": "Respiratory Care:\nPt on a trach mask and doing fairly well. He does C+R stringy white secretions occasionally. MDI's with trach spacer given. To XRT this PM...\n" }, { "category": "Nursing/other", "chartdate": "2111-06-25 00:00:00.000", "description": "Report", "row_id": 1662502, "text": "Full code\n\nNeuro: Alert, answering questions appropriately but occasionally appears confused via actions. OOB to chair today and very well tolerated. Good . Afebrile.\nCV: NSR w/o ectopy, ST with activity. BP's stable. Heparin gtt @ 775units/hr after PTT 0f 82.5. PPP's b/l\nResp: RRR, LSCTA b/l, remains on trach mask @ 35%. Pt sometimes removes mask and sats remain >98%. Sxn X1 for small mod amt thick yellow sputum, otherwise coughing/clearing on own.\nGI: Abd firm/nt. TF at goal of 55cc with no notable residuals. +BS. No stool this shift.\nGU: Pt voiding in urinal and in bed. Amt estimated to be moderate with each void. need condom catheter overnoc to maintain skin integrity.\nSkin: Wound inferior to trach cleansed w NS and placed fresh Allevyn dressing as per wound care RN. No exudate or odor noted.\nID: Remains on Meropenem and Gentamicin IV and Flagyl pPEG.\nPlan: Monitor and support resp status\n Abx as ordered\n NEXT PTT DUE @ ; Heparin gtt\n Safety\n called out to floor\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662445, "text": "RESPIRATORY CARE:\n\nPt remains trached, currently vent supported on PSV/CPAP. Pt on trache collar at 50%, approx 5 hours overnight without difficulty. Placed back on vent during an episode of cyanosis, with desaturation to 70's- after O2 pulled off. Sx'd large amounts thick white secretions after episode, and rest of shift. Increased oral secretions noted also. Pt's neck seemingly more enlarged overnight, ? related to episode and change in secretions. BS's coarse. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-29 00:00:00.000", "description": "Report", "row_id": 1662519, "text": "Shift Note: 0700-1900\nNeuro: MS greatly improved today compared to previously. Pt Oriented X 3 this am, knew this RN's name. Discussing articles in the newspaper this afternoon, though pt w/ increasing confusion later in afternoon, asking to go downstairs to get changed. Lorazepam has been D/C'd previously and pt receiving occasional haldol 1mg IV as ordered for . Pt denies pain t/o shift. MAE. OOB to chair X 4.5hr today, tolerated well and able to take several steps w/ moderate 1 assist.\n\nResp: Remains trached on 35% FiO2 via TM for humidity. Continues w/ copious amounts of thick white secretions w/ no significant change in quantity or quality over past several weeks. Remains afebrile. Underwent XRT today and tolerated well.\n\nCV: HR 80's to low 100's - sinus w/ no appreciable ectopy. Continues on heparin gtt w/ PPT therapeutic X 2. Heparin continues at 950 units/hr and repeat PTT due w/ Am labs. Pt started on coumadin for heparin to coumadin therapy and received 1st dose tonight. BP remains stable.\n\nFEN: Tolerating TF at goal rate w/ minimal residuals. FSBS remain <150 and pt has not required SSI coverage for several days. Foley catheter patent and draining clear yellow urine. Hct remains stable.\n\nSocial: Dr. w/ palliative care in to see pt today. Pt's fiance, sister-in-law and brother in to see pt. Updated on pt status and POC. All questions answered. Family appreciative of care.\n\nPlan: Continue to monitor VS and labs. Continue agressive pulmonary toilet. Last XRT tx tomorrow per rad onc. Continue haldol PRN as ordered for agitaiton. Heparin to coumadin therapy. Increase activtiy as tolerated. Continue support for pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-30 00:00:00.000", "description": "Report", "row_id": 1662520, "text": "NPN 1900-0700\nDNR NKDA XRT scheduled \nDx: Stage IV Subglottic squamous cell Ca\n\nNeuro: Awake most of shift, alert to self, month, knows he is in a hospital. Confusion waxes and wanes; attempts OOB and pulls at trach mask. MAE, OOB for brief ambulation. Denies pain. Good . Afebrile.\n\nCV: NSR-ST with no ectopy noted. Stable BP's. Denies CP. +PPP's b/l. s/p RUE DVT (resolved), on heparin gtt @ 950units/hr, am PTT =70. PTT has been therapeutic for ~24hrs, next PTT due w/am labs. Bridging to coumadin, first dose 7/30 @ 1600. PT/INR =13/1.1. Hct 25.4, also stable since yesterday.\n\nResp: RRR in teens, trach mask @ 0.35, consistently satting in high 90's to 100. Requires very frequent suctioning for small to moderate amts thick white sputum.\n\nGI/Endo/GU: TF @ goal of 55cc/hr, FS 174,164 and required 2units reg insulin x2. Patent foley draining clear, dark yellow urine @ 40cc/hr which is decreased from yesterday. Dr. aware.\n\nSkin: Wound at trach, dressed with Allevyn trach dressing. Stage 1 pressure ulcer on back. Aloe vesta applied and frequent turning\n\nLines: Patent PICC in R with dressing CDI and not due for change unitl , #22 PIV in L arm patent, outdates this pm.\n\nPlan: XRT today\n aggressive pulmonary toilet\n PGT Flagyl for \n Frequent t/c/db\n heparin to coumadin\n emotional support\n" }, { "category": "Nursing/other", "chartdate": "2111-06-18 00:00:00.000", "description": "Report", "row_id": 1662471, "text": "Nursing Note: 0700-1900\n\nNeuro: pt 2, follows commands fairly consistently, some confusion noted (attempting to pull at lines). c/o pain nonverbally, 2mg dilaudid x2 today. wrist restraints remain applied for protection of invasive lines.\n\nResp: remains on 50% humidified trach collar, sats 95-100. able to expectorate thick yellow, suctioned as needed, trach care performed by RRT, and dressing changed. lungs coarse/rhonchi upper, diminished bases.\n\nCV: HR 70-80's SR no ectopy, NBP stable (see careview). afebrile. HCT this PM 26.4. repleated w/ 40meq K this AM. continues weeping from bilat arms, sm drainage bag remains on r arm. neck remains swollen.\n\nOncology: received radiation therapy today at 1400, tolerated well, next treatment tomorrow and will be re-evaluated.\n\nGI: TF cont @ 55/hr via PEG. tolerating well. pos BS. large continuous passing of liquid stool noted this AM and mushroom cath inserted. approx 500cc stool out today.\n\nGU: foley cath remains in place, 20mg IV lasix today, urine output adequate (see careview). clear yellow urine, minimal bleeding noted around meatus.\n\nIV: left brachial midline, pos blood return this AM, unable to draw blood from line this afternoon. dressing soiled and will be changed.\n\nID: remains on multiple antibiotics: flagyl, bactrim, gentamycin, meropenem.\n\nPlan:\ncont to monitor resp status, vitals, labs, trach care.\n\nplan for next radiation tx tomorrow.\n\ncontinue to assess pt for pain and anxiety, medicate as ordered and cont to provide emotional support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-23 00:00:00.000", "description": "Report", "row_id": 1662493, "text": "resp care - Pt trached and on .35 TM. Pt expectorated moderate to copious amounts of secretions, with some suctioning help. MDIs given as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-18 00:00:00.000", "description": "Report", "row_id": 1662472, "text": "resp care\nremains with #8.o portex DIC trach in place with cuff deflated. expectoring on own for yellow sputum, minimal sxning required. mdi's given per . no need for vent post radiation today. will continue to follow for airway management and bronchodilator therapy.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-19 00:00:00.000", "description": "Report", "row_id": 1662473, "text": "Nsg.notes 1900-0700hrs\n\nshift uneventful\n\nNeuro:slept well throughout the shift.alert and oriented ,at times confused and trying to remove lines and sheet.denies any pain.both hands and neck edema,weeping from hands.collection bag on Rt.hand.\n\nResp:trache collar 50%,sats 96-100%.suctioned moderate thick white secretions.coughed out thick secretions.no SOB.trache care given.\n\nCVS:hr 74-80/MIN,NSR,no ectopics noted.BP 120-140/60-70 MM of hg.both hands restrained for protection of lines and tubes.,circulation adequate.\n\nGU/GI:Abdomen soft,bowel sounds present,PEG,on feed 55ml/hr,tolerated well.mushroom cath present,no BM this shift.foley cath,UO adequate clear yellow urine.mild bleed around meatus.\n\nIntegu:skin intact except edema.bath given and positioned.afebrile.on multiple antibiotics,meropenam,flagyl,zosyn,bactrim and genta\n\nSocial:brother visited early shift and updated.calm and co operative.full code.on contact precautions.\n\nPlan:for XRT today.care of trache and airway management.continue current care.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-19 00:00:00.000", "description": "Report", "row_id": 1662474, "text": "Respiratory Care:\n\nPt remain on Trach collar via # 8 size tracheotomy, IC in place and patent. He was confortable, easily arousable. MDI's adm as ordered. We are sxtn for mod amt of thick yel secretions, he can also cough up plegm out of trach. Plan: XRT today, provide support. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-23 00:00:00.000", "description": "Report", "row_id": 1662494, "text": "FINAED 4 ICU NPN \nVSS. T-max 99.6 PO. Cont on gent & meropenem.\nA/B physical therapy. Able to weight bear to chair. Toll OOB X 3 hrs.\nCarboplatin & taxol administered by Onc RN. Premed with pepcid, benedryl, dexamethasone. XRT treatment done.\nPt becoming more fidgetity & restless & confused. reatraints on throughout the day. PIV came out ? intentionally. Trach noted to be partially out. Pushed back in by Dr. . Passy Muir valve in. Pt upset he is not being fed by mouth, wants to \"get out of here'. Reminded him several X's why he is unable to take PO's etc... Haldol 5mg total given.\nPalliative care RN, in to meet with pt. Rec haldol as well as PRN.\nExcellent . Able to expectorate large amts yellow to white secretions. Suctioned X2 for mod amts white, secretions.\n Inc of mod amts pinkish colored urine X2.\nInc of light brown, diarrhea X2. TF at 55 cc hr (goal).\nUE swelling R>L.\nA/P; Stable. Cont antibiotics.\nCont to assess MS. for safety. HAldol, orient PRN. Pscch consult for rec's. when called out to floor.\nPlace linen soiled with urine, stool or emisis in chemo box.\nUS RUE to r/o clot.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-24 00:00:00.000", "description": "Report", "row_id": 1662495, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. HAD UNEVENTFUL SHIFT. 1:1 DC'D YESTERDAY. PT. REMAINED CALM THROUGHOUT SHIFT. NO NOTED. PSYCH IN TO ASSESS PT. AND DETERMINED THAT PT. IS COMPETENT TO MAKE OWN DECISIONS. HEMODYNAMICALLY STABLE. TOLERTAING 35% ATC. PT. RECEIVING CHEMO AND RADIATION QD. ? C/O TO FLOOR TODAY.\n\nNEURO: PT. ALERT AND ORIENTATED X3. COMMUNICATING USING PMV. MAE. BILAT WRISTS RESTRAINED FOR SAFETY OF TUBES. OOB TO CHAIR YESTERDAY WITH PT. NO C/O PAIN THIS SHIFT.\n\nRESP: PT. WITH TRACH. REMAINS ON ATC 35%. PT. WITH STRONG . CLEARS SECRETIONS ON HIS OWN. BREATH SOUNDS CTA. NO C/O SOB.\n\nCV: PT. NSR/ST. NO ECTOPY NOTED. BP WNL. + PULSES. AFEBRILE\n\nGI: PEG IN PLACE WITH TFEEDS AT GOAL OF 55CC/HR. NO RESIDUALS. ABD. SOFT. BS+. INCONTINENT OF LOOSE STOOL X5 THIS SHIFT.\n\nGU: PT. INCONTINENT OF URINE. UROLOGY DOES NOT WANT TO REPLACE FOLEY AT THIS TIME AS LONG AS PT. VOIDING.\n\nSKIN: INTACT\n\nACCESS: R UA PICC\n\nPLAN: ? C/O TODAY. PT. TO COME GET PT. OOB TODAY. ? SPEECH AND SWALLOW EVAL IN NEAR FUTURE. TO HAVE RADIATION AND CHEMO TODAY. PT. REMAINS FULL CODE. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-24 00:00:00.000", "description": "Report", "row_id": 1662496, "text": "Resp Care\nFollowed patient overnight. Wearing 35% trach collar all of shift. Doing well with Passy Muir valve for speech.Had been using it most of the day. It was taken off at , inner cannula put back in place and pt suctioned for large amount of thick white sputum. Cuff left deflated overnight. He is generally able to on his own. Inhalers given q6 hrs as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-24 00:00:00.000", "description": "Report", "row_id": 1662497, "text": "events: positive for dvt rt vessel per ultsnd, started on heparin, # 8 tx xrt of 12 tx should complete on tues on next week. paliative care in to see pt.\n\nneuro: pupils dilated to 3-4 mm oriented x3 talking with passe muir valve. calm through out shift but did note a bit anxious and somewhat demanding. pt settled down when he realized that we were helping him. seems to be struggling with depression and anxiety of death and dying issues. no c/o pain.\n\nresp: suctioned q 1.5-3 hr thick mod amdt white secretions. trach care done and now using allevan trach sponges. skin care consult initiated and will see pt for excoriation and exudated at trach site. sat 100 % on 35% tranh mask, ls clear cont antibs for pseudomonis PNA\n\ncard: nsr rate 80-100. no ectopy. afebrile and + pedal pulses. fluid status pos cc last 24 hr and currently 850 cc positive. edema noted in arms only. dvt found in rt brachial by ultsnd and started heparin at 900 units /hr and need to recheck ptt at .\n\ngi: tf at goal via g tube. bm liquid x1 and then more loose x1. c diff cult are neg x2 and continues flagyl for past pos cult.\n\ngu: some control to use urinal and bed pan for urination. small amts 25- 50 cc. then incont. very lg vol urine in xrt wetting entire bed.\nurine yellow with 1x sm clot noted in am\n\nca: chemo x 1 dose and # 8 of 12 xrt tx today. hair is falling out but no c/o nausea or sore throat.\n\nendo: glu fs in nml range no insulin required.\n\npsy: pt is much less aggitated and are off without problems lines or trach. prn haldol d/ced and awaiting further orders for haldol but pt not seeming to need it this shift. trying to avoid benzos. pt is talking about feeling s about his diagnosis and life.refused clergy at this time\n\naccess: new iv placed lt arm and picc midline still in place.\n\nplan : poss call soon and finish xrt and poss to hosp or rehab after that. remove passe muir valve and monitor for resp compromise and safety issues\n" }, { "category": "Nursing/other", "chartdate": "2111-06-24 00:00:00.000", "description": "Report", "row_id": 1662498, "text": "resp care - Pt seen for routine trach care and med tx. MDIs given as ordered. IC changed. Pt wore PMV for most of the PM.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-11 00:00:00.000", "description": "Report", "row_id": 1662438, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: NKDA\n\nNeuro: Pt A&O x (most times unaware of place), able to MAE, follows commands consistently. Periods of confusion, given PRN ativan with good effect. Complaining of pain to neck, responds well to PRN dilaudid.\n\nCV: HR 60-70 NSR with no ectopy noted, NBP 110-140/50-60, ECHO results unremarkable. Heparin gtt at 1150 at this writing, AM PTT pending. Next due at 1000. AM HCT 25 down from 27, team aware, will discuss goal crit.\n\nResp: Remains on MMV 50%/+5/PS15, STV 500-700, MV , RR 20's with sats >95%. Lung sounds coarse throughout, suctioned q2-3h for small amounts of white, thick secretions.\n\nGI: BS x 4, no stool this shift. Pt tolerating TF well, currently infusing @ 25cc/hr with goal rate of 55cc/hr. PEG tube patent, placement checked.\n\nGU: Foley patent and draining adequate amounts of clear, yellow urine. UO 80-140 q2h. Will replete AM labs as ordered.\n\nID: Tmax 99.6 PO, continues on ABX for CDIFF and PNA. Urine culture growing yeast, other cultures pending.\n\nSocial: Brother in last evening, updated on pt's condition and plan of care.\n\nPlan:\nwean vent as tolerated\nCT today for mapping of tumor?\nPTT @ 1000, titrate gtt accordingly\npain control\npulmonary toileting\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2111-06-11 00:00:00.000", "description": "Report", "row_id": 1662439, "text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. No changes made overnight, on MMV, no apneas or low MV noted. BS's coarse. Sxing small amts. thick pale yellow secretions. RSBI=95 this am.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-11 00:00:00.000", "description": "Report", "row_id": 1662440, "text": "Respiratory Care\nPt weaned to t-piece today without complications. pt traveled via vent for mapping and radiation today without incident, plan to leave vent stand-by.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-11 00:00:00.000", "description": "Report", "row_id": 1662441, "text": "RESP; SUCTIONED FREQ FOR THICK WHITE SECRETIONS. PLACED ON T-PIECE AT AROUND 12NOON AND DID RELATIVELY WELL. BS'S COARSE. PLACED BACK ON VENT ON RETURN FROM RADIATION.\nGI; TF'INGS RESTARTED WITH CORRECT SOLUTION. TOL. WELL. 25CC RESIDUALS. NO STOOL.\nRENAL; ADEQUATE U/O'S.\nNEURO; CONFUSED. ORIENTATED TO SELF. MAE.\nCV: HEMODYNAMICALLY STABLE.\nONCOLOGY: PT. TO FOR MAPPING AND THEN TO RADIATION THERAPY WHERE WE SPENT 3HRS. PT. UNDERWENT TX WITHOUT PROBLEMS. MEDICATED WITH DILAUDID X3 TODAY WITH GOOD EFFECT.\nID: FEBRILE TO 100.8PO. YEAST IN URINE. NEED TO CHANGE FOLEY THIS EVENING AND OBTAIN NEW URINE SAMPLES. CONT. ON ANTIBIOTICS. AWAITING CX RESULTS.\nENDOC: LYTES REPLETED THIS AM.\nCOAGS: PTT SENT AT AROUND 12:30PM-TOO LITTLE BLOOD IN TUBE???? SENT ANOTHER PTT ON RETURN TO UNIT. PRESENTLY HEPARIN AT 1450U/HR.\nHEM; HCT STABLE AT 25. PLAN TO TRANSFUSE IF 21.\nSOCIAL; NO CONTACT WITH BROTHER TODAY.\nPLAN: CHANGE FOLEY-SENT CX.\nVANCO LEVEL IN AM.\nCHECK PTT RESULTS.\nRADIATION PLANNED FOR 14PM TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-12 00:00:00.000", "description": "Report", "row_id": 1662442, "text": "Nursing Event Note:\n\nat 0140 pt found to be cyanotic on 70% trach collar w/ copious secretions via trach and orally, pt was slumped down in bed and was pulling at foley cath and spo2 probe off. pt suctioned for copious white thick and pt was pulled up in bed and RRT present and pt placed back on ventilator. pts color improved and sats 96-100. 2mg ativan IV prn given. pt resting comfortably at present.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-14 00:00:00.000", "description": "Report", "row_id": 1662455, "text": "Shift Note: 0700-1900\nNeuro: MS continue to improve. Pt received several doses of ativan overnoc and initially very sedated though pt w/ increasing alertness t/o shift. Now opens eyes spontaneously, follows commands, and mouths word \"hospital\" when asked where he is. Able to make needs known. Bilat wrist restraints remain in place for pt's safety as ordered. receiving dilaudid 2mg IV q3-4hr PRN as ordered for pain w/ good effect as pt denies pain between doses. Remains calm and relaxed t/o shift.\n\nResp: Pt trached and vented - requires no sedation. Initially on AC now CPAP/PS w/ settings weaned to FiO2 50%. Much fewer secretions today. SpO2 remains 96-100%. Pt remains free of s/s resp distress t/o shift. Remains afebrile, continues gent/meropenem/vanc as ordered w/ flagyl PO for C-Diff. ANC 330 today - continues w/ neutropenic precautions, neupogen and fluconazole started. BBS relatively clear t/o shift. Plan for next XRT 1400 tomorrow. Plan for BAL this afternoon.\n\nCV: HR 50's to 70's, SB to SR w/ no appreciable ectopy. SBP remains 100's to 120's. Facial edema continues to improve as above - pt continues on decadron as ordered. Continues on heparin per protocol as ordered. Last PTT 101.6 and dose decreased to 1300 units per protocol, next PTT due at .\n\nFEN: Received pt w/ TF at goal rate though high residuals this am. Abdomen obese, non-tender w/ BS hypoactive. TF residuals remain elevated t/o shift and feeding remain on hold. Team aware. FSBS w/ SSI coverage. Foley catheter patent and draining clear yellow urine w/ UOP 100-200ml/hr. Lytes repleated as ordered.\n\nSocial: Brother, fiance and sister in-law arriving presently to visit. Update on pt status and POC. Goals have been to tx pt to enable D/C home w/ palliative care though pt remains full code at this time. Team to address code status w/ family today.\n\nPlan: Continue to monitor VS and labs as ordered. Continue abx as ordered. Neutropenic precautions. Pt to continue XRT as ordered tomorrow. Monitor MS and continue dilaudid as ordered for pain management w/ ativan PRN for - though pt has not required any ativan doses today. Continue support for pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-14 00:00:00.000", "description": "Report", "row_id": 1662456, "text": "Nursing Progress Note:\nFamily conference w/ , and , and brother, fiance and sister-in-law. Family updated on pt status and POC. Family concerns addressed. Family verbalizes understanding that disease process is not cureable. Current plan to continue w/ agressive treatments w/ goals for D/C to home. Pt to continue daily XRT tomorrow and continue current treatment regimen w/ plan for repeat family meeting later in week with medicine and oncology present. Pt remains full code at this time. Family denies any further questions or concerns at this time and very appreciative of care.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-14 00:00:00.000", "description": "Report", "row_id": 1662457, "text": "Respiraoty care\npt weaned from a/c to cpap/psv tol well, plan to travel to xrt tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-15 00:00:00.000", "description": "Report", "row_id": 1662458, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 104/49-136/59. SB/SR WITH HR RANGING FROM 50-60, NO ECTOPY OBSERVED. PPP BILAT. PT DOES HAVE + PERIPH EDEMA. FACIAL EDEMA HAS IMPROVED IN THE PAST SEVERAL DAYS WITH THE DECADRON Q8HR. HEPARIN HAD INFUSED AT 1300 UNITS HR UNTIL 0600 WHEN IT WAS DECREASED TO 1150UNITS HR FOR A PTT OF 103. NEXT PTT DUE AT 1200. ANC WAS 330 YESTERDAY WHICH WAS DOWN FROM 1200 PREVIOUS DAY AND IS NOW ON NEUPOGEN AND FLUCONAZOLE AND REMAINS ON NEUTROPENIC PRECAUTIONS.\n\nRESP: TRACH WITH CPAP AT 50%/. SX Q2-3HR FOR MOD AMTS OF THICK WHITE SPUTUM. PT HAS COUGH WITH SX AND FACE TURNS RED. DURING THE DAY YESTERDAY PT DID NEBS TO HELP WITH COUGH. SAO2 HAS REMAINED 96-100%. LUNGS HAVE REMAINED CLEAR. PT DOES HAVE YELLOW DRAINAGE AROUND THE TRACH SITE.\n\nNEURO: PT HAS HAD NO ATIVAN THROUGHOUT THE SHIFT. HAS HEAD APPROPRIATELY IN RESPONSE TO QUESTIONS AND HAS FOLLOWED SIMPLE COMMANDS. DOES MOUTH WORDS. MED X3 FOR C/O NECK AREA PAIN WITH DILAUDID 2MGIV WITH GOOD EFFECT NOTED. NO CONFUSION NOTED. AFFECT FLAT.\n\nGU/GI: FOLEY CATH PATENT DRAINING ADEQUATE AMTS OF AMBER URINE. TF HAS REMAINED OFF THROUGOUT THE SHIFT AS PT HAS CONT TO HAVE LG AMTS OF BILI. CONN TO LIS AND PT \"YES\" AFTER BEING ASKED IF BELLY FELT BETTER. NO MEASURABLE AMT OF STOOL NOTED. PT IS ON FLAGYL PO FOR C-DIFF.\n\nID: PT REMAINS ON VANCO/MEROPENEM AND GENT. HAS REMAINED AFEBRILE.\n\nENDO: ON SSIC WHICH HAS NOT BEEN NEEDED WITH FSBS 158/130.\n\nSOCIAL: PT HAS A FIANCE. BROTHER IS HCP. FAMILY MEETING HELD YESTERDAY AND PT IS TO BE A FULL CODE.\n\nPLAN: CONT TO MONITOR LABS AND REPLENISH LYTES AS NEEDED. PT WILL GO TO XRT TODAY AT 1400. XRT WILL BE DAILY UNLESS PT HAS SEVERE REACTION AND SWELLING/SECRETIONS INCREASE TOO MUCH. CONT WITH ATB AS ORDERED. DILAUDID FOR PAIN. PROVIDE EMOTIONAL SUPPORT FOR PT AND FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-15 00:00:00.000", "description": "Report", "row_id": 1662459, "text": "Resp Care\nRemains trached and ventilated on pressure support with no remarkable changes overnight. Suctioning thick yellow sputum. Appears comfortable, sleeping most of shift.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-15 00:00:00.000", "description": "Report", "row_id": 1662460, "text": "Mr. is a 61 year old male with subglottal squamous cell carcinoma admitted from OSH. s/p g-tube placement , trached after being intubated for pseudomonas Pneumonia; developed c-diff, treated with Flagyl PO; transferred @ for continued chemotherapy and XRT\n\nNeuro: alert, mouthing words. received dilaudid IV 2 mgs x 1 for neck pain due to swelling with relief; moves all extremities; restraints off, patient very cooperative, not noted to be pulling out his tubes nor PIV's ( mental status clearing ); patient consistently asking when he is going home, verbalizing \" i want to go home, get me out of here\"; however he also wants to continue with XRT and goals is to treat the tumor. Takes naps intermittently, most of the day watching TV show\n\nCV: hemodynamically stable despite intermittent bradycardia 48-56, SR without ectopy; denies any chest pain, pedal pulses easily palpable. Swelling of neck area noted, no peripheral edema noted. Double lumen midline @ R antecubital with small bleeding at site during dressing change. received 2 gms of calcium gluconate this am as replacement for Ca of 7.7\n\nRespi: received on PS 5/5 50% FiO2, switched to trache mask 50% @ 10 lpm sats > 95% lung osunds coarse, strong cough able to expectorate moderate amount of white frotty secretions. given 40 mgs of lasix for pleural effusion noted CXR; denies SOB, patient desatted low 80's but bump up on its own during XRT\n\nGI: started on tube feeds ( nutren pulmonary with beneprotein ) @ 15cc/hr after no residuals noted and no bilious drainage per G-tube; Tube feeds goal 55cc/hr. intermittent suctioning dc'd at 0800; bowel sounds present, non-tender abdomen.\n\nGU: put out 1L after the lasix was given, + 1L LOS and - 1L since MN\n\nID: on neutropenic precaution, WBC 1.1, afebrile T max 98.1 continues on Vancomycin, meropenem, gentamycin and flagyl. Dexamethasone dc'd today. Gentamycin dose increased from 80 mgs to 100mgs; For gentamycin Peak level tomorrow 30 mins after morning dose is given. ID following patient.\n\nOnc: came and talked with patient regarding therapy and goal, paln of care; G-CSF still low ( 480 mcg ) will contimue chemotherapy once level has recovered, goal > 2000mcg; received his 3rd XRT today; radiation dept will call in am for the next schedule. XRT started last thurday.\n\nEndo: on RISS, coverage given @ nootime for FS 172; ISS adjusted with patient starting on tube feeds.\n\nSkin: weeping edema noted Right LFA, moderate amount of serous drainage noted, contained with pedia collection bag.\n\nSocial: Team till talk with HCP ( patient's brother ) and fiance regarding patient's wishes; brother phone this pm, no calls after that. No family visits today. Patient consistently verbalizing to get out of the hospital \" im tired of being here \" Per oncology that it is not feasible for patient to go home until hospice care is arranged; with patient's set goal he does not want hospice.\n\nplan:\n\nkeep on trache mask as t\n" }, { "category": "Nursing/other", "chartdate": "2111-06-09 00:00:00.000", "description": "Report", "row_id": 1662431, "text": "Resp Care\nPt was tranfered from OHS trached with # 8.0 portex trach. He was placed on same settings as OSH PSV 15/5. BLBS course, suctioned for sm amt thick white secretions. Plan to continue on vent support and wean settings as toelrated.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-28 00:00:00.000", "description": "Report", "row_id": 1662515, "text": "Shift note: 0700-1900\nNeuro: Pt initially sedated s/p receiving ativan and haldol over noc. LOC improved t/o shift w/ pt increasingly restless this afternoon. Pt has remained OX1 only and increasingly pulling against soft and reaching for tubes and lines. Continues w/ 1:1 at all times for safety. Per psych recommendations ativan has been D/C'd and pt ordered for haldol PRN. Given haldol 1mg IV X 1 w/ good effect, pt now resting quietly in bed, somewhat less restless. Has denied pain t/o shift.\n\nResp: Trached, FiO2 35% via TM. Coninues w/ copious amounts of thick white secretions requiring snx q1-2hr. BBS CTA to somewhat diminished at bilat bases. Sputum cx sent as ordered.\n\nCV: HR 90's to 1teens, SR to ST w/ no appreciable ectopy. BP remains stable. Hct remains stable. Pt continues on heparin gtt, titrating according to SS. Next PTT due at .\n\nFEN: Pt tolerating TF at goal rate w/ minimal residuals. Abd soft, non-tender w/ BS present. Foley catheter patent and draining clear yellow urine. FSBS remains stable and has not required SSI coverage this shift. Pt w/ mod loose brown BM X 2 this shift - guiac negative. Specimen sent as ordered. UA specimen sent as ordered.\n\nSocial: Brother, sister-in-law and fiance in to visit. Updated on pt status and POC.\n\nPlan: Continue to monitor VS and labs. Continue agressive pulmonary toilet. Continue heparin gtt as orderd. Continue w/ bilat soft and 1:1 at bedside at all times for pt safety.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-29 00:00:00.000", "description": "Report", "row_id": 1662516, "text": "NPN 1900-0700\nNeuro: Agitated early in shift, oriented only to self. Rec'd 1mg Haldol. Slept for ~ 4h then alert, cooperative. Speech clear. Continues to be frequently confused. Afebrile\n\nCV: NSR-ST, stable BP's. Denies CP/palps. AM Hct 39.0. Awaiting PTT results for Heparin gtt rate.\n\nResp: RR in 8-teen's, sats 100% on 35%. LS coarse to clear in upper lobes, diminished at bases. Decreased need for suctioning this shift.\n\nGI/Endo: RISS, see Carevue. No Nutramen Pulm with Beneprotein available, pt rec'd Nutren pulm FS overnight. Abd s/nt/nd, very small hard BM x1.\n\nGU: patent foley continues to drain clear yellow urine @ ~ 65cc/hr\n\nSkin: Trach wound yellow at base, swab taken, dressing changed.\n\nPlan: Monitor and support resp status.\n Reorient, 1:1 . OOB to chair if poss today. Haldol prn\n Monitor Hct, PTT for Heparin gtt.\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-29 00:00:00.000", "description": "Report", "row_id": 1662517, "text": "Resp Care,\nPt. remains on 35% trach collar. C&R/suctioned for thick tan sputum. MDI's as ordered. Sputum amount decreased.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-29 00:00:00.000", "description": "Report", "row_id": 1662518, "text": "Respiratory Care:\nPt becomes ?? confused at times and demands to go home.. but is more often lucid. Secretions have not been a problem but needs watching. Had an XRT Tx this PM.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-09 00:00:00.000", "description": "Report", "row_id": 1662432, "text": "NPN 1800-1900\n Patient arrived from hospital in @ 1800. C/o feeling like he was choking. Sx frequently for mod amt thin white secretions from back of throat & trach (in-line). Medicated w/4mg IV morphine for c/o neck pain with some relief. RR 8-30's O2 sat 94-97% on CPAP with FiO2 40%/PS 15/ PEEP 5. New peripheral IV placed R forearm #20. Came w/ R upper arm IV #20 near axilla, placed . See flowsheet for vs & assessment. Fingers white-used forehead for O2 sat.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 1662433, "text": "Resp Care\nPt. received trached with #8 Portex, orignally on PSV mode. Pt. has episodes of rapid shallow breathing followed by 20-30secs of apnea.Possibly from pain/anxiety. Placed on MMV with target volume 6LPM. Mechanical breaths noted infrequently.\nBS:dim. equal bilat. sxn'd for mod-copious thick white. Multilobar pna/MD.\nPlan: Cont. support.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 1662434, "text": "MICU Nursing Progress Note 1900-0700\n\nCode: Full\nAllergies: NKDA\n\nPt is a 61 year old male with history of ETOH abuse, smoking, supraglottic SCC stage , initailly admitted to OSH on for g-tube placement (pt with impaired swallow due to mass). Course complicated by ETOH withdrawal, respiratory failure requiring intubation and later tracheostomy, CDIFF infection, and pseudomonas PNA. Pt also noted to have drop in HCT (transfused 2 units PRBC) with unclear etiology. Recently began chemotherapy, while on floor became tachypneic and hypoxic, short course in ICU. Transferred from hospital for emergent XRT and chemo, and management of bilateral IJ clots.\n\nEvents: Started on heparin gtt, CT for contrast scan of head/neck/chest to eval mass, ECHO to be done this AM.\n\nNeuro: Pt alert, unable to assess orientation. Pt attempting to communicate needs by writing on board however at times illegible. Able to MAE, following commands consistently. Pt complaining of pain to neck area, receiving 1mg Dilaudid with desired response. Also receiving fentanyl/ativan for periods of agitation. CT results pending.\n\nCV: HR NSR 70-80 with no ectopy noted, EKG done with no abnormalities noted, NBP 120-140/60s, AM HCT 27.9 will discuss with team transfusion threshold. Heparin gtt started for bilateral IJ clots, currently infusing at 1000 units/hr, AM PTT 58.7, next due at 1000. Pt febrile, however temperature trending downward. Skin warm and dry. Peripheral pulses palpable.\n\nResp: Pt trached with #8 portex (extra cannula in room), vent settings as follows MMV 50%/+5/PS15, STV 500, MV , RR 20's with sats >95%. Suctioned frequently for small to moderate amounts of clear, thick secretions. Lung sounds coarse throughout. CXR revealing multilobar PNA.\n\nGI: BS x 4, no stool this shift. NPO per team, waiting for nutrition consult for TF recommendations. PEG tube patent, placement checked via auscultation. Guiac all stools MD request. Specs needed for culture, CDIFF tests. Pt having liquid stools at OSH, history of impaction.\n\nGU: Foley patent and draining adequate amounts of clear, yellow urine. IVF (NS) @ 150cc/hr. PM K repleted with 40mEq via PEG tube. Will replete AM labs as ordered.\n\nEndo: Ordered for sliding scale, no coverage needed this shift.\n\nID: Tmax 100.6, trending downward. Blood/urine/sputum cultures sent, results pending. Continues on cefepime for PNA, vanco for broad coverage.\n\nSocial: No contact from family overnight.\n\nPlan:\npulmonary toileting\npain management\nfollow up CT results, culture data\nXRT, chemo?\nwean vent as tolerated by pt\nPTT 1000, titrate gtt according to order\nroutine ICU care and monitoring\nsupport to pt and family\n" }, { "category": "Nursing/other", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 1662435, "text": "RESP: BS'S COARSE. SUCTIONED FOR THICK WHITE SECRETIONS Q2=3 HRS. REMAINS ON MMV AT 50%. 5 PEEP 15 PS. CXR SHOWS BIL. PLEURAL EFFUSIONS.\nGI: TF'INGS STARTED AT 15CC/HR WITHOUT THE BENEPROTEIN. HO AWARE. NO STOOL TODAY. BS'S PRESENT.\nRENAL: IVF'S D/C';ED AT 14PM. U/O'S 75-100CC Q2HRS.\nNEURO: ALERT, BUT DISORIENTATED. UNABLE TO GIVE THE RIGHT YEAR AND PLACE, BUT ORIENTATEDTO PERSON.\nCV: HEMODYNAMICALLY STABLE. CARDIAC ECHO DONE. ? RESULTS.\nID: ANTIBIOTICS FOR C-DIFF AND PSEUDOMONAS PNEUMONIA. AFEBRILE. AWAITING CX RESULTS FROM .\nENDOC: MG+ REPLETED AND PHOS.\nCOAGS: PTT THERAPEUTIC. CHECK PTT AT 11PM.\nPAIN CONTROL: MEDICATED WITH 2MG DILAUDID WITH GOOD EFFECT. PT. CAN HAVE UP TO 5MG IF NEEDED.\nONC: ONCOLOGY CONSULT AND RADIATION ONCOLOGY UP TO EVALUATE PT. AWAITING RESULTS OF CHEST AND NECK CT SCAN FROM .\nSOCIAL: BROTHER INTO VISIT AND SPOKE WITH HO'S.\nPLAN: NEEDS STOOL FOR C-DIFF.\nACCESS: 2X PERIPHS. ABLE TO DRAW FROM UPPER ARM PERIPH.\n? OF PICC VS MIDLINE PLACEMENT AT SOME POINT IF NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 1662436, "text": "Resp Care\nPt remains trached with #8.0 portex cuff inflated to 25cm pressure on psv 15/5 50% no vent changes made this shift. BLBS course, suctioned for mod amt thick white secretions, MDIs given per order. Continue current vent support as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-10 00:00:00.000", "description": "Report", "row_id": 1662437, "text": "addendum to the above note: pt with low grade fever. pt oriented x1 only but pleasnt,cooperative and consistently following simple commands. vent settings unchanged. suctione trach for lg amts of thick white sputum. hourly uo via foley remains adequate. continue with present medical management.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-27 00:00:00.000", "description": "Report", "row_id": 1662511, "text": "Shift Note: 0700-1900\nNeuro: Pt alert, confused at times. OOB to chair X 4hr today and tolerated well. Stood and took several steps w/ mod 2 assist. Has been occassionally pulling at tubes and lines, though able to re-orient. Bilat soft- have remained in place for safety. This afternoon pt w/ increasing , and despite frequent orientation, q 15 min checks and bilat soft restaints intact, pt found w/ trach tube lying on chest. Team and RT in and new trach placed w/ difficulty. Denies pain t/o shift.\n\nResp: Event as above. Pt continues on FiO2 35% via trach mask, and continues w/ copious amounts of thick white secretions requiring snx ~ q 1hr despite also strong productive for large amounts of thick white secretions. BBS remain clear to somewhat diminshed at bilat bases. SpO2 remains 96-100%. Pt remains afebrile.\n\nCV: HR 70's to 80's, SR w/ no appreciable ectopy. BP stable.\n\nFEN: Abd soft, non-tender w/ BS present. No BM today. Tolerating TF at goal rate w/ minimal residuals. FSBS remain <150 and have not required SSI coverage. Foley catheter patent and draining clear yellow urine.\n\nSocial: Brother and sister-in-law in to visit. Updated on pt status and POC. Very appreciative of care. Social service and palliative care following. Pt is DNR.\n\nPlan: Continue to monitor VS and labs as ordered. Continue w/ soft and 1:1 at all times for safety. Continue aggressive pulmonary toilet. Increase activity as tolerated. XRT to resume on Monday for 3 more treatments. Anticipate additional chemo dosing early this week. Continue support for pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-28 00:00:00.000", "description": "Report", "row_id": 1662512, "text": "NPN 1900-0700\nDNR/DNI NKDA Contact precautions for \nPt is a 61 yo M w/ Stage IV large supraglottic SCC tumor (dx ), s/p trach and PEG, pseudomonal PNA, at transferred to for resp failure on vent, b/l IJ clots, XRT to shrink tumor burden. PMH includes smoking, ETOH abuse. Also, pt had secondary, false urinary tract/tear which requires catheter placement by urology using cystoscope.\n\nEvent: Pt confused, agitated pulled out trach for second time in 24hrs despite and . New cuffless #7 replaced without difficulty. Pt received Ativan 2mg IV with no effect, Haldol 1mg IV with small effect. After remaining awake and intermittently agitated overnoc--?sundowning--pt received additional 2mg Ativan IV with good effect.\n\nNeuro: Currently resting comfortably. Had been awake/alert and intermittently agitated overnoc. 1:1 and . Tmax 100.0 orally, T current =99.7. Decreased strength noted.\n\nCV: NSR-ST w/o noted ectopy. BP's ranging from 114-146/63-72. Hct dropped to 21.4, pt received PRBC x1 unit. Well tolerated. Current Hct=26.7. Remains on Heparin gtt after DVT on RUE, @ 900units per hour. AM PTT pending.\n\nResp: RR in 20's, sats maintained @ >95% even during trach and O2 removal described above. Frequently deep sxn'd for moderate amts thick white sputum. LS clear to coarse superiorly, diminished at bases b/l.\n\nGI/Endo/GU: Soft abd nt/nd with pos BS, scant amt brown stool this shift, unable to guaic. TF at goal of 55cc, Nutren w/Beneprotein in pt fridge. RISS, no insulin coverage required @ 0000, am lab pending. Patent 3-way foley catheter draining clear, dark yellow urine @ 65+cc/hr.\n\nSkin: CDI, ecchymotic areas noted on UE's b/l.\n\nID: Flagyl 500mg via g-tube TID\n\nLines: PICC patent w/ dressing CDI, #22PIV in L forearm, patent.\n\nSocial: Family left from visit very early in shift. No additional contact.\n\nPlan: Guaiac stool, monitor Hct changes\n Monitor and support respiratory status\n Heparin gtt to continue\n RISS, TF @ 55cc/hr\n Reorient prn, , \n OOB to chair in am\n\n\n" }, { "category": "Nursing/other", "chartdate": "2111-06-28 00:00:00.000", "description": "Report", "row_id": 1662513, "text": "Resp Care,\nPt. remains on 35% trach collar. Pulled trach out early in shift, #7 portex cuffless trach inserted without difficulty by MD. Suctioned for large amounts thick tan blood tinged sputum. MDI's as ordered. Appears confused at times.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-28 00:00:00.000", "description": "Report", "row_id": 1662514, "text": "resp. care\npt. remains trached and on 35% trach mask. still sx'ing\nlarge amts. secretions. mdi's given. continue trach mask.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 1662487, "text": "Event Note:\nAt start of shift pt very agitate and restless. Oriented X 2, reporting date \".\" Pt able to speak w/ hoarse voice and trach noted to be coming out. Bilat soft wrist-restraints were in place at that time. RT to bedside, though unable to advance trach. Dr. to bedside and also unable to advance trach. Dr to bedside and unable to visualize trachea via bronch, trach changed and confirmed via bronch and end-title CO2. Pt medictated w/ Hydromophone 2mg IV prior to trach change. Pt tolerated procedure well. Now resting quielty in bed, free of distress. Lethargic though no longer agitated.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 1662488, "text": "resp care - Pt followed for routine trach care and bronchdilator MDI therapy. This AM, pt's trach was protruding from the stoma and was not able to be reinserted. Bronch was unable to determine cause due to poor visual image. New #8 Portex trach was inserted w/o incident. Cuff is down. Pt traveled to radiation therapy and IR without incident. Meds were given as ordered. Pt has strong, productive , but also required suctioning x3. Continued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 1662489, "text": "Shift Note: 1900-0700\nNeuro: Pt continues to be very restless and agitated t/o shift, reaching towards trach and pulling at tubes and lines despite bilat soft-wrist restraints. Remains alert, OX2-3 though very poor short term memory. Mouthing words, shaking and nodding head and able to make needs known. Pt now w/ 1:1 r/t continuous restlessness, and pulling at tubes and lines. Continues w/ bilat soft wrist restraints as ordered for safety.\n\nResp: Event requiring trach change at start of shift per previous note. Continues on TM, FiO2 35%. BBS course to diminshed at bases. Continues coughing up large amounts of thick white mucus, and continues to require frequent tracheal snx. Pt to XRT today and Mid line placed in IR. T-max 99.2 axillary, continues on abx as ordered. Plan for chemo tomorrow. Consent tubed to 7F RN and Dr. to leave chemo orders on 7F for oncology RN.\n\nCV: HR 90's to 1 teens, remains SR w/ no appreciable ectopy. BP remains stable. No significant change in edema today compared w/ yesterday.\n\nFEN: Pt remains hyponatremic. Continues w/ minimal free water intake and continues w/ UOP >100ml/hr. PM lytes w/ Na up to 130, K 4.5. Tolerating TF at goal rate w/ minimal residuals.\n\nSocial: Palliative care and social services in on consult. Family meetings today w/ social services and discussed care options in the setting of patients status. Code status discussed and subsequent family meeting w/ Dr. took place to address pateints condition and plan of care, as well as code status. Goals for continued treatment regimen, pt to remain full code at this time, though discussion and support ongoing. Family verbalizes understanding, denies any further questions, and very appreciative of care.\n\nPlan: Monitor VS, and labs as ordered. Continue pulm toilet. Continue skin care measures. Continue abx, XRT and chemo as ordered. 1:1 and bilat soft wrist restraints for safety. Continue support for patient and family. Palliative care and social services following.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-23 00:00:00.000", "description": "Report", "row_id": 1662490, "text": "NPN 7P-7A\nPLEASE SEE CAREVIEW FOR OBJECTIVE DATA\n\nEVENTS: PT. NOW HAS 1:1 FOR CONTINUED . PT. PULLED OUT TRACH YESTERDAY, WHICH HAD TO BE REPLACED WITH BRONCHOSCOPY AS MD'S UNABLE TO MANUALLY REPLACE WITHOUT VISUALIZATION. PT. RESTARTED RADIATION YESTERDAY AND WILL START CHEMOTHERAPY TODAY.\n\nNEURO: PT. A+0X3. REMAINS AGITATED AND RESTLESS. ATTEMPTS TO CLIMB OOB, GRAB TUBES/TRACH. 1:1 AND BILAT WRISTS RESTRAINED. PT. MEDICATED WITH HALDOL 5MG X1 AND ATIVAN 4MG X1 WITH LITTLE EFFECT.\n\nRESP: PT. REMAINS TRACHED. ON 35% ATC. BREATH SOUNDS COARSE. DIMINISHED IN BASES. SUCTIONED FOR LG. AMOUNTS OF THICK YELLOW/WHITE SPUTUM. AREA REMAINS RED/SWOLLEN. UNCHANGED FROM PREVIOUS ASSESSMENTS.\n\nCV: PT. NSR/ST. NO ECTOPY NOTED. SBP HIGH 90'S TO LOW 120'S. + PULSES. TMAX 99.3 AXILLARY. SODIUM REMAINS LOW. FREE WATER BOLUSES DC'D YESTERDAY.\n\nGI: PT. WITH PEG. TFEEDS AT GOAL RATE OF 55CC/HR. TOLERATING WELL. ABD. SOFT. BS+. NO BM THIS SHIFT.\n\nGU: FOLEY IN PLACE DRAINING CLEAR YELLOW URINE. GOOD OUTPUT.\n\nACCESS: R UA PICC PLACED IN IR YESTERDAY\n\nPSYCHOSOC: FAMILY MEETING LAST EVENING WITH DR. (ONCOLOGY ) AND PALLIATIVE CARE. PT.'S FAMILY DISCUSSED CODE STATUS AND PT.'S PROGNOSIS WITH MD'S. HIS TIME HE REMAINS A FULL CODE.\n\nPLAN: CONTINUE WITH CURRENT POC. PT. TO HAVE CHEMO/RADIATION THERAPY TODAY. CONTINUE WITH ANTIBIOTICS FOR CDIFF. MONITOR RESP/HEMODYNAMIC STATUS CLOSELY. 1:1 AT ALL TIMES. FULL CODE. AM LABS PENDING.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-23 00:00:00.000", "description": "Report", "row_id": 1662491, "text": "ADDENDUM TO NPN 7P-7A\nAT 0400, NO URINE IN METER. ATTEMPT MADE TO FLUSH FOLEY CATHETER UNSUCCESSFUL. FOLEY REMOVED WITH LARGE CLOT NOTED AT TIP OF CATHETER, OBSTRUCTING THE TIP. LARGE AMOUNT OF URINE NOTED AFTER REMOVAL. ATTEMPT MADE BY 2 RN'S TO REPLACE FOLEY CATHETER. UNSUCCESSFUL. SOME BLOOD NOTED WITH ATTEMPTS. MD'S AWARE. TO CONSULT UROLOGY TO PLACE NEW CATHETER THIS AM.\n" }, { "category": "Nursing/other", "chartdate": "2111-06-23 00:00:00.000", "description": "Report", "row_id": 1662492, "text": "Resp Care\nMr. remains on 35% trach collatr. Breath sounds mostly clear. Given alubteral and atrovent inhalers via trach. Suctioned for large amounts of thick when sputum\n\n" }, { "category": "ECG", "chartdate": "2111-06-22 00:00:00.000", "description": "Report", "row_id": 225655, "text": "Sinus tachycardia. Otherwise, normal tracing. Since previous tracing\nof sinus tachycardia is now present.\n\n" }, { "category": "ECG", "chartdate": "2111-06-09 00:00:00.000", "description": "Report", "row_id": 225656, "text": "Baseline artifact\nSinus rhythm\nLow limb lead QRS voltages - is nonspecific and may be normal variant\nOtherwise baseline artifact makes assessment difficult\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Physician ", "chartdate": "2132-08-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 690871, "text": "Chief Complaint:\n Primary Care Physician: , \n .\n Chief Complaint: trach fell out.\n HPI:\n Pt is a 65 y.o male with h.o severe OSA (central and peripheral), who\n is usually trached with cannula who presents after trach\n had not been in place for a few days. Pt ordinarily changes his trach\n by himself q3months. However, on this occasion, it was too difficult to\n replace and now the trach has been off for a few days. Pt did go to\n local ER yesterday (), but he was unable to have the trach\n replaced and was noted to have significant granulation tissue at the\n stoma site.\n .\n In the ED, initial vs were: T P BP R O2 sat.\n + 17:15 0 98.4 68 146/94 20 96\n IP was consulted and observed that ordinarily pt needs to close the\n stoma to talk and now can talk without closing the stoma. IP suggests\n bipap overnight. If pt required intubation, the cuff would have to be\n placed below the stoma. IP is planning to do a rigid bronch tomorrow to\n either revise the stoma vs. place a T-tube.\n .\n Pt states that over the last few months, he has noticed increased\n difficulty when changing his trach every 4-6months. This week, pt\n noticed increased difficulty when changing his trach, a few days ago,\n he also noticed that something did not feel right after he coughed and\n eventually the tube feel out and pt was unable to replace it. In\n addition, pt states he has had a multiple revisions and was told there\n is a great deal of scar tissue at the site. He has not tolerated bypap\n in the past and states he uses 4L at tM at night at baseline.\n On the floor, pt feels well. He denies SOB/PND, fever/chills, CP/palp,\n URI/cough, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria, skin rash,\n +chronic b/l ankle pain. However, pt reports that he has been unable to\n sleep for the last 3 days trach malfunction, he has been sleeping\n upright and did awake with an am headache yesterday. In addition, he\n reports palp ~1months ago, with a reportedly negative w/u.\n .\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 Glucosamine-Chondroitin 250 mg-200 mg Cap\n Advair Diskus 500 mcg-50 mcg/Dose for Inhalation\n 1 puff Twice a day\n Salmon Oil-1000 1,000 mg-200 mg Cap\n Multivitamins Chewable Tab\n Ventolin 5 mg/mL (0.5 %) Neb Solution\n 1 Puff As neded\n Levothyroxine 125 mcg Tab\n 1 Tablet(s) by mouth\n Rhinocort Aqua 32 mcg/Actuation Nasal Spray\n 1 Puff Twice a day\n Ipratropium Bromide 0.03 % Nasal Spray Aerosol\n 1 As needed\n Past medical history:\n Family history:\n Social History:\n -obstructive and central sleep apnea-dx\n 20 years ago s/p uvulopalatopharyngoplasty, multiple\n attempts with CPAP,tracheostomy eight years ago.\n -hypothyroid\n -OA\n -asthma\n sister with DM.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: works in sales, selling sheet metal. He lives with his wife,\n drinks 1 ETOH drink daily, denies any w/d symptoms or seizures, denies\n drug use.\n Review of systems:\n Flowsheet Data as of 11:22 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: 70 (70 - 76) bpm\n BP: 145/77(93) {145/77(93) - 145/77(93)} mmHg\n RR: 18 (18 - 24) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 87%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 140 105 16 95 AGap=12\n 4.1 27 0.9\n estGFR: >75 (click for details)\n 92\n 7.1 15.8 219\n 48.3\n N:52.9 L:34.9 M:7.2 E:4.1 Bas:0.9\n PT: 12.1 PTT: 26.5 INR: 1.0\n Imaging: echo :Suboptimal image quality. The left atrium is\n mildly dilated. No atrial septal defect is seen by 2D or color Doppler.\n Left ventricular wall thickness, cavity size, and global systolic\n function are normal (LVEF>55%). Due to suboptimal technical quality, a\n focal wall motion abnormality cannot be fully excluded. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is mildly dilated. 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. The pulmonary artery systolic pressure\n could not be determined. There is no pericardial effusion.\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar.\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management\n ICU Care\n Nutrition: npo after mn\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: n/a\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU o/n\n" }, { "category": "Physician ", "chartdate": "2132-08-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 690873, "text": "Chief Complaint:\n Primary Care Physician: , \n .\n Chief Complaint: trach fell out.\n HPI:\n Pt is a 65 y.o male with h.o severe OSA (central and peripheral), who\n is usually trached with cannula who presents after trach\n had not been in place for a few days. Pt ordinarily changes his trach\n by himself q3months. However, on this occasion, it was too difficult to\n replace and now the trach has been off for a few days. Pt did go to\n local ER yesterday (), but he was unable to have the trach\n replaced and was noted to have significant granulation tissue at the\n stoma site.\n .\n In the ED, initial vs were: T P BP R O2 sat.\n + 17:15 0 98.4 68 146/94 20 96\n IP was consulted and observed that ordinarily pt needs to close the\n stoma to talk and now can talk without closing the stoma. IP suggests\n bipap overnight. If pt required intubation, the cuff would have to be\n placed below the stoma. IP is planning to do a rigid bronch tomorrow to\n either revise the stoma vs. place a T-tube.\n .\n Pt states that over the last few months, he has noticed increased\n difficulty when changing his trach every 4-6months. This week, pt\n noticed increased difficulty when changing his trach, a few days ago,\n he also noticed that something did not feel right after he coughed and\n eventually the tube feel out and pt was unable to replace it. In\n addition, pt states he has had a multiple revisions and was told there\n is a great deal of scar tissue at the site. He has not tolerated bypap\n in the past and states he uses 4L at tM at night at baseline.\n On the floor, pt feels well. He denies SOB/PND, fever/chills, CP/palp,\n URI/cough, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria, skin rash,\n +chronic b/l ankle pain. However, pt reports that he has been unable to\n sleep for the last 3 days trach malfunction, he has been sleeping\n upright and did awake with an am headache yesterday. In addition, he\n reports palp ~1months ago, with a reportedly negative w/u.\n .\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 Glucosamine-Chondroitin 250 mg-200 mg Cap\n Advair Diskus 500 mcg-50 mcg/Dose for Inhalation\n 1 puff Twice a day\n Salmon Oil-1000 1,000 mg-200 mg Cap\n Multivitamins Chewable Tab\n Ventolin 5 mg/mL (0.5 %) Neb Solution\n 1 Puff As neded\n Levothyroxine 125 mcg Tab\n 1 Tablet(s) by mouth\n Rhinocort Aqua 32 mcg/Actuation Nasal Spray\n 1 Puff Twice a day\n Ipratropium Bromide 0.03 % Nasal Spray Aerosol\n 1 As needed\n Past medical history:\n Family history:\n Social History:\n -obstructive and central sleep apnea-dx\n 20 years ago s/p uvulopalatopharyngoplasty, multiple\n attempts with CPAP,tracheostomy eight years ago.\n -hypothyroid\n -OA\n -asthma\n sister with DM.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: works in sales, selling sheet metal. He lives with his wife,\n drinks 1 ETOH drink daily, denies any w/d symptoms or seizures, denies\n drug use.\n Review of systems:\n Flowsheet Data as of 11:22 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: 70 (70 - 76) bpm\n BP: 145/77(93) {145/77(93) - 145/77(93)} mmHg\n RR: 18 (18 - 24) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 87%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 140 105 16 95 AGap=12\n 4.1 27 0.9\n estGFR: >75 (click for details)\n 92\n 7.1 15.8 219\n 48.3\n N:52.9 L:34.9 M:7.2 E:4.1 Bas:0.9\n PT: 12.1 PTT: 26.5 INR: 1.0\n Imaging: echo :Suboptimal image quality. The left atrium is\n mildly dilated. No atrial septal defect is seen by 2D or color Doppler.\n Left ventricular wall thickness, cavity size, and global systolic\n function are normal (LVEF>55%). Due to suboptimal technical quality, a\n focal wall motion abnormality cannot be fully excluded. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is mildly dilated. 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. The pulmonary artery systolic pressure\n could not be determined. There is no pericardial effusion.\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar.\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management\n ICU Care\n Nutrition: npo after mn\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: n/a\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU o/n\n ------ Protected Section ------\n Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA\n General: Alert, oriented, no acute distress, occasional sounds of air\n from trach.\n HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD, +trach site with granulation\n tissue, pink mucosa, no drainage/C/D/I.\n Lungs: b/l ae +crackles at bases, no w/r\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n ------ Protected Section Addendum Entered By: , MD\n on: 23:42 ------\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 690963, "text": "Chief Complaint: trach malfunction\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65M with OSA, trach malfunction at home (fell out and could not be\n replaced), presents to MICU for airway monitoring in anticipation of\n rigid bronch and stoma repair\n 24 Hour Events:\n -stable overnight; no events\n -on trach mask, no cpap\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n synthrooid, mvi, atrovent, advair, colace\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:07 AM\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: 61 (55 - 76) bpm\n BP: 106/70(78) {106/64(77) - 147/80(93)} mmHg\n RR: 16 (12 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 1,800 mL\n Urine:\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 240 mL\n -1,800 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 15.7 g/dL\n 219 K/uL\n 110 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 107 mEq/L\n 142 mEq/L\n 46.3 %\n 6.4 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 6.4\n Hct\n 46.3\n Plt\n 219\n Cr\n 0.8\n Glucose\n 110\n Other labs: PT / PTT / INR:12.9/27.9/1.1, ALT / AST:34/32, Alk Phos / T\n Bili:58/0.9, Differential-Neuts:48.9 %, Lymph:36.8 %, Mono:8.8 %,\n Eos:4.4 %, Albumin:4.4 g/dL, LDH:184 IU/L, Ca++:9.3 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Imaging: cxr - clear\n Assessment and Plan\n 65M with severe osa, s/p trach for 15 yrs, presents with trach\n dislodgement, awaiting procedure by IP for stoma revision. Pt did well\n overnight without bipap.\n osa\n -awaiting IP procedure\n asthma\n -cont advair\n possible dispo to home after procedure\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2132-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 690964, "text": "65 year old male with severe OSA s/p trach with trach dislodgement. Has\n had trach x 15years the most recent trach type trach x 8\n years.\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 690965, "text": "Chief Complaint:\n 24 Hour Events:\n Pt with trach collar O2 at stoma site overnight.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems: denies\n Flowsheet Data as of 06:37 AM\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: 35.9\nC (96.7\n HR: 60 (55 - 76) bpm\n BP: 135/80(93) {124/64(77) - 147/80(93)} mmHg\n RR: 14 (12 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 1,350 mL\n Urine:\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 240 mL\n -1,350 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA\n General: Alert, oriented, no acute distress, occasional sounds of air\n from trach.\n HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD, +trach site with granulation\n tissue, pink mucosa, no drainage/C/D/I.\n Lungs: b/l ae +crackles at bases, no w/r\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 219 K/uL\n 15.7 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 107 mEq/L\n 142 mEq/L\n 46.3 %\n 6.4 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 6.4\n Hct\n 46.3\n Plt\n 219\n Cr\n 0.8\n Glucose\n 110\n Other labs: PT / PTT / INR:12.9/27.9/1.1, ALT / AST:34/32, Alk Phos / T\n Bili:58/0.9, Differential-Neuts:48.9 %, Lymph:36.8 %, Mono:8.8 %,\n Eos:4.4 %, Albumin:4.4 g/dL, LDH:184 IU/L, Ca++:9.3 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar qhs prn\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management.\n Pending outcome of procedure may be able to go home.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 690930, "text": "Chief Complaint:\n 24 Hour Events:\n Pt with trach collar O2 at stoma site overnight.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\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: 35.9\nC (96.7\n HR: 60 (55 - 76) bpm\n BP: 135/80(93) {124/64(77) - 147/80(93)} mmHg\n RR: 14 (12 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 1,350 mL\n Urine:\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 240 mL\n -1,350 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n Labs / Radiology\n 219 K/uL\n 15.7 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 107 mEq/L\n 142 mEq/L\n 46.3 %\n 6.4 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 6.4\n Hct\n 46.3\n Plt\n 219\n Cr\n 0.8\n Glucose\n 110\n Other labs: PT / PTT / INR:12.9/27.9/1.1, ALT / AST:34/32, Alk Phos / T\n Bili:58/0.9, Differential-Neuts:48.9 %, Lymph:36.8 %, Mono:8.8 %,\n Eos:4.4 %, Albumin:4.4 g/dL, LDH:184 IU/L, Ca++:9.3 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar qhs prn\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 690931, "text": "Chief Complaint:\n 24 Hour Events:\n Pt with trach collar O2 at stoma site overnight.\n History obtained from Patient\n Allergies:\n History obtained from PatientNo Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:37 AM\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: 35.9\nC (96.7\n HR: 60 (55 - 76) bpm\n BP: 135/80(93) {124/64(77) - 147/80(93)} mmHg\n RR: 14 (12 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 1,350 mL\n Urine:\n 1,350 mL\n NG:\n Stool:\n Drains:\n Balance:\n 240 mL\n -1,350 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA\n General: Alert, oriented, no acute distress, occasional sounds of air\n from trach.\n HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD, +trach site with granulation\n tissue, pink mucosa, no drainage/C/D/I.\n Lungs: b/l ae +crackles at bases, no w/r\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n Labs / Radiology\n 219 K/uL\n 15.7 g/dL\n 110 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 107 mEq/L\n 142 mEq/L\n 46.3 %\n 6.4 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 6.4\n Hct\n 46.3\n Plt\n 219\n Cr\n 0.8\n Glucose\n 110\n Other labs: PT / PTT / INR:12.9/27.9/1.1, ALT / AST:34/32, Alk Phos / T\n Bili:58/0.9, Differential-Neuts:48.9 %, Lymph:36.8 %, Mono:8.8 %,\n Eos:4.4 %, Albumin:4.4 g/dL, LDH:184 IU/L, Ca++:9.3 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar qhs prn\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2132-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 691004, "text": "65 year old male with severe OSA s/p trach with trach dislodgement. Has\n had trach x 15years the most recent trach type trach x 8\n years.\n Obstructive sleep apnea (OSA)\n Assessment:\n On ra with sats 90% or greater. Sitting in cardiac chair. No c/o. stoma\n with leaking of air. Serosanginous dried drainage around stoma. Stoma\n cleansed.\n Action:\n Or called placed on call.\n Response:\n Anethsia and ip fellow up to pick patient up. Transported to or.\n Plan:\n To or for rigid bronch and trach vs t tube placement.\n ------ Protected Section ------\n Returned from or at 1345. Had rigid bronch with stoma revision and\n trach cannula placement. Receivewd a total of 2mg versed, 160mg\n succinylcholine, 150mcgs of fentanyl, 2gm cefazoline, 5mg neostimine,\n 200mg propofol, 7mg vecuronium and 1mg glycopryrolane.\n ------ Protected Section Addendum Entered By: , RN\n on: 14:02 ------\n" }, { "category": "Nursing", "chartdate": "2132-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 690894, "text": "Pt is a 65 y.o male with h/o severe OSA (central and peripheral), who\n is usually trached with cannula who presents after trach\n had not been in place for a few days. Pt ordinarily changes his trach\n by himself q4-6months. However, on this occasion, it was too difficult\n to replace and now the trach has been off for a few days. Pt did go to\n local ER yesterday (), but he was unable to have the trach\n replaced and was noted to have significant granulation tissue at the\n stoma site.\n Pt was seen in the ED by IP, who decided to wait until tomorrow to have\n new one placed, as pt has been stable without it for a few days. Pt\n transferred to MICU for observation overnight.\n On arrival to MICU, pt is alert and oriented x3, pleasant and in good\n spirits. Pt able to ambulate off of stretcher to ICU bed independently,\n w/o SOB. Sats low 90s on RA while awake. Trach collar was placed on pt\n overnight while sleeping, 50% cool mist. Pt normally uses 4.0L of O2\n via trach collar at home only at night. Pt does not tolerate masked\n ventilation. Pt\ns stoma site is clean, small amount of serosang\n drainage from site. No signs of infection. Large amount of granulation\n tissue is seen around the site. Pt has been desatting as low as 70s\n while sleeping, but quickly comes back up to low 90s without\n intervention.\n Plan is for pt to have rigid bronch this am to eval for stoma revision\n vs T-tube placement. Pt has been NPO since MN.\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 691018, "text": "Chief Complaint: trach malfunction\n I saw and examined the patient, and was physically present with the ICU\n Fellow for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 65M with OSA, trach malfunction at home (fell out and could not be\n replaced), presents to MICU for airway monitoring in anticipation of\n rigid bronch and stoma repair\n 24 Hour Events:\n -stable overnight; no events\n -on trach mask, no cpap\n History obtained from Patient\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Other medications:\n synthrooid, mvi, atrovent, advair, colace\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Nutritional Support: NPO\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 09:07 AM\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: 61 (55 - 76) bpm\n BP: 106/70(78) {106/64(77) - 147/80(93)} mmHg\n RR: 16 (12 - 24) insp/min\n SpO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 240 mL\n PO:\n 240 mL\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 1,800 mL\n Urine:\n 1,800 mL\n NG:\n Stool:\n Drains:\n Balance:\n 240 mL\n -1,800 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ///26/\n Physical Examination\n General Appearance: Well nourished, Overweight / Obese\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : )\n Abdominal: Soft, Obese\n Extremities: Right: Absent, Left: Absent\n Skin: Warm\n Neurologic: Attentive, Responds to: Not assessed, Movement: Not\n assessed, Tone: Not assessed\n Labs / Radiology\n 15.7 g/dL\n 219 K/uL\n 110 mg/dL\n 0.8 mg/dL\n 26 mEq/L\n 4.0 mEq/L\n 16 mg/dL\n 107 mEq/L\n 142 mEq/L\n 46.3 %\n 6.4 K/uL\n [image002.jpg]\n 04:12 AM\n WBC\n 6.4\n Hct\n 46.3\n Plt\n 219\n Cr\n 0.8\n Glucose\n 110\n Other labs: PT / PTT / INR:12.9/27.9/1.1, ALT / AST:34/32, Alk Phos / T\n Bili:58/0.9, Differential-Neuts:48.9 %, Lymph:36.8 %, Mono:8.8 %,\n Eos:4.4 %, Albumin:4.4 g/dL, LDH:184 IU/L, Ca++:9.3 mg/dL, Mg++:2.1\n mg/dL, PO4:3.6 mg/dL\n Imaging: cxr - clear\n Assessment and Plan\n 65M with severe osa, s/p trach for 15 yrs, presents with trach\n dislodgement, awaiting procedure by IP for stoma revision. Pt did well\n overnight without bipap.\n osa\n -awaiting IP procedure\n asthma\n -cont advair\n possible dispo to home after procedure\n ICU Care\n Nutrition:\n Glycemic Control: Blood sugar well controlled\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT: Boots(Systemic anticoagulation: None)\n Stress ulcer: Not indicated\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 50 minutes\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: 65M severe OSA c/b chronic trach, progressive\n stomal narrowing, trach now out and unable to be replaced. Case d/w IP\n team at bedside.\n Exam notable for Tm 97.3 BP 114/60 HR 60 RR 18 with sat 98 on 40%TM.\n Obese man, NAD. Coarse BS B. RRR s1s2. Soft +BS. 1+ edema. Labs notable\n for WBC 6K, HCT 46, K+ 4.0, Cr 0.8. CXR with clear lungs.\n Agree with plan to pursue operative revision of tracheal stoma. Likely\n will require replacement of similar tube post revision, though T-tube\n may also be needed. Will continue remainder of home regimen. Asthma is\n stable without evidence of flare. NPO for now awaiting OR. Remainder of\n plan as outlined above.\n Total time: 50 min\n" }, { "category": "Nursing", "chartdate": "2132-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 691023, "text": "65 year old male with severe OSA s/p trach with trach dislodgement. Has\n had trach x 15years the most recent trach type trach x 8\n years.\n Obstructive sleep apnea (OSA)\n Assessment:\n On ra with sats 90% or greater. Sitting in cardiac chair. No c/o. stoma\n with leaking of air. Serosanginous dried drainage around stoma. Stoma\n cleansed.\n Action:\n Or called placed on call.\n Response:\n Anethsia and ip fellow up to pick patient up. Transported to or.\n Plan:\n To or for rigid bronch and trach vs t tube placement.\n ------ Protected Section ------\n Returned from or at 1345. Had rigid bronch with stoma revision and\n trach cannula placement. Receivewd a total of 2mg versed, 160mg\n succinylcholine, 150mcgs of fentanyl, 2gm cefazoline, 5mg neostimine,\n 200mg propofol, 7mg vecuronium and 1mg glycopryrolane.\n ------ Protected Section Addendum Entered By: , RN\n on: 14:02 ------\n Patient recovered in micu. Order written for d/c. D/c plan gone over\n with patient. To go home on same meds. Urinated postop. No c/o of pain.\n New trach cannulation site clean with scant amounts serosang drainage.\n D/c plan signed by patient and nurse. Copy in placed in chart. Copy\n given to patient. Valuables from security given to patient. Patient\n iv dc\nd. Awaiting a ride.\n ------ Protected Section Addendum Entered By: , RN\n on: 16:30 ------\n" }, { "category": "Nursing", "chartdate": "2132-08-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 690988, "text": "65 year old male with severe OSA s/p trach with trach dislodgement. Has\n had trach x 15years the most recent trach type trach x 8\n years.\n Obstructive sleep apnea (OSA)\n Assessment:\n On ra with sats 90% or greater. Sitting in cardiac chair. No c/o. stoma\n with leaking of air. Serosanginous dried drainage around stoma. Stoma\n cleansed.\n Action:\n Or called placed on call.\n Response:\n Anethsia and ip fellow up to pick patient up. Transported to or.\n Plan:\n To or for rigid bronch and trach vs t tube placement.\n" }, { "category": "Physician ", "chartdate": "2132-08-12 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 690880, "text": "Chief Complaint:\n Primary Care Physician: , \n .\n Chief Complaint: trach fell out.\n HPI:\n Pt is a 65 y.o male with h.o severe OSA (central and peripheral), who\n is usually trached with cannula who presents after trach\n had not been in place for a few days. Pt ordinarily changes his trach\n by himself q3months. However, on this occasion, it was too difficult to\n replace and now the trach has been off for a few days. Pt did go to\n local ER yesterday (), but he was unable to have the trach\n replaced and was noted to have significant granulation tissue at the\n stoma site.\n .\n In the ED, initial vs were: T P BP R O2 sat.\n + 17:15 0 98.4 68 146/94 20 96\n IP was consulted and observed that ordinarily pt needs to close the\n stoma to talk and now can talk without closing the stoma. IP suggests\n bipap overnight. If pt required intubation, the cuff would have to be\n placed below the stoma. IP is planning to do a rigid bronch tomorrow to\n either revise the stoma vs. place a T-tube.\n .\n Pt states that over the last few months, he has noticed increased\n difficulty when changing his trach every 4-6months. This week, pt\n noticed increased difficulty when changing his trach, a few days ago,\n he also noticed that something did not feel right after he coughed and\n eventually the tube feel out and pt was unable to replace it. In\n addition, pt states he has had a multiple revisions and was told there\n is a great deal of scar tissue at the site. He has not tolerated bypap\n in the past and states he uses 4L at tM at night at baseline.\n On the floor, pt feels well. He denies SOB/PND, fever/chills, CP/palp,\n URI/cough, abd pain/n/v/d/c/melena/brbpr/dysuria/hematuria, skin rash,\n +chronic b/l ankle pain. However, pt reports that he has been unable to\n sleep for the last 3 days trach malfunction, he has been sleeping\n upright and did awake with an am headache yesterday. In addition, he\n reports palp ~1months ago, with a reportedly negative w/u.\n .\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 Glucosamine-Chondroitin 250 mg-200 mg Cap\n Advair Diskus 500 mcg-50 mcg/Dose for Inhalation\n 1 puff Twice a day\n Salmon Oil-1000 1,000 mg-200 mg Cap\n Multivitamins Chewable Tab\n Ventolin 5 mg/mL (0.5 %) Neb Solution\n 1 Puff As neded\n Levothyroxine 125 mcg Tab\n 1 Tablet(s) by mouth\n Rhinocort Aqua 32 mcg/Actuation Nasal Spray\n 1 Puff Twice a day\n Ipratropium Bromide 0.03 % Nasal Spray Aerosol\n 1 As needed\n Past medical history:\n Family history:\n Social History:\n -obstructive and central sleep apnea-dx\n 20 years ago s/p uvulopalatopharyngoplasty, multiple\n attempts with CPAP,tracheostomy eight years ago.\n -hypothyroid\n -OA\n -asthma\n sister with DM.\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: works in sales, selling sheet metal. He lives with his wife,\n drinks 1 ETOH drink daily, denies any w/d symptoms or seizures, denies\n drug use.\n Review of systems:\n Flowsheet Data as of 11:22 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: 70 (70 - 76) bpm\n BP: 145/77(93) {145/77(93) - 145/77(93)} mmHg\n RR: 18 (18 - 24) insp/min\n SpO2: 87%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 87%\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Fluid analysis / Other labs: 140 105 16 95 AGap=12\n 4.1 27 0.9\n estGFR: >75 (click for details)\n 92\n 7.1 15.8 219\n 48.3\n N:52.9 L:34.9 M:7.2 E:4.1 Bas:0.9\n PT: 12.1 PTT: 26.5 INR: 1.0\n Imaging: echo :Suboptimal image quality. The left atrium is\n mildly dilated. No atrial septal defect is seen by 2D or color Doppler.\n Left ventricular wall thickness, cavity size, and global systolic\n function are normal (LVEF>55%). Due to suboptimal technical quality, a\n focal wall motion abnormality cannot be fully excluded. Right\n ventricular chamber size and free wall motion are normal. The ascending\n aorta is mildly dilated. 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. The pulmonary artery systolic pressure\n could not be determined. There is no pericardial effusion.\n Assessment and Plan\n Assessment and Plan: Pt is a 65 y.o male with h.o severe OSA\n (central/peripheral) s/p trach who now presents s/p trach dislodgement.\n .\n #airway management-Pt with h.o severe OSA who failed trials of cpap in\n the past. Pt with trach x8 yrs per history. Now, has been a few days\n w/o trach in place and with evidence of granulation tissue and healing\n stoma. IP consulted and recommended MICU observation o/n.\n -monitor for signs of respiratory distress\n -Bypap o/n prn\n -if intubation required, intubate with cuff below stoma.\n -nebs and asthma meds prn\n -IP following, with plans to perform rigid bronch in am to eval for\n stoma revision vs. T-tube.\n -\n -CXR\n -4L via trach collar.\n .\n #OSA-with management as above. Pt with h.o central and peripheral sleep\n apnea. Will attempt to manage with bipap o/n.\n .\n #asthma-home advair, albuterol, ipratropium\n .\n #hypothyroidism-continue home levoxyl\n .\n FEN: NPO o/n, lytes prn\n .\n Prophylaxis: pneumoboots, then hep SC after procedure.\n .\n Access: peripherals\n .\n Code: Full (discussed with patient)\n .\n Communication: Patient\n .\n Disposition: ICU pending stability of airway and OSA management\n ICU Care\n Nutrition: npo after mn\n Glycemic Control:\n Lines:\n 18 Gauge - 10:58 PM\n Prophylaxis:\n DVT: pneumoboots\n Stress ulcer: n/a\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU o/n\n ------ Protected Section ------\n Vitals: T 97.3, BP 145/77, HR 76, RR 18 sat 87-93% on RA\n General: Alert, oriented, no acute distress, occasional sounds of air\n from trach.\n HEENT: nc/at, perrla, Sclera anicteric, MMM, oropharynx clear\n Neck: supple, JVP not elevated, no LAD, +trach site with granulation\n tissue, pink mucosa, no drainage/C/D/I.\n Lungs: b/l ae +crackles at bases, no w/r\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops\n Abdomen: soft, non-tender, non-distended, bowel sounds present, no\n rebound tenderness or guarding, no organomegaly\n GU: no foley\n Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema\n ------ Protected Section Addendum Entered By: , MD\n on: 23:42 ------\n Addendum:\n I have seen and examined the patient with the resident and agree with\n the assessment and plan as detailed above with the following\n emphasis/modifications:\n 65 year old male with severe OSA and chronic trach who attempted to\n change trach on his own (does this routinely) and unable to get back\n in. Despite the tracheal dislodgement, his respiratory status remains\n stable and adequate through the stoma. IP evaluated the patient in the\n ED and plan for rigid bronch tomorrow. Admitted to the ICU overnight\n in anticipation of procedure tomorrow.\n T 97.3 P 76 BP 145/77 RR 18 Sat: 87-93% on RA\n Obese in NAD distress\n - stoma present and air exchange adequate across stoma\n - crackles at bases\n Heart and abdominal exam normal\n CXR: normal\n A: Tracheal Dislodgement\n Plan: IP to perform bronch in AM for eval/therapy\n ------ Protected Section Addendum Entered By: , MD\n on: 00:46 ------\n" }, { "category": "ECG", "chartdate": "2132-08-12 00:00:00.000", "description": "Report", "row_id": 243671, "text": "Sinus bradycardia. No previous tracing available for comparison.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 1344805, "text": "12a-7a\nNeuro: Pt sedated on Propofol overnoc. Intermittent periods of agitation requiring increasing propofol as high as 60mcg/kg/min to keep sedated. With the periods of agitation, pt able to follow commands and mae. Perrla. Morphine IV prn for pain.\n\nCV: HR 60-70s SR No ectopy. SBP 95-130s. Titrating neo to keep SBP\n~120 as MD . See carevue for details. Palpable pulses. Minor ST elevation noted in Leads 2,3,F from 12 lead EKG. MD aware, New order for repeat in EKG in am at 6am. Left radial aline patent and intact. TLC LIJ intact and patent.\n\nResp: LS coarse diminished at bases. On CMV rate at present time. Rate of 14, FiO2 50%, TV 550. See carevue for abgs. Right pleural chest tube in place and intact. + crepitus around chest tube site. MD aware, CXR ordered for am. No air leak. Sats 99-100%.\n\nEndo: Insulin gtt stopped for blood sugar 78. Follow blood sugar per protocol.\n\nGI/GU: Abd soft absent BS. OGT +placement. Draining bilious drainage. Foley draining adequate amts of clear yellow urine.\n\nPlan: Monitor hemodynamics. Monitor respiratory status. Follow blood sugars. Precedex gtt to start in am, ? extubate in am.\n" }, { "category": "Nursing/other", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 1344806, "text": "Resp. Care:\n Pt. remains intubated and on vent. support at this time. Sedation weaned. Pt. agitated. RSBI=68. Changed to PSV/C-PAP mode. See flow sheet for more information.\n" }, { "category": "Nursing/other", "chartdate": "2111-12-22 00:00:00.000", "description": "Report", "row_id": 1344807, "text": "Addendum\nPt tolerated CPAP 5/5 in am. See carevue for ABGS. Pt extubated at 0640, to 70% CMM. Chest PT done. Pt encouraged deep breathng and coughing.\n" }, { "category": "Nursing/other", "chartdate": "2111-12-21 00:00:00.000", "description": "Report", "row_id": 1344802, "text": "~1113 PATEINT ADMITTED FROM OR S/P PFO REPAIR. TEMP 93, BAIR HUGGER ON. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. PSERL. CT'S PATENT FOR MINIMAL SERO-SANG DRAINAGE. NO PACER, NO SWAN. OG IN PLACE, PATENT FOR BILIOUS, PLACCEMENT CHECKED. FOLEY PATENT FOR LARGE AMT CLEAR YELLOW URINE. PALPABLE PULSE. WIFE IN.\nEXPLAINED TO WIFE PLAN, ONCE PATIENT TEMP RISES TO 96 WILL REVERSE AND WEAN TO EXTUBATE.\n" }, { "category": "Nursing/other", "chartdate": "2111-12-21 00:00:00.000", "description": "Report", "row_id": 1344803, "text": "EXTUBATED AT 1610 WITH PROPOFOL AT 20 TO FACE MASK. PROPOFOL STOPPED PRIOR TO EXTUBATION. OG DC'D WITH EXTUABTION. PATIENT SNORING, ^ VENTILATION WITH CHIN LIFT. NASAL TRUMPET IN RT NARES WITH SOME EFFECT. BIPAP ADDED. ABG PH 7.2. DECESION MADE TO INTUBATE. PRIOR TO PATIENT EXTREMELY AGITATED, NOT RESPONDING TO COMMANDS, MAE, THRASHING ABOUT IN BED. SEDATED WITH IV MIDAZ WITHOUT EFFECT, IV HALDOL WITHOUT EFFECT. PATIENT HAS NEVER FOLLOWED COMMANDS, DOES MAE PURPOSEFULLY.\n\nINTUBATED BY ANESTHESIA WITH # 7.5, 21 AT LIP, AWAITING CHEST X RAY. OG REPLACED, PLACEMENT CHECKED BUT WILL BE VERIFIED BY X RAY. SEDATED WITH SUCC. AND ETONOMIDATE PER ANESTHESIA.\n\nWIFE NOTIFIED OF EVENTS BY NP\n" }, { "category": "Nursing/other", "chartdate": "2111-12-21 00:00:00.000", "description": "Report", "row_id": 1344804, "text": "NEURO: MAE AT TIMES, THRASHING IN BED. ~2100 PATIENT ABLE TO SQUEEZE WITH HIS RT HAND AND WIGGLE TOES, WOULD/COULD NOT DO IT WITH LT HAND. OPENED EYES ONCE WHEN I CALLED HIS NAME, APPEARED TO BE LISTENING TO ME BUT THEN CONTINUED TO THRASH ABOUT BED. WIFE IN, NO DIFFERENT WITH HER.\n\nRESP: REINTUBATED, SEE PRIOR NOTE, CHEST X RAY DONE, TUBE ADVANCED 2 CM, NOW 23 AT LIP. SUCTIONED X 1 FOR SCANT WHITE. ? PRECEDEX IN AM AND WEAN TO EXTUBATE.\n\nCARDIAC: MP SR WITHOUT ECTOPY. CT PATENT FOR SMALL AMT SERO-SANG DRAINAGE, NO LEAK. PALPABLE PULSES. IV NEO TO KEEP SB/P ^ 90 OR MAP ^ 60-65\n\nGI: OG REINSERTED WITH INTUBATION. PATENT FOR BILIOUS.\n\nGU: FOLEY IN PLACE, PATENT FOR CLEAR YELLOW.\n\nENDO: INSULIN GTT ^, FOLLOWING PROTOCOL.\n\nWIFE HERE IN WAITING ROOM FOR THE NIGHT, AWARE OF EVENTS AND PLANS.\n" }, { "category": "ECG", "chartdate": "2111-12-21 00:00:00.000", "description": "Report", "row_id": 205232, "text": "Sinus rhythm. Normal ECG. No diagnostic change since the previous tracing\nof .\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2111-12-20 00:00:00.000", "description": "Report", "row_id": 205233, "text": "Sinus rhythm. Normal ECG. No previous tracing available for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2111-12-23 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 892238, "text": " 3:18 PM\n CHEST (PA & LAT) Clip # \n Reason: s/p chest tube removal -r/o PTX\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n\n REASON FOR THIS EXAMINATION:\n s/p chest tube removal -r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, PA AND LATERAL:\n\n Status post removal of right chest tube. Equivocal tiny residual right apical\n pneumothorax. Subcutaneous emphysema in the right chest wall with small\n effusions in both costophrenic sulci. Atelectasis at both lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 891971, "text": " 5:59 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: check ett placement\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p Min Inv Closure of PFO and reintubation\n\n REASON FOR THIS EXAMINATION:\n check ett placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Endotracheal tube placement.\n\n CHEST, ONE VIEW: Comparison with 5 hours prior shows the endotracheal tube is\n unchanged in position approximately 3 cm above the carina. The remainder of\n the tubes and lines are unchanged, other than the NG tube being advanced, and\n now curled within the the stomach. There is interval increase in the right\n subcutaneous emphysema. Stable bibasilar linear atelectasis. No other acute\n changes.\n\n" }, { "category": "Radiology", "chartdate": "2111-12-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 892006, "text": " 4:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated, + crepitus around right chest tube site\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p Min Inv Closure of PFO and reintubation\n\n REASON FOR THIS EXAMINATION:\n intubated, + crepitus around right chest tube site\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:31 A.M. ON \n\n HISTORY: PFO closure.\n\n IMPRESSION: AP chest compared to :\n\n Small right pneumothorax persists despite an apical pleural tube. Small left\n pleural effusion has increased. Atelectasis is present at the base of the\n right lung. Subcutaneous emphysema in the right anterior chest wall is less\n pronounced. ET tube and left internal jugular line are in standard\n placements. A nasogastric tube passes below the diaphragm and out of view.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-21 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 891886, "text": " 12:58 PM\n CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: ptx, effusion\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p Min Inv Closure of PFO\n REASON FOR THIS EXAMINATION:\n ptx, effusion\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of closure of patent foramen ovale.\n\n Endotracheal tube is 3 cm above carina. Left jugular CV line is in left\n brachiocephalic vein. Chest tube is present in right apical region and NG\n tube has tip located in the body of stomach. Linear and discoid atelectases\n are present at the right lung base.\n\n\n" }, { "category": "Radiology", "chartdate": "2111-12-21 00:00:00.000", "description": "CHEST (PRE-OP PA & LAT)", "row_id": 891843, "text": " 12:47 AM\n CHEST (PRE-OP PA & LAT) Clip # \n Reason: AORTIC STENOSIS\n Admitting Diagnosis: AORTIC STENOSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with\n REASON FOR THIS EXAMINATION:\n pre op for CABG\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Preop for CABG.\n\n No prior studies are available for comparison.\n\n PA AND LATERAL CHEST: The heart size is normal. The mediastinal and hilar\n contours are normal. The lungs are clear, without vascular congestion or\n consolidation. There is no pleural effusion or pneumothorax. Osseous\n structures are unremarkable.\n\n IMPRESSION: No evidence of acute cardiopulmonary process.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2192-12-28 00:00:00.000", "description": "SCROTAL U.S.", "row_id": 1163923, "text": " 3:40 PM\n SCROTAL U.S. Clip # \n Reason: Please eval for epididimytis\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old man with scrotal pain and tenderness on L\n REASON FOR THIS EXAMINATION:\n Please eval for epididimytis\n ______________________________________________________________________________\n WET READ: MDAg FRI 5:30 PM\n left epidydimitis.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Left scrotal pain and tenderness.\n\n COMPARISON: No relevant comparison is available.\n\n FINDINGS: The right testicle measures 2.7 x 2.1 x 3.7 cm. The left testicle\n measures 3.0 x 2.0 x 3.8 cm. The testicular echogenicity is normal without\n focal abnormalities. Vascularity is normal and symmetric in the testes\n bilaterally.\n\n The right epididymis is mildly prominent by size with normal blood flow. The\n left epididymis is enlarged with marked hyperemia.\n\n IMPRESSION: Left epididymitis without orchitis.\n\n" }, { "category": "Radiology", "chartdate": "2192-12-28 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1163924, "text": " 3:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for peri-nephric abscess, colitis\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35M p/w abd pain, sepsis\n REASON FOR THIS EXAMINATION:\n eval for peri-nephric abscess, colitis\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old male with abdominal pain and sepsis, question of\n perinephric abscess or evidence of colitis.\n\n COMPARISON: CT abdomen and pelvis from .\n\n TECHNIQUE: 64-row MDCT obtained of the abdomen and pelvis with IV contrast.\n Images obtained from the lung bases through to the proximal femora. Coronal\n and sagittal reformations reviewed alongside axial displays.\n\n FINDINGS:\n CT ABD WITH IV and ORAL CONTRAST:\n This is limited by the patient's marked rotary scoliosis and extensive\n metallic star artifact from the spinal fixation rods. The visualized lung\n bases are clear. The heart and pericardium appear normal. The liver,\n gallbladder, spleen, and pancreas appear unremarkable. The right kidney is\n normal.\n\n There is heterogeneous enhancement of the right kidney worrisome for\n pyelonephritis. There is no perinephric abscess seen. There is enlarged left\n paraaortic lymph node at the hilum of the left kidney measuring 3.4 cm,\n possibly suggestive of reactive lymphadenopathy. Of note, this enlarged lymph\n node was seen in the prior study when patient presented with similar symptoms.\n There is no organized abscess within the kidney or in the perinephric area\n that would be amendable to drainage. The right ureter is tortuous (300b, 29).\n However, it can be traced distally emptying into the bladder. The left ureter\n is not visualized; however, there is no evidence of hydronephrosis to suggest\n obstruction on this current study. Evaluation of intra-abdominal loops of\n bowel with significant star artifact from the hardware. There does not appear\n to be any enhancing wall thickening of the colon to suggest colitis.\n\n CT PELVIS WITH IV CONTRAST: There is no free air or free fluid within the\n pelvis. The bladder wall is circumferentially thickened and unchanged from\n prior consistent with known history of neurogenic bladder. Rectum contains\n stool. The remaining bowel is unremarkable. Numerous enlarged inguinal lymph\n nodes with the largest measuring 1.1 cm (2, 51). These are musculoskeletal.\n There is no evidence of hardware failure or spinal fixation device. There is\n thinning of the skin of the right ischium without any signs of gas within the\n soft tissue. As mentioned, there is marked rotary scoliosis. There are rods,\n hooks and cerclage wire is seen throughout the visualized distal thoracic and\n lumbar spine without any evidence of mechanical hardware failure.\n (Over)\n\n 3:44 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for peri-nephric abscess, colitis\n Admitting Diagnosis: SEPSIS\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Heterogenous enhancement of the left kidney worrisome for pyelonephritis.\n There no perinephric abscess. There is no hydronephrosis.\n 2. There is no perinephric, intraabdominal or intrapelvic fluid collection,\n 3. There is no obvious evidence to suggest colitis. Findings were discussed\n with Medical Team at 5:30 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2192-12-28 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1163932, "text": " 5:31 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35M p/w fever, sepsis\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n EXAM: Chest frontal and lateral views.\n\n CLINICAL INFORMATION: 35-year-old male with history of fever, sepsis.\n\n COMPARISON: .\n\n FINDINGS: Frontal and lateral views of the chest were obtained. There has\n been interval removal of a left PICC line. Bilateral spinal rods are again\n noted. Asymmetry of the hemithorax is stable. Slight prominence of the left\n hilum is likely without significant change as compared to , given\n differences in technique and may relate to patient positioning. However, small\n underlying consolidation is not excluded and attention at followup chest\n radiographs is advised. The right lung is clear. No pleural effusion or\n pneumothorax is seen.\n\n" }, { "category": "ECG", "chartdate": "2192-12-28 00:00:00.000", "description": "Report", "row_id": 228102, "text": "Normal sinus rhythm. Within normal limits. Compared to the previous tracing\nof there are non-specific T wave changes with T waves which are less\nprominent than was true at that time, but tracing remains within normal limits.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2104-03-05 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1128260, "text": " 1:58 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p CABG - please page if there is concern\n with findings\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 65-year-old male post-CABG.\n\n COMPARISON: .\n\n CHEST, AP: There is mild interstitial edema. Changes of CABG are seen with\n median sternotomy wires, mediastinal clips, and two mediastinal drains. An\n endotracheal tube ends 5 cm from the carina. A Swan-Ganz catheter terminates\n in the main PA, just beyond the right ventricular outflow tract. A left chest\n tube is seen. There is no pneumothorax. Bilateral small effusions are\n present, left greater than right. The cardiomediastinal and hilar contours\n are normal.\n\n IMPRESSION: Post-operative changes.\n\n" }, { "category": "Radiology", "chartdate": "2104-03-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1128469, "text": " 4:55 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p ct removal ? ptx\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with s/p cabg\n REASON FOR THIS EXAMINATION:\n s/p ct removal ? ptx\n ______________________________________________________________________________\n WET READ: AJy FRI 12:55 AM\n ETT and left chest tubes out. no large PTX. ? small apical pneumo, rec\n attention on AM imaging. right IJ line exchanged for short sheath.\n retrocardiac opactiy unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of the patient after CABG with removal of\n the chest tube.\n\n Portable AP chest radiograph was compared to .\n\n The patient was extubated with removal of the NG tube, ET tube, chest tube,\n mediastinal drains, and exchange of the Swan-Ganz catheter by a right internal\n jugular sheath.\n\n Cardiomediastinal silhouette is stable. There is vertical lucency projecting\n over the mid portion of the sternum which is less than 1.5 mm in width and\n still most likely does not represent dehiscence. The left lower lobe\n consolidation is unchanged. There is minimal left apical lucency consistent\n with minimal pneumothorax that should be further evaluated on the subsequent\n study. No evidence of edema is present.\n\n" }, { "category": "Nursing", "chartdate": "2104-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530663, "text": "A paced for underlying sr rhythm in the 60\ns( 1^st degree avb pr .24)\n alternating with occasional junctional with frequent multifocal pvc\n lytes repleted with little effect,Amiodarone given with short lived\n effect. After warming,turning pacer occasionally sensing\n inappropriately with failure to capture at times despite polarity & ma\n changes,team aware.hemodynamically stable after initial volume,remains\n on low dose epi per dr. . Epi briefly decreased to 0.01 to see\n if there was any effect on rhythm but returned to 0.02 after noticing\n no change per team.extubated to np\ns without incident. Cooperative with\n deep breathing,? Osa like pattern observed. Feet cool bilat. With\n Dopplerable pulses x 4,right fainter than right. Transient nausea post\n extubation relieved with reglan. Hypoactive bowel sounds.glucoses\n managed per protocol,see flowsheet. Pain well controlled with\n morphine,will advance to percocet as tolerated after nausea\n dissipates. Wife in,questions answered. Remains anxious but reassured\n with progress.\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530941, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3. Follows command.\n Received on Epinephrine @ 0.01. Good Index and cardiac output.\n Mild incisional pain with coughing and deep breathing.\n Mild nauseated with turning and movement. Improves with zofran.\n SR 80-90 with frequent Multifocal PVCs. HR drops in the 40\ns at times\n with BP drop. Pacemaker capturing well in am.\n SBP 90s-120s\n 3L NC sats >98%.\n HUO moderate. Good response to lasix.\n Action:\n Toradol 15mg IV and percocet for pain relief with good effect.\n Epi weaned to off. CO/CI remains stable. Swan removed.\n Introducer left in place. PVX1.\n Zofran given for nausea x1 with good effect.\n Started lasix and low dose lopressor in pm.\n Lytes repleted.\n Taking good po\n OOB x1 today. Tolerating well.\n Response:\n Good pain control with Toradol and percocet.\n IS cc.\n Cont to have multifocal PVCs but less frequent in pm.\n HR still drops in the mid 40\ns occasionally in pm.\n Plan:\n Keep in CVICU overnight to monitor HR.\n Monitor HR and Rhythm. Reassess lopressor MD.\n Pain management.\n Encourage pulm toilet/IS.\n Advance diet and activity.\n Pre-medicate with zofran as needed with OOB.\n" }, { "category": "Rehab Services", "chartdate": "2104-03-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 531168, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: CAD / 414.00\n Reason of referral: eval and treat\n History of Present Illness / Subjective Complaint: 65yoM devoloped SOB\n in that he felt was secondary to abx for PNA at that time. PCP\n referred for ETT that was positive and then for cardiac cath that\n revealed 3VD. Pt u/w CABGx3\n Past Medical / Surgical History: CAD, cardiomyopathy, HTN,\n hyperlipidemia, prostatitis, R renal cyst, previous back injury w/L4\n herniation, rosacea, TIA () w/transient R arm weakness, cataract\n surgery, colonic polypectomy(adenoma), tonsellectomy\n Medications: carvedilol, lasix, asa, rosuvastatin, amiodarone, insulin,\n tylenol, ultram\n Radiology: CXR: LLL , L apical PTX\n Labs:\n 29.8\n 10.0\n 105\n 10.1\n [image002.jpg]\n Other labs:\n INR 1.0\n K 4.2\n Activity Orders: as tolerated per cardiac rehab guidelines\n Social / Occupational History: lives c wife, retired, former smoker,\n reports (+) family hx\n Living Environment: 10 stairs to enter 2 level home but will stay on\n first level\n Prior Functional Status / Activity Level: indep amb, ADLs/IADLs, no use\n of AD, enjoys walking dog daily ~2 miles and attending aerobics classes\n with wife\n Objective \n Arousal / Attention / Cognition / Communication: A&Ox3, pleasant,\n cooperative, receptive\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n 85\n 129/69\n 14\n 94% RA\n Activity\n 96-100\n 142/83\n 92-94% RA\n Stand\n 98\n 168/75\n 16\n 94% RA\n Recovery\n 82\n 145/80\n 96% RA\n Total distance walked: 80'\n Minutes:\n Pulmonary Status: lungs sounds diminished B bases, strong\n non-productive, non-congested cough, cueing for PLB c amb, no c/o SOB\n Integumentary / Vascular: tele, pacing wires in place but turned off,\n sternal dressing c proximal drainage, R IJ central port, PIV port\n Sensory Integrity: intact to light touch t/o, no c/o numbness or\n tingling\n Pain / Limiting Symptoms: 0/10 at rest c increase to c coughing\n only\n Posture: mild forward head and rounded shoulders\n Range of Motion\n Muscle Performance\n BUEs and \n B grip strong\n BUEs >/= \n BLEs \n Motor Function: able to isolate all muscle groups\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n \n Mod\n Max\n Gait, Locomotion: Pt presented in recliner chair\n Smooth transition sit-stand c proper use of sternal precautions\n Amb 40'x2 pushing w/c, mild static c/o lightheadedness\n Verbal cueing for pacing t/o\n Sit-sup c cueing for technique\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n T\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: Static sitting steady c S, immediate standing balance steady,\n no LOB c amb\n Education / Communication: c RN re: pt status and plan of care\n Pt education re: role and goal of PT, sternal precautions and activity\n guidelines, pacing, PLB, plan of care\n Diagnosis:\n 1.\n Impaired functional mobility\n 2.\n Impaired balance\n 3.\n Impaired endurance\n 4.\n Impaired knowledge: sternal precautions\n Clinical impression / Prognosis: yoM s/p CABGx3 now POD #2 presents\n today c the above impairments c/w cardiovascular pump dysfunction. Pt\n is most limited by impaired endurance and gait but is motivated to\n progress to d/c to home in next few days. He will benefit from\n increased activity/amb c nsg staff and more PT sessions prior to\n d/c to home. Outpt cardiac rehab f/u will be recommended.\n Goals\n Time frame: PT sessions\n 1.\n Indep bed mobility\n 2.\n Sit-stand indep no AD\n 3.\n Amb 500' indep no AD\n 4.\n Ascend/descend 1 flight of stairs indep\n 5.\n Demonstrate use of sternal precautions c all activity\n 6.\n Anticipated Discharge: Home without PT\n Treatment :\n Frequency / Duration: 2-4x/1 week\n bed mob, transfer and gait training, endurance activities, stair\n negotiation\n Pt education\n d/c planning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n Face Time: 1000-1045\n Pager: \n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530716, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3\n c/o some incisional pain with coughing and deep breathing\n received pt A Paced at 90 with frequent Multifocal PVCs and occ beats\n not paced (pacer not capturing)\n Underlying 1^st degree with some junctional beats where rate\n drops 40s\n SBP 90s-120s\n Epi @ 0.02mcg with CI >3\n LS CTA, 3L NC sats >98%\n Min CT drainage, -air leak\n HUO adequate\n Insulin gtt infusing\n Action:\n Toradol 15mg IV for pain relief\n Encouraged sternal precautions\n Checked wires, changed settings and continues to have periods where\n pacer not capturing 100%\n Lytes repleted\n Cefazolin per orders\n BS checked Q1 and gtt titrated per CVICU protocol\n Response:\n + pain relief from Toradol\n Cont to have multifocal PVCs and junctional beats despite lyte\n repletion\n Insulin gtt transitioned to SC per protocol\n Plan:\n Wean epi and deline per team\n Monitor HR and Rhythm\n Pain management\n Toradol IV Q6 and percocet PO\n Encourage pulm toilet\n 2 more doses cefazolin\n ^ Diet and exercise\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 531153, "text": "Severely depressed EF 15-20%. Stayed in CVICU POD #1 d/t inotrope\n requirement.\n Coronary artery bypass graft (CABG)\n Assessment:\n POD #2 from CABG x3. NSR. Short run of PVCs overnight. RA sats wnl.\n Lungs clear, diminished in bases. Strong non-productive cough. Positive\n flatus. Voiding QS. Dopperable pulses. Minimal c/o pain. Pt did have\n c/o nausea during previous shifts with motion.\n Action:\n Pt assisted oob. Ate half a piece of toast for breakfast. AM ivp lasix\n admin. Pt started on po lopressor on previous shift. Changed to coreg\n d/t low EF, 1^st dose of coreg due tonight at 1800. Lytes checked and\n repleted. A-line dc\nd. PT consulted. Started on PO ultram for pain\n management, last dose at 0830. Zofran admin x1 for nausea after being\n moved w/overhead ceiling lift.\n Response:\n Strong steady gait. Dizziness and nausea slightly better after zofran.\n HR 80s, SBP 120s after am beta-blocker, Rare PVCs noted late this\n morning. .\n Plan:\n Deline & transfer to 6. Continue to mobilize. Pulm hygiene. Pain\n management. Advance per protocol. Post-op education. Monitor motion\n sickness.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 88 kg\n Daily weight:\n 97.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,prostatitis,cataract\n surgery,colonic polypectomy for adenoma,previous back injury with l4\n herniation,rosacea,tia 's with rt. arm weakness-normal pre op\n nics,cad with cardiomyopathy,cath->mvd ef 20%,tte->dilated lv with\n global severe hk,septal dyskinetic,akinetic inf. wall,lae,normal pap's.\n baseline creat. 0.9,A1c 5.8%\n Surgery / Procedure and date: c x 3 lima ->lad, vg->om,pda pre\n T->severely depressed lvf ef 15-20%. off on low dose epi with improved\n ef to 35-40%. a paced for sb 50's. fem. a line placed for iabp access\n if needed.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:127\n D:79\n Temperature:\n 96.4\n Arterial BP:\n S:\n D:6\n Respiratory rate:\n 13 insp/min\n Heart Rate:\n 75 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 95% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 611 mL\n 24h total out:\n 1,340 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 50 bpm\n Temporary atrial sensitivity:\n Yes\n Temporary atrial sensitivity threshold:\n 1.2 mV\n Temporary atrial sensitivity setting:\n 0.6 mV\n Temporary atrial stimulation threshold :\n 10 mA\n Temporary atrial stimulation setting:\n 20 mA\n Temporary ventricular sensitivity:\n Yes\n Temporary ventricular sensitivity threshold:\n 6 mV\n Temporary ventricular stimulation threshold :\n 21 mA\n Temporary pacemaker wire condition:\n Attached-Pacer\n Temporary pacemaker wires atrial:\n 2\n Temporary pacemaker wires ventricular:\n 2\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:27 AM\n Potassium:\n 4.4 mEq/L\n 08:46 AM\n Chloride:\n 104 mEq/L\n 02:27 AM\n CO2:\n 27 mEq/L\n 02:27 AM\n BUN:\n 14 mg/dL\n 02:27 AM\n Creatinine:\n 0.8 mg/dL\n 02:27 AM\n Glucose:\n 104 mg/dL\n 08:46 AM\n Hematocrit:\n 29.8 %\n 02:27 AM\n Finger Stick Glucose:\n 117\n 10:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 20g piv , 2a/2v epicardial wires.\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife \n / Money:\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: wife\n Jewelry: none\n Transferred from: cvicu a 791\n Transferred to: 6\n Date & time of Transfer: 12:00 PM\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530935, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3. Follows command.\n Received on Epinephrine @ 0.01. Good Index and cardiac output.\n Mild incisional pain with coughing and deep breathing.\n Mild nauseated with turning and movement. Improves with zofran.\n SR 80-90 with frequent Multifocal PVCs. HR drops in the 40\ns at times\n with BP drop. Pacemaker capturing well in am.\n SBP 90s-120s\n 3L NC sats >98%.\n HUO moderate.\n Action:\n Toradol 15mg IV and percocet for pain relief with good effect.\n Epi weaned to off. CO/CI remains stable. Swan removed.Introducer left\n in place.\n Encouraged sternal precautions\n Reglan and zofran given for nausea\n Checked wires, changed settings and continues to have periods where\n pacer not capturing 100%\n Lytes repleted\n Epi weaned to 0.01mcg\n Cefazolin per orders\n BS checked Q1 and gtt titrated per CVICU protocol\n Response:\n + pain relief from Toradol\n Cont to have multifocal PVCs and junctional beats despite lyte\n repletion\n Insulin gtt transitioned to SC per protocol\n Plan:\n Wean epi and deline per team\n Monitor HR and Rhythm\n Pain management\n Toradol IV Q6 and percocet PO\n Encourage pulm toilet\n 2 more doses cefazolin\n ^ Diet and exercise\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 531128, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 531132, "text": "Severely depressed EF 15-20%. Stayed in CVICU POD #1 d/t inotrope\n requirement.\n Coronary artery bypass graft (CABG)\n Assessment:\n POD #2 from CABG x3. NSR. Short run of PVCs overnight. RA sats wnl.\n Lungs clear, diminished in bases. Strong non-productive cough. Positive\n flatus. Voiding QS. Dopperable pulses. Minimal c/o pain. Pt did have\n c/o nausea during previous shifts with motion.\n Action:\n Pt assisted oob. Ate half a piece of toast for breakfast. AM ivp lasix\n admin. Pt started on po lopressor on previous shift. Changed to coreg\n d/t low EF, 1^st dose of coreg due tonight at 1800. Lytes checked and\n repleted. A-line dc\nd. PT consulted. Started on PO ultram for pain\n management, last dose at 0830.\n Response:\n Strong steady gait. No c/o nausea. HR 80s, SBP 120s after am\n beta-blocker, no ectopy this am.\n Plan:\n Deline & transfer to 6. Continue to mobilize. Pulm hygiene. Pain\n management. Advance per protocol. Post-op education.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n CORONARY ARTERY DISEASE CORONARY ARTERY BYPASS GRAFT /SDA\n Code status:\n Full code\n Height:\n 70 Inch\n Admission weight:\n 88 kg\n Daily weight:\n 97.5 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: No Additional Precautions\n PMH:\n CV-PMH:\n Additional history: htn,dyslipidemia,prostatitis,cataract\n surgery,colonic polypectomy for adenoma,previous back injury with l4\n herniation,rosacea,tia 's with rt. arm weakness-normal pre op\n nics,cad with cardiomyopathy,cath->mvd ef 20%,tte->dilated lv with\n global severe hk,septal dyskinetic,akinetic inf. wall,lae,normal pap's.\n baseline creat. 0.9,A1c 5.8%\n Surgery / Procedure and date: c x 3 lima ->lad, vg->om,pda pre\n T->severely depressed lvf ef 15-20%. off on low dose epi with improved\n ef to 35-40%. a paced for sb 50's. fem. a line placed for iabp access\n if needed.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:129\n D:69\n Temperature:\n 96.4\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 18 insp/min\n Heart Rate:\n 85 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 93% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 24h total in:\n 551 mL\n 24h total out:\n 640 mL\n Pacer Data\n Temporary pacemaker type:\n Epicardial Wires\n Temporary pacemaker mode:\n Atrial demand\n Temporary pacemaker rate:\n 50 bpm\n Pertinent Lab Results:\n Sodium:\n 137 mEq/L\n 02:27 AM\n Potassium:\n 4.4 mEq/L\n 08:46 AM\n Chloride:\n 104 mEq/L\n 02:27 AM\n CO2:\n 27 mEq/L\n 02:27 AM\n BUN:\n 14 mg/dL\n 02:27 AM\n Creatinine:\n 0.8 mg/dL\n 02:27 AM\n Glucose:\n 104 mg/dL\n 08:46 AM\n Hematocrit:\n 29.8 %\n 02:27 AM\n Finger Stick Glucose:\n 117\n 10:00 PM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n 20g piv , 2a/2v epicardial wires\n Valuables / Signature\n Patient valuables: None\n Other valuables:\n Clothes: Sent home with: wife \n / Money:\n No money / \n Cash Amount: 0\n Credit Cards: 0\n Cash / Credit cards sent home with: wife, \n Jewelry: none\n Transferred from: cvicu a\n Transferred to: 6\n Date & time of Transfer: 11:00 AM\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 531122, "text": "CVICU\n HPI:\n HD3 POD 2-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day3\n Foley:Day3\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n PMHx: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n Current medications:\n 2. 250 mL D5W 3. Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium\n Gluconate 7. Dextrose 50% 8. Docusate Sodium 9. Epinephrine 10.\n Furosemide 11. Furosemide 12. Insulin 13. Ketorolac 14. Magnesium\n Sulfate 15. Metoclopramide 16. Metoprolol Tartrate 17. Metoprolol\n Tartrate 18. Milk of Magnesia 19. Morphine Sulfate 20. Nitroglycerin\n 21. Ondansetron 22. Oxycodone-Acetaminophen 23. Phenylephrine 24.\n Pneumococcal Vac Polyvalent 25. Potassium Chloride 26. Ranitidine 27.\n Rosuvastatin Calcium\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:30 AM\n PA CATHETER - STOP 12:45 PM\n Post operative day:\n POD#2 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:24 PM\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Metoprolol - 02:35 AM\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 85 (63 - 96) bpm\n BP: 137/61(87) {97/41(57) - 143/72(98)} mmHg\n RR: 11 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 5 (3 - 6) mmHg\n PAP: (23 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.65 L/min) / (3.2 L/min/m2)\n SVR: 782 dynes*sec/cm5\n SV: 84 mL\n SVI: 41 mL/m2\n Total In:\n 1,593 mL\n 349 mL\n PO:\n 590 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,003 mL\n 109 mL\n Blood products:\n Total out:\n 2,965 mL\n 350 mL\n Urine:\n 2,705 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,372 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 105 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 104 mEq/L\n 137 mEq/L\n 29.8 %\n 10.1 K/uL\n [image002.jpg]\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n 02:47 PM\n 02:27 AM\n WBC\n 13.0\n 11.4\n 10.1\n Hct\n 33\n 36\n 37.7\n 33.0\n 33.3\n 31.7\n 29.8\n Plt\n 152\n 144\n 105\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 108\n 125\n 125\n 138\n 129\n 131\n 130\n Other labs: PT / PTT / INR:12.2/32.8/1.0, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 65M s/p CABG x3(LIMA-LAD,SVG-OM,SVG-PDA) 3/31now\n extubated and ready for transfer to floor\n Neurologic: Neuro checks Q: 4 hr, Pain controlled on percocet\n Cardiovascular: HD stable. Aspirin, Increase lopressor today. PO amio\n added overnight for runs of NSVT.\n Pulmonary: IS, OOB to chair. Ambulate.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Diurese for goal of .5 L negative\n overnight, Lasix increased to this end.\n Hematology: stable post-operative anemia\n Endocrine: RISS. Glucose well controlled overnight, goal <150.\n Infectious Disease: NGTD\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition: Heart healthy\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:22 PM\n Cordis/Introducer - 02:24 PM\n 20 Gauge - 03:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531077, "text": "65yo man devoloped SOB in /09 that\nhe felt was secondary to antibx at that time. PCP referred for\nETT that was positive and then for cardiac cath thet revealed 3VD\n----------------------------------------------------------------\nCardiac Catheterization: Date: Place: MWMC\nEF 20%\nLM 40%, LAD 70%, Lft Cx: large w/minor ostial narrowing\nRCA 90% prox\nCardiac Echocardiogram: - dialted LV w/global hypokinesis.\nEF 20-25%\nmild MV thickening and mild MR\nLA enlargement. Normal PA presssures\nCarotid Ultrasound:\nOther diagnostics:Nuclear stress test: no ischemic changes at\nmoderate workload. Fixed anterior defects.\nEF 29%\n----------------------------------------------------------------\nPast Medical History:\nCAD- cardiomyopathy\n^lipids\nProstatitis\nRt renal cyst\nPrevious back injury w/L4 herniation\nRosacea\nTIA in ' w/transient rt arm weakness\n----------------------------------------------------------------\nPast Surgical History: cataract surgery, Colonic\npolypectomy(adenoma), tonsellectomy\n Coronary artery bypass graft (CABG)\n Assessment:\n Patient in bed in NAD.\n Using IS with good cough\n Monitoring Rhythm and his b/p with it.\n Couple runs of VT, self limiting\n Action:\n Lopressor 2.5mg IV x 2\n Amio 400mg PO started\n Magnesium sulfate given 2 gms\n KCL 20mEq IV\n Zofran for nausea\n Response:\n Ectopy resolved and HR slowed\n Blood pressure normalized\n No vomiting but patient has c/o nausea\n Plan:\n Transfer to floor\n Watch rhythm and treat electrolytes as needed.\n Lopressor increased this am.\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 531215, "text": "CVICU\n HPI:\n HD3 POD 2-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day3\n Foley:Day3\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Events:\n OR-\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n Dextrose 50% 8. Docusate Sodium 9. Epinephrine 10. Furosemide 11.\n Furosemide 12. Insulin 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Milk\n of Magnesia 19. Morphine Sulfate 20. Nitroglycerin 21. Ondansetron 22.\n Oxycodone-Acetaminophen 23. Phenylephrine 24. Pneumococcal Vac\n Polyvalent 25. Potassium Chloride 26. Ranitidine 27. Rosuvastatin\n Calcium\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:30 AM\n PA CATHETER - STOP 12:45 PM\n Post operative day:\n POD#2 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:24 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Metoprolol - 02:35 AM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 85 (63 - 96) bpm\n BP: 137/61(87) {97/41(57) - 143/72(98)} mmHg\n RR: 11 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.5 kg (admission): 88 kg\n Height: 70 Inch\n CVP: 5 (3 - 6) mmHg\n PAP: (23 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.65 L/min) / (3.2 L/min/m2)\n SVR: 758 dynes*sec/cm5\n SV: 94 mL\n SVI: 45 mL/m2\n Total In:\n 1,593 mL\n 351 mL\n PO:\n 590 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,003 mL\n 111 mL\n Blood products:\n Total out:\n 2,965 mL\n 350 mL\n Urine:\n 2,705 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,372 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 105 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 104 mEq/L\n 137 mEq/L\n 29.8 %\n 10.1 K/uL\n [image002.jpg]\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n 02:47 PM\n 02:27 AM\n WBC\n 13.0\n 11.4\n 10.1\n Hct\n 33\n 36\n 37.7\n 33.0\n 33.3\n 31.7\n 29.8\n Plt\n 152\n 144\n 105\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 108\n 125\n 125\n 138\n 129\n 131\n 130\n Other labs: PT / PTT / INR:12.2/32.8/1.0, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 65M s/p CABG x3(LIMA-LAD,SVG-OM,SVG-PDA) 3/31now\n extubated and ready for transfer to floor\n Neurologic: Percocet PRN pain\n Cardiovascular: Ventricular Ectopy cont'd off Epi overnight -->\n lopressor started, Amio resumed, lytes repleted --> will cont to follow\n on tele.\n Pulmonary: OOB / IS\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, start lasix qd for goal 1 liter negative\n today.\n Hematology: MIld anemia\n Endocrine: RISS\n Infectious Disease: Periop antibx\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:22 PM\n Cordis/Introducer - 02:24 PM\n 20 Gauge - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530686, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530740, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3\n c/o some incisional pain with coughing and deep breathing\n pt becomes very nauseated with turning and movement\n received pt A Paced at 90 with frequent Multifocal PVCs and occ beats\n not paced (pacer not capturing)\n Underlying 1^st degree with some junctional beats where rate\n drops 40s\n SBP 90s-120s\n Epi @ 0.02mcg with CI >3\n LS CTA, 3L NC sats >98%\n Min CT drainage, -air leak\n HUO adequate\n Insulin gtt infusing\n Action:\n Toradol 15mg IV for pain relief\n Encouraged sternal precautions\n Reglan and zofran given for nausea\n Checked wires, changed settings and continues to have periods where\n pacer not capturing 100%\n Lytes repleted\n Epi weaned to 0.01mcg\n Cefazolin per orders\n BS checked Q1 and gtt titrated per CVICU protocol\n Response:\n + pain relief from Toradol\n Cont to have multifocal PVCs and junctional beats despite lyte\n repletion\n Insulin gtt transitioned to SC per protocol\n Plan:\n Wean epi and deline per team\n Monitor HR and Rhythm\n Pain management\n Toradol IV Q6 and percocet PO\n Encourage pulm toilet\n 2 more doses cefazolin\n ^ Diet and exercise\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531022, "text": "65yo man devoloped SOB in /09 that\nhe felt was secondary to antibx at that time. PCP referred for\nETT that was positive and then for cardiac cath thet revealed 3VD\n----------------------------------------------------------------\nCardiac Catheterization: Date: Place: MWMC\nEF 20%\nLM 40%, LAD 70%, Lft Cx: large w/minor ostial narrowing\nRCA 90% prox\nCardiac Echocardiogram: - dialted LV w/global hypokinesis.\nEF 20-25%\nmild MV thickening and mild MR\nLA enlargement. Normal PA presssures\nCarotid Ultrasound:\nOther diagnostics:Nuclear stress test: no ischemic changes at\nmoderate workload. Fixed anterior defects.\nEF 29%\n----------------------------------------------------------------\nPast Medical History:\nCAD- cardiomyopathy\n^lipids\nProstatitis\nRt renal cyst\nPrevious back injury w/L4 herniation\nRosacea\nTIA in ' w/transient rt arm weakness\n----------------------------------------------------------------\nPast Surgical History: cataract surgery, Colonic\npolypectomy(adenoma), tonsellectomy\n Coronary artery bypass graft (CABG)\n Assessment:\n Patient in bed in NAD.\n Using IS with good cough\n Monitoring Rhythm and his b/p with it.\n Action:\n Lopressor 2.5mg IV x 2\n Amio 400mg PO started\n Magnesium sulfate given 2 gms\n KCL 20mEq IV\n Zofran for nausea\n Response:\n Ectopy resolved and HR slowed\n Blood pressure normalized\n No vomiting but patient has c/o nausea\n Plan:\n Transfer to floor\n Watch rhythm and treat electrolytes as needed.\n" }, { "category": "Physician ", "chartdate": "2104-03-06 00:00:00.000", "description": "Intensivist Note", "row_id": 530885, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day2\n Foley:Day2\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness\n PSH: cataract surgery, Colonic polypectomy(adenoma), \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Allergies: NKDA\n Events:\n OR-\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN\n 8. Dextrose 50% 9. Docusate Sodium 10. Epinephrine 11. Insulin 12.\n Ketorolac 13. Magnesium Sulfate\n 14. Metoclopramide 15. Milk of Magnesia 16. Morphine Sulfate 17.\n Nitroglycerin 18. Oxycodone-Acetaminophen\n 19. Phenylephrine 20. Pneumococcal Vac Polyvalent 21. Potassium\n Chloride 22. Ranitidine\n 24 Hour Events:\n NASAL SWAB - At 01:27 PM\n OR RECEIVED - At 01:27 PM\n INVASIVE VENTILATION - START 01:27 PM\n ARTERIAL LINE - START 02:22 PM\n ARTERIAL LINE - START 02:23 PM\n PA CATHETER - START 02:23 PM\n CORDIS/INTRODUCER - START 02:24 PM\n EKG - At 02:40 PM\n EXTUBATION - At 06:55 PM\n INVASIVE VENTILATION - STOP 06:55 PM\n Post operative day:\n POD#1 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:11 AM\n Infusions:\n Epinephrine - 0.01 mcg/Kg/min\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Meperidine (Demerol) - 03:29 PM\n Ranitidine (Prophylaxis) - 05:31 PM\n Morphine Sulfate - 08:52 PM\n Insulin - Regular - 09:00 PM\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: 37.8\nC (100\n T current: 37.4\nC (99.3\n HR: 88 (64 - 90) bpm\n BP: 118/56(76) {84/45(59) - 154/85(110)} mmHg\n RR: 12 (9 - 18) insp/min\n SPO2: 99%\n Heart rhythm: A Paced\n Height: 70 Inch\n CVP: 3 (2 - 15) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.76 L/min) / (3.3 L/min/m2)\n SVR: 757 dynes*sec/cm5\n SV: 86 mL\n SVI: 41 mL/m2\n Total In:\n 5,449 mL\n 395 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,449 mL\n 395 mL\n Blood products:\n Total out:\n 3,750 mL\n 1,095 mL\n Urine:\n 3,330 mL\n 945 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 1,699 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 655 (572 - 870) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 55 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/45/232/24/0\n Ve: 6.8 L/min\n PaO2 / FiO2: 464\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 144 K/uL\n 11.3 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.3 %\n 11.4 K/uL\n [image002.jpg]\n 11:39 AM\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n WBC\n 13.0\n 11.4\n Hct\n 33\n 33\n 36\n 37.7\n 33.0\n 33.3\n Plt\n 152\n 144\n Creatinine\n 0.8\n 0.7\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 110\n 108\n 125\n 125\n 138\n 129\n 131\n Other labs: PT / PTT / INR:12.8/40.7/1.1, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: Assessment:65M s/p CABG\n x3(LIMA-LAD,SVG-OM,SVG-PDA) \n Neurologic: Percocet PRN pain\n Cardiovascular: Post-op shock --> wean epi gtt off today.\n Pulmonary: Extubated; OOB, IS\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Start Lasix for diuresis.\n Hematology: MIdl anemia post-op\n Endocrine: Insulin drip, Lantus (R)\n Infectious Disease: Periop antibx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires, Remove Chest Tubes\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion, Lantus (R) protocol\n Lines:\n Arterial Line - 02:23 PM\n PA Catheter - 02:23 PM\n Cordis/Introducer - 02:24 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530952, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3. Follows command.\n Received on Epinephrine @ 0.01. Good Index and cardiac output.\n Mild incisional pain with coughing and deep breathing.\n Mild nauseated with turning and movement. Improves with zofran.\n SR 80-90 with frequent Multifocal PVCs. HR drops in the 40\ns at times\n with BP drop. Pacemaker capturing well in am.\n SBP 90s-120s\n 3L NC sats >98%.\n HUO moderate. Good response to lasix.\n Action:\n Toradol 15mg IV and percocet for pain relief with good effect.\n Epi weaned to off. CO/CI remains stable. Swan removed.\n Introducer left in place. PVX1.\n Zofran given for nausea x1 with good effect.\n Started lasix and low dose lopressor in pm.\n Lytes repleted.\n Taking good po\n OOB x1 today. Tolerating well.\n Response:\n Good pain control with Toradol and percocet.\n IS cc.\n Cont to have multifocal PVCs but less frequent in pm.\n HR still drops in the mid 40\ns occasionally in pm.\n Plan:\n Keep in CVICU overnight to monitor HR.\n Monitor HR and Rhythm. Reassess lopressor MD.\n Pain management.\n Encourage pulm toilet/IS.\n Advance diet and activity.\n Pre-medicate with zofran as needed with OOB.\n ------ Protected Section ------\n Short run of wide complexe AF/vs VT x7 beat. Asymptomatic. NP E.\n notified. Converts on his own to SR 70\n ------ Protected Section Addendum Entered By: , RN\n on: 18:40 ------\n" }, { "category": "Nursing", "chartdate": "2104-03-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 531016, "text": "65yo man devoloped SOB in /09 that\nhe felt was secondary to antibx at that time. PCP referred for\nETT that was positive and then for cardiac cath thet revealed 3VD\n----------------------------------------------------------------\nCardiac Catheterization: Date: Place: MWMC\nEF 20%\nLM 40%, LAD 70%, Lft Cx: large w/minor ostial narrowing\nRCA 90% prox\nCardiac Echocardiogram: - dialted LV w/global hypokinesis.\nEF 20-25%\nmild MV thickening and mild MR\nLA enlargement. Normal PA presssures\nCarotid Ultrasound:\nOther diagnostics:Nuclear stress test: no ischemic changes at\nmoderate workload. Fixed anterior defects.\nEF 29%\n----------------------------------------------------------------\nPast Medical History:\nCAD- cardiomyopathy\n^lipids\nProstatitis\nRt renal cyst\nPrevious back injury w/L4 herniation\nRosacea\nTIA in ' w/transient rt arm weakness\n----------------------------------------------------------------\nPast Surgical History: cataract surgery, Colonic\npolypectomy(adenoma), tonsellectomy\n Coronary artery bypass graft (CABG)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2104-03-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 530653, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 75.3 None\n Ideal tidal volume: 301.2 / 451.8 / 602.4 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: Suctioned / None\n Comments:\n Bedside Procedures:\n Comments: Patient extubated to nasal cannula. Has a positive cuff leak,\n cough and gag. Breath sounds are clear. Tolerating well,\n maintaining spo2 in the high 90s.\n" }, { "category": "Physician ", "chartdate": "2104-03-06 00:00:00.000", "description": "ICU Note - CVI", "row_id": 530823, "text": "CVICU\n HPI:\n 65M s/p CABG x3(LIMA-LAD,SVG-OM,SVG-PDA) \n PMHx:\n CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst, Previous\n back injury w/L4 herniation, Rosacea, TIA in ' w/transient rt arm\n weakness, cataract surgery, Colonic polypectomy(adenoma), tonsellectomy\n Current medications:\n 3. Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN 8. Dextrose 50% 9. Docusate Sodium 10. Epinephrine 11.\n Insulin 12. Ketorolac 13. Magnesium Sulfate 14. Metoclopramide 15.\n Metoprolol Tartrate 16. Milk of Magnesia 17. Morphine Sulfate 18.\n Nitroglycerin 19. Oxycodone-Acetaminophen 20. Phenylephrine 21.\n Pneumococcal Vac Polyvalent 22. Potassium Chloride 23. Ranitidine\n 24 Hour Events:\n NASAL SWAB - At 01:27 PM\n OR RECEIVED - At 01:27 PM\n INVASIVE VENTILATION - START 01:27 PM\n ARTERIAL LINE - START 02:22 PM\n ARTERIAL LINE - START 02:23 PM\n PA CATHETER - START 02:23 PM\n CORDIS/INTRODUCER - START 02:24 PM\n EKG - At 02:40 PM\n EXTUBATION - At 06:55 PM\n INVASIVE VENTILATION - STOP 06:55 PM\n Post operative day:\n POD#1 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 09:49 AM\n Infusions:\n Epinephrine - 0.01 mcg/Kg/min\n Other ICU medications:\n Meperidine (Demerol) - 03:29 PM\n Ranitidine (Prophylaxis) - 05:31 PM\n Morphine Sulfate - 08:52 PM\n Insulin - Regular - 09:00 PM\n Flowsheet Data as of 11:06 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100\n T current: 37.3\nC (99.1\n HR: 65 (63 - 90) bpm\n BP: 108/46(64) {84/41(57) - 154/85(110)} mmHg\n RR: 12 (9 - 18) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 5 (2 - 15) mmHg\n PAP: (21 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (5.75 L/min) / (2.8 L/min/m2)\n SVR: 779 dynes*sec/cm5\n SV: 94 mL\n SVI: 46 mL/m2\n Total In:\n 5,449 mL\n 695 mL\n PO:\n 120 mL\n Tube feeding:\n IV Fluid:\n 5,449 mL\n 575 mL\n Blood products:\n Total out:\n 3,750 mL\n 1,345 mL\n Urine:\n 3,330 mL\n 1,175 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 1,699 mL\n -649 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 655 (572 - 870) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 55 cmH2O/mL\n SPO2: 97%\n ABG: 7.36/45/232/24/0\n Ve: 6.8 L/min\n PaO2 / FiO2: 464\n Physical Examination\n Labs / Radiology\n 144 K/uL\n 11.3 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.3 %\n 11.4 K/uL\n [image002.jpg]\n 11:39 AM\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n WBC\n 13.0\n 11.4\n Hct\n 33\n 33\n 36\n 37.7\n 33.0\n 33.3\n Plt\n 152\n 144\n Creatinine\n 0.8\n 0.7\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 110\n 108\n 125\n 125\n 138\n 129\n 131\n Other labs: PT / PTT / INR:12.8/40.7/1.1, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Imaging: CXR:sm left effusion\n Microbiology: NGTD\n ECG: SR\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 65M s/p CABG x3(LIMA-LAD,SVG-OM,SVG-PDA) 3/31now\n extubated but on epi gtt\n Neurologic: Neuro checks Q: 4 hr, Pain controlled on percocet\n Cardiovascular: Aspirin, Beta-blocker, Wean epi gtt today. Initiate\n beta-blockade today as toelrated. Start zocor today.\n Pulmonary: IS, OOB to chair. Ambulate.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Diurese for goal of .5 L negative\n overnight.\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), Glucose well controlled overnight, goal\n <150.\n Infectious Disease: NGTD\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition:Heart healthy\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:23 PM\n PA Catheter - 02:23 PM\n Cordis/Introducer - 02:24 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation, Mouth care\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2104-03-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 530699, "text": "Coronary artery bypass graft (CABG)\n Assessment:\n Alert & Ox3\n c/o some incisional pain with coughing and deep breathing\n received pt A Paced at 90 with frequent Multifocal PVCs and occ beats\n not paced (pacer not capturing)\n Underlying 1^st degree with some junctional beats where rate\n drops 40s\n Does not perfuse always\n SBP 90s-120s\n Epi @ 0.02mcg with CI >3\n LS CTA, 3L NC sats >98%\n Min CT drainage, -air leak\n HUO adequate\n Insulin gtt infusing\n Action:\n Toradol 15mg IV for pain relief\n Encouraged sternal precautions\n Checked wires, changed settings and continues to have periods where\n pacer not capturing 100%\n Lytes repleted\n Cefazolin per orders\n BS checked Q1 and gtt titrated per CVICU protocol\n Response:\n + pain relief from Toradol\n Cont to have multifocal PVCs and junctional beats\n Insulin gtt transitioned to SC per protocol\n Plan:\n Wean epi and deline per team\n Monitor HR and Rhythm\n Pain management\n Toradol IV Q6 and percocet PO\n Encourage pulm toilet\n 2 more doses cefazolin\n ^ Diet and exercise\n" }, { "category": "Physician ", "chartdate": "2104-03-06 00:00:00.000", "description": "Intensivist Note", "row_id": 530747, "text": "CVICU\n HPI:\n HD2 POD 1-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day2\n Foley:Day2\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness\n PSH: cataract surgery, Colonic polypectomy(adenoma), \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Allergies: NKDA\n Events:\n OR-\n Chief complaint:\n PMHx:\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n CefazoLIN\n 8. Dextrose 50% 9. Docusate Sodium 10. Epinephrine 11. Insulin 12.\n Ketorolac 13. Magnesium Sulfate\n 14. Metoclopramide 15. Milk of Magnesia 16. Morphine Sulfate 17.\n Nitroglycerin 18. Oxycodone-Acetaminophen\n 19. Phenylephrine 20. Pneumococcal Vac Polyvalent 21. Potassium\n Chloride 22. Ranitidine\n 24 Hour Events:\n NASAL SWAB - At 01:27 PM\n OR RECEIVED - At 01:27 PM\n INVASIVE VENTILATION - START 01:27 PM\n ARTERIAL LINE - START 02:22 PM\n ARTERIAL LINE - START 02:23 PM\n PA CATHETER - START 02:23 PM\n CORDIS/INTRODUCER - START 02:24 PM\n EKG - At 02:40 PM\n EXTUBATION - At 06:55 PM\n INVASIVE VENTILATION - STOP 06:55 PM\n Post operative day:\n POD#1 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 02:11 AM\n Infusions:\n Epinephrine - 0.01 mcg/Kg/min\n Insulin - Regular - 1 units/hour\n Other ICU medications:\n Meperidine (Demerol) - 03:29 PM\n Ranitidine (Prophylaxis) - 05:31 PM\n Morphine Sulfate - 08:52 PM\n Insulin - Regular - 09:00 PM\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: 37.8\nC (100\n T current: 37.4\nC (99.3\n HR: 88 (64 - 90) bpm\n BP: 118/56(76) {84/45(59) - 154/85(110)} mmHg\n RR: 12 (9 - 18) insp/min\n SPO2: 99%\n Heart rhythm: A Paced\n Height: 70 Inch\n CVP: 3 (2 - 15) mmHg\n PAP: (20 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.76 L/min) / (3.3 L/min/m2)\n SVR: 757 dynes*sec/cm5\n SV: 86 mL\n SVI: 41 mL/m2\n Total In:\n 5,449 mL\n 395 mL\n PO:\n Tube feeding:\n IV Fluid:\n 5,449 mL\n 395 mL\n Blood products:\n Total out:\n 3,750 mL\n 1,095 mL\n Urine:\n 3,330 mL\n 945 mL\n NG:\n 50 mL\n Stool:\n Drains:\n Balance:\n 1,699 mL\n -700 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: Standby\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 655 (572 - 870) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n PIP: 0 cmH2O\n Plateau: 15 cmH2O\n Compliance: 55 cmH2O/mL\n SPO2: 99%\n ABG: 7.36/45/232/24/0\n Ve: 6.8 L/min\n PaO2 / FiO2: 464\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 144 K/uL\n 11.3 g/dL\n 131 mg/dL\n 0.7 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 10 mg/dL\n 107 mEq/L\n 138 mEq/L\n 33.3 %\n 11.4 K/uL\n [image002.jpg]\n 11:39 AM\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n WBC\n 13.0\n 11.4\n Hct\n 33\n 33\n 36\n 37.7\n 33.0\n 33.3\n Plt\n 152\n 144\n Creatinine\n 0.8\n 0.7\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 110\n 108\n 125\n 125\n 138\n 129\n 131\n Other labs: PT / PTT / INR:12.8/40.7/1.1, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: Assessment:65M s/p CABG\n x3(LIMA-LAD,SVG-OM,SVG-PDA) \n Neurologic: Percocet PRN pain\n Cardiovascular: Post-op shock --> wean epi gtt off today.\n Pulmonary: Extubated; OOB, IS\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Advance diet as tolerated\n Renal: Foley, Adequate UO, Start Lasix for diuresis.\n Hematology: MIdl anemia post-op\n Endocrine: Insulin drip, Lantus (R)\n Infectious Disease: Periop antibx\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires, Remove Chest Tubes\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: Post-op shock\n ICU Care\n Nutrition:\n Glycemic Control: Insulin infusion, Lantus (R) protocol\n Lines:\n Arterial Line - 02:23 PM\n PA Catheter - 02:23 PM\n Cordis/Introducer - 02:24 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 531051, "text": "CVICU\n HPI:\n HD3 POD 2-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day3\n Foley:Day3\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Chief complaint:\n PMHx:\n Current medications:\n 2. 250 mL D5W 3. Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium\n Gluconate 7. Dextrose 50%\n 8. Docusate Sodium 9. Epinephrine 10. Furosemide 11. Furosemide 12.\n Insulin 13. Ketorolac 14. Magnesium Sulfate\n 15. Metoclopramide 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18.\n Milk of Magnesia 19. Morphine Sulfate\n 20. Nitroglycerin 21. Ondansetron 22. Oxycodone-Acetaminophen 23.\n Phenylephrine 24. Pneumococcal Vac Polyvalent\n 25. Potassium Chloride 26. Ranitidine 27. Rosuvastatin Calcium 28.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:30 AM\n PA CATHETER - STOP 12:45 PM\n Post operative day:\n POD#2 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:24 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Metoprolol - 02:35 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 85 (63 - 96) bpm\n BP: 137/61(87) {97/41(57) - 143/72(98)} mmHg\n RR: 11 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 5 (3 - 6) mmHg\n PAP: (23 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.65 L/min) / (3.2 L/min/m2)\n SVR: 782 dynes*sec/cm5\n SV: 84 mL\n SVI: 41 mL/m2\n Total In:\n 1,593 mL\n 349 mL\n PO:\n 590 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,003 mL\n 109 mL\n Blood products:\n Total out:\n 2,965 mL\n 350 mL\n Urine:\n 2,705 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,372 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SPO2: 97%\n ABG: ///27/\n Physical Examination\n Labs / Radiology\n 105 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 104 mEq/L\n 137 mEq/L\n 29.8 %\n 10.1 K/uL\n [image002.jpg]\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n 02:47 PM\n 02:27 AM\n WBC\n 13.0\n 11.4\n 10.1\n Hct\n 33\n 36\n 37.7\n 33.0\n 33.3\n 31.7\n 29.8\n Plt\n 152\n 144\n 105\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 108\n 125\n 125\n 138\n 129\n 131\n 130\n Other labs: PT / PTT / INR:12.2/32.8/1.0, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\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 ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:22 PM\n Cordis/Introducer - 02:24 PM\n 20 Gauge - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "ICU Note - CVI", "row_id": 531053, "text": "CVICU\n HPI:\n HD3 POD 2-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day3\n Foley:Day3\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Chief complaint:\n PMHx:\n Current medications:\n 2. 250 mL D5W 3. Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium\n Gluconate 7. Dextrose 50%\n 8. Docusate Sodium 9. Epinephrine 10. Furosemide 11. Furosemide 12.\n Insulin 13. Ketorolac 14. Magnesium Sulfate\n 15. Metoclopramide 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18.\n Milk of Magnesia 19. Morphine Sulfate\n 20. Nitroglycerin 21. Ondansetron 22. Oxycodone-Acetaminophen 23.\n Phenylephrine 24. Pneumococcal Vac Polyvalent\n 25. Potassium Chloride 26. Ranitidine 27. Rosuvastatin Calcium 28.\n Sodium Chloride 0.9% Flush\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:30 AM\n PA CATHETER - STOP 12:45 PM\n Post operative day:\n POD#2 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:24 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Metoprolol - 02:35 AM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 85 (63 - 96) bpm\n BP: 137/61(87) {97/41(57) - 143/72(98)} mmHg\n RR: 11 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n CVP: 5 (3 - 6) mmHg\n PAP: (23 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.65 L/min) / (3.2 L/min/m2)\n SVR: 782 dynes*sec/cm5\n SV: 84 mL\n SVI: 41 mL/m2\n Total In:\n 1,593 mL\n 349 mL\n PO:\n 590 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,003 mL\n 109 mL\n Blood products:\n Total out:\n 2,965 mL\n 350 mL\n Urine:\n 2,705 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,372 mL\n -1 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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 : , Diminished: bilateral bases ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present,\n hypoactive\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact), Left EVH ace wrap\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n (Responds to: Verbal stimuli), Moves all extremities\n Labs / Radiology\n 105 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 104 mEq/L\n 137 mEq/L\n 29.8 %\n 10.1 K/uL\n [image002.jpg]\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n 02:47 PM\n 02:27 AM\n WBC\n 13.0\n 11.4\n 10.1\n Hct\n 33\n 36\n 37.7\n 33.0\n 33.3\n 31.7\n 29.8\n Plt\n 152\n 144\n 105\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 108\n 125\n 125\n 138\n 129\n 131\n 130\n Other labs: PT / PTT / INR:12.2/32.8/1.0, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan: 65M s/p CABG x3(LIMA-LAD,SVG-OM,SVG-PDA) 3/31now\n extubated but on epi gtt\n Neurologic: Neuro checks Q: 4 hr, Pain controlled on percocet\n Cardiovascular: Aspirin, Beta-blocker, Wean epi gtt today. Initiate\n beta-blockade today as toelrated. Start zocor today.\n Pulmonary: IS, OOB to chair. Ambulate.\n Gastrointestinal / Abdomen: Bowel regimen.\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, Diurese for goal of .5 L negative\n overnight.\n Hematology: stable post-operative anemia\n Endocrine: RISS, Lantus (R), Glucose well controlled overnight, goal\n <150.\n Infectious Disease: NGTD\n Lines / Tubes / Drains: Foley, Chest tube - pleural , Chest tube -\n mediastinal, Pacing wires\n Wounds: Dry dressings\n Consults: P.T.\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:22 PM\n Cordis/Introducer - 02:24 PM\n 20 Gauge - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n" }, { "category": "Physician ", "chartdate": "2104-03-07 00:00:00.000", "description": "Intensivist Note", "row_id": 531059, "text": "CVICU\n HPI:\n HD3 POD 2-CABG x3(LIMA-LAD,SVG-OM,SVG-PDA)\n Ejection Fraction:20-30\n Hemoglobin A1c:5.8\n Pre-Op Weight:195 lbs 88.45 kgs\n Baseline Creatinine:0.8\n TLD:R IJ cordis:Day3\n Foley:Day3\n PMH: CAD- cardiomyopathy, HTN, ^lipids, Prostatitis, Rt renal cyst,\n Previous back injury w/L4 herniation, Rosacea, TIA in ' w/transient\n rt arm weakness, cataract surgery, Colonic polypectomy(adenoma),\n \n : Bilberry extract qd, Zolpidem 10/hs, Lisinopril 30', Crestor 5'\n Coenzyme Q 2tabs , 3 fatty acid 1000', ASA 81', Flax seed\n 1000', Ntg-prn\n Events:\n OR-\n Current medications:\n Acetaminophen 4. Amiodarone 5. Aspirin EC 6. Calcium Gluconate 7.\n Dextrose 50% 8. Docusate Sodium 9. Epinephrine 10. Furosemide 11.\n Furosemide 12. Insulin 13. Ketorolac 14. Magnesium Sulfate 15.\n Metoclopramide 16. Metoprolol Tartrate 17. Metoprolol Tartrate 18. Milk\n of Magnesia 19. Morphine Sulfate 20. Nitroglycerin 21. Ondansetron 22.\n Oxycodone-Acetaminophen 23. Phenylephrine 24. Pneumococcal Vac\n Polyvalent 25. Potassium Chloride 26. Ranitidine 27. Rosuvastatin\n Calcium\n 24 Hour Events:\n ARTERIAL LINE - STOP 10:30 AM\n PA CATHETER - STOP 12:45 PM\n Post operative day:\n POD#2 - c x 3\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 05:24 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Metoprolol - 02:35 AM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.8\nC (98.2\n HR: 85 (63 - 96) bpm\n BP: 137/61(87) {97/41(57) - 143/72(98)} mmHg\n RR: 11 (8 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 97.5 kg (admission): 88 kg\n Height: 70 Inch\n CVP: 5 (3 - 6) mmHg\n PAP: (23 mmHg) / (8 mmHg)\n CO/CI (Thermodilution): (6.65 L/min) / (3.2 L/min/m2)\n SVR: 758 dynes*sec/cm5\n SV: 94 mL\n SVI: 45 mL/m2\n Total In:\n 1,593 mL\n 351 mL\n PO:\n 590 mL\n 240 mL\n Tube feeding:\n IV Fluid:\n 1,003 mL\n 111 mL\n Blood products:\n Total out:\n 2,965 mL\n 350 mL\n Urine:\n 2,705 mL\n 350 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,372 mL\n 1 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\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: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 3), Follows simple commands,\n Moves all extremities\n Labs / Radiology\n 105 K/uL\n 10.0 g/dL\n 130 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 14 mg/dL\n 104 mEq/L\n 137 mEq/L\n 29.8 %\n 10.1 K/uL\n [image002.jpg]\n 12:07 PM\n 12:56 PM\n 01:38 PM\n 01:52 PM\n 06:47 PM\n 09:00 PM\n 09:50 PM\n 02:08 AM\n 02:47 PM\n 02:27 AM\n WBC\n 13.0\n 11.4\n 10.1\n Hct\n 33\n 36\n 37.7\n 33.0\n 33.3\n 31.7\n 29.8\n Plt\n 152\n 144\n 105\n Creatinine\n 0.8\n 0.7\n 0.8\n 0.8\n TCO2\n 26\n 25\n 25\n 26\n Glucose\n 108\n 125\n 125\n 138\n 129\n 131\n 130\n Other labs: PT / PTT / INR:12.2/32.8/1.0, Lactic Acid:1.6 mmol/L,\n Ca:7.6 mg/dL, Mg:2.0 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n CORONARY ARTERY BYPASS GRAFT (CABG)\n Assessment and Plan:\n Neurologic: Percocet PRN pain\n Cardiovascular: Ventricular Ectopy cont'd off Epi overnight -->\n lopressor started, Amio resumed, lytes repleted --> will cont to follow\n on monitor.\n Pulmonary: OOB / IS\n Gastrointestinal / Abdomen: standard bowel regimen\n Nutrition: Regular diet\n Renal: Foley, Adequate UO, start lasix qd for goal 1 liter negative\n today.\n Hematology: MIld anemia\n Endocrine: RISS\n Infectious Disease: Periop antibx\n Lines / Tubes / Drains: Foley, Pacing wires\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: KVO\n Consults: CT surgery\n Billing Diagnosis: (Respiratory distress: Insufficiency / Post-op)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 02:22 PM\n Cordis/Introducer - 02:24 PM\n 20 Gauge - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 12 minutes\n" }, { "category": "Echo", "chartdate": "2104-03-05 00:00:00.000", "description": "Report", "row_id": 103471, "text": "PATIENT/TEST INFORMATION:\nIndication: CABG\nStatus: Inpatient\nDate/Time: at 11:49\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.\n\nLEFT VENTRICLE: Severely depressed LVEF.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Simple atheroma in descending aorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild [1+] TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. The patient was under\ngeneral anesthesia throughout the procedure. The TEE probe was passed with\nassistance from the anesthesioology staff using a laryngoscope. No TEE related\ncomplications.\n\nConclusions:\nPre-CPB:\nNo spontaneous echo contrast is seen in the left atrial appendage.\nOverall left ventricular systolic function is severely and globally depressed\n(LVEF= 15 - 20 %).\nRight ventricular chamber size and free wall motion are normal.\nThere are simple atheroma in the descending thoracic aorta.\nThe aortic valve leaflets (3) appear structurally normal with good leaflet\nexcursion and no aortic regurgitation. The mitral valve leaflets are mildly\nthickened. Mild (1+) mitral regurgitation is seen.\nThere is no pericardial effusion.\n\nPost-CPB:\nThe patient is AV-Paced, on Epi @ 0.03 mcg/kg/min + NTG @ .3.\nPreserved RV systolic fxn.\nLV systolic fxn is globally improved to an EF = 35 - 40%.\nTrace - mild MR. . Aorta intact.\n\n\n" }, { "category": "ECG", "chartdate": "2104-03-05 00:00:00.000", "description": "Report", "row_id": 297946, "text": "Sinus rhythm. Consider left atrial abnormality. Left anterior fascicular block.\nAnterolateral lead T wave abnormalities are non-specific but cannot exclude\nmyocardial ischemia. Clinical correlation is suggested. Since the previous\ntracing there is no significant change.\n\n" }, { "category": "Radiology", "chartdate": "2104-03-09 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1128831, "text": " 1:18 PM\n CHEST (PA & LAT) Clip # \n Reason: f/u LL atelectasis\n Admitting Diagnosis: CORONARY ARTERY DISEASE\\CORONARY ARTERY BYPASS GRAFT /SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 65 year old man with CABG\n REASON FOR THIS EXAMINATION:\n f/u LL atelectasis\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post CABG, left lower lobe atelectasis.\n\n CHEST:\n\n The cardiac size is mildly enlarged, status post CABG. Some reexpansion of\n the atelectasis in the left lower lobe has occurred. There is some still\n persists. Blunting of the right and left costophrenic angle are still\n present. Lung fields are otherwise clear.\n\n IMPRESSION: Improving.\n\n\n" } ]

[ { "category": "ECG", "chartdate": "2139-12-31 00:00:00.000", "description": "Report", "row_id": 135939, "text": "Sinus rhythm. Normal tracing. Compared to the previous tracing of \nno change.\n\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident/Attending Admission Note - MICU", "row_id": 650979, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Noncontributory\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n As above. Has pain everywhere but no chest pain.\n He experienced chills, fevers. Has headache. Has had nausea with\n movement. Denies SOB. Denies any bleeding including blood in stool,\n blood in urine, dysuria. No swelling. No sorethroat.\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section ------\n 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 her\n note above, including assessment and plan.\n Key Points:\n EtOH withdrawal in pt with h/o DTs, now with high CIWA scale.\n Unreliable exam, ROS as pt is moving easily/quickly around bed when he\n does not realize he is being observed but seeks pain meds. Not\n prescribed outpt pain meds. No reason by exam or data to suspect\n organic cause of abd pain. Psych involved for SI.\n Critically ill\n 30 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 01:05 ------\n" }, { "category": "Nursing", "chartdate": "2139-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650943, "text": "Events: On arrival to MICU agitated-\nnow that I\nm here I need you to\n give me pain meds\n, amb from stretcher to bed independently. Chief\n complaint\nm in the worst pain of my life and I need a blanket\n Concerned about getting pain meds\nm afraid for my life\n and\n requesting to watch TV. Denies any persons to contact. 18 while\n admitting. Denies thoughts of hurting himself/anyone else\nI just\n needs meds to make me better, then I can get better\n Alcohol abuse\n Assessment:\n States does not have regular drinking patter but denies any days\n without a drink, last drink pt stated wat @ 4PM\n Action:\n Response:\n Plan:\n .H/O liver function abnormalities\n Assessment:\n Action:\n Response:\n Plan:\n .H/O pancreatitis, chronic\n Assessment:\n Action:\n Response:\n Plan:\n Ineffective Coping\n Assessment:\n Action:\n Response:\n Plan:\n Impaired Health Maintenance\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Suicide\n Assessment:\n Action:\n Response:\n Plan:\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650981, "text": "Alcohol abuse\n Assessment:\n Episodes of agitation,restlessness. Pt demanding food,water,pain meds.\n Has noticeable fine tremors while hands are at rest by side. \n visual changes, but c/o ha. Follows commands, but stubborn refusing to\n comply during examine, for no ggod reasons. No seizure activity noted.\n Refuses to stay in bed, gets up to void. Appears steady on ft. but\n supervised w all act. c/o to many monitors and leads. Asking how often\n he can get valium doses. States has difficulty sleeping and requests\n pain med. When agitated hr ^ 80\ns w sbp 150-170\n Action:\n Ciwa scale, valium 5mg q 4/hr per scale. Md aware of behavior pt\n re-oriented to icu and call system. Trazadone 50mg given @ hs\n Response:\n Currnelty sleeping w stable vs, no seizure act noted\n Plan:\n Ciwa scale and valium prn\n .H/O pancreatitis, chronic\n Assessment:\n Con\nt to c/p ruq pain, states pain is mod to severe in nature. Will\n con\nt ask for pain meds po and iv. Despite c/o hr remains 70-80 except\n w agitation hr ^80\ns. sbp 130-140. states area is tender to touch.\n Even with c/o pain pt is asking to eat dinner and drink fluids. After\n pt receives valium falls asleep and appears comfortable\n Action:\n Remains npo x meds. Md notifed of pt con\nt c/o severe pain despite no\n chg in vs. provides emotional support offered back rub but pt refused\n Response:\n Con;t c/o pain without chg in vs\n Plan:\n Con;\nt to assess pain and any chg in vs associated w pain.\n Risk for Injury\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2140-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650982, "text": "Alcohol abuse\n Assessment:\n Episodes of agitation,restlessness. Pt demanding food,water,pain meds.\n Has noticeable fine tremors while hands are at rest by side. \n visual changes, but c/o ha. Follows commands, but stubborn refusing to\n comply during examine, for no ggod reasons. No seizure activity noted.\n Refuses to stay in bed, gets up to void. Appears steady on ft. but\n supervised w all act. c/o to many monitors and leads. Asking how often\n he can get valium doses. States has difficulty sleeping and requests\n pain med. When agitated hr ^ 80\ns w sbp 150-170\n Action:\n Ciwa scale, valium 5mg q 4/hr per scale. Md aware of behavior pt\n re-oriented to icu and call system. Trazadone 50mg given @ hs\n Response:\n Currnelty sleeping w stable vs, no seizure act noted\n Plan:\n Ciwa scale and valium prn\n .H/O pancreatitis, chronic\n Assessment:\n Con\nt to c/p ruq pain, states pain is mod to severe in nature. Will\n con\nt ask for pain meds po and iv. Despite c/o hr remains 70-80 except\n w agitation hr ^80\ns. sbp 130-140. states area is tender to touch.\n Even with c/o pain pt is asking to eat dinner and drink fluids. After\n pt receives valium falls asleep and appears comfortable\n Action:\n Remains npo x meds. Md notifed of pt con\nt c/o severe pain despite no\n chg in vs. provides emotional support offered back rub but pt refused\n Response:\n Con;t c/o pain without chg in vs\n Plan:\n Con;\nt to assess pain and any chg in vs associated w pain.\n Risk for Injury\n Assessment:\n Oob w supervision to voids. Bed alarms set . no attempts to harm self.\n Action:\n Supervision w all act. Offering support but pt states he just wants\n pain meds.\n Response:\n Currently safe no attempts to harm self.\n Plan:\n Closely observe monitor for 1:1 sitter needs.\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 651066, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:00 PM\n URINE CULTURE - At 06:00 PM\n Pt refused AM labs\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:00 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 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 58 (58 - 103) bpm\n BP: 128/65(79) {128/65(79) - 187/127(131)} mmHg\n RR: 19 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 550 mL\n PO:\n 50 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 475 mL\n 500 mL\n Urine:\n 475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress, able to sit and move without obvious\n discomfort.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n PT refused AM labs\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n banana bag given in ED. Utox negative. Pt refused AM labs.\n - continue CIWA protocol\n - daily folate and thiamine\n - social work consult today\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO overnight, pt with good apetite and requesting food, will ADAT\n - IVF until adequate PO intake.\n - trend labs\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Urine negative for UTI/pyelo. Clinically not suspicious for abdominal\n aneurysm or bowel ischemia. Pt with no peritoneal signs, able to sit,\n stand, move without discomfort when not being examined. Inconsistent\n exam for pain/tenderness.\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation: Pt generally calm, though uncooperative overnight.\n - appreciate psych recs\n - may not leave AMA until re-evaluated by Psych.\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stools\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: C/O to floor or d/c home pending pysch eval and labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-01-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 651118, "text": "48 YOM last drink 4 PM - pt states\nI was at the library\n and called for an ambulance\n. EMD to ED- via report EMS found and pt\n requested Dilaudid and blanket. Initial ETOH level 272. In pt stated\n if he could not get pain medications he would go home and hang himself.\n Psych colsulted in ED 1:1 Sitter- may not leave AMA. Amitted for ETOH\n WD- + SI though has denied suicidal ideation since admission. CIWA\n consistently >20 in ED revieving total 20mg PO Valium, 6 PO Ativan, 4mg\n IV Atival and amitted to MICU for high CIWA.\n Events: Transferred to PO Valium. Sleeping throughout most of day w/o\n complaint- when waking\nve never been treated so bad, I\nm hooked up\n to monitor and getting no pain medication\n. Refusing blood work,\n monitoring, assessments. Acetaminphen for HA\nthe Tylenol and Valium\n help but only for 20 min-so you need to give it to me more often\n. C/O\n t floor v D/C to home.\n Alcohol abuse\n Assessment:\n States does not have regular drinking patter but denies any days\n without a drink, last drink pt stated what @ 4PM- CIWA never less\n than 10- pt sleeping most of day- waking to go to bathroom and have\n dinner\n Action:\n CIWA Q4hrs- PO Diazepam PRN CIWA >10\n Response:\n Agitated\nif I\nm not getting my pain meds what if the point of being\n here? You\nre doing nothing to fix me\n Plan:\n CIWA Q4hrs, known to social work, support for outpt detox program\n .H/O liver function abnormalities\n Assessment:\n -AM labs done @ 1500\n Action:\n Checking labs, monitoring for change in abd pain\n Response:\n No acute change\n Plan:\n Cont to monitor, ? inpt w/u- pt has had scheduled appointment as outpt\n in past\n .H/O pancreatitis, chronic\n Assessment:\n LUQ pain- pt states constant pain worse when talking, ambulating, touch\n 10.5/10 pain cont\n Action:\n Distraction, NPO\n Response:\n No acute change\n Plan:\n NPO, AM labs, monitor for change in pain\n Ineffective Coping\n Assessment:\n Agitated,\nm done talking to you because your not helping me, I have\n acute pancreatitis and afraid for my life\n, will not elaborate on\n patterns of drinking, detox, medical history of further pain\n assessment, bargaining for medications, occ shouting,\nI won\nt have\n blood work-they need to work me up for this pain, I can\nt leave the\n hospital with pancreatitis\n perseverates on pain control over formal\n workup,\nthey \nt know that they are doing- I can\nt leave until I get\n better- \n \n Action:\n Attempting emotional support, social work following\n Response:\n refuses\n Plan:\n Cont emotional support, information about detox, psych following\n regarding SI in ED\n Impaired Health Maintenance\n Assessment:\n Homeless w/ little support\n Action:\n Refusing information\n Response:\n Plan:\n Provide information for post hospital maintenance\n Risk for Suicide\n Assessment:\n Denies SI/HI on arrival to MICU,- currently will state\nif they \n fix me I won\nt leave, I\nll tell them I\nll end it if they try to make me\n leave without fixing my pain\n Action:\n Cont monitoring, ? 1:1 sitter if condition changes\n Response:\n Plan:\n psych F/U, - cleared to leave AMA w/ no current SI emotional support\n Risk for Injury\n Assessment:\n self harm, impulsive and agitated\n Action:\n Bed alarms, CIWA\n Response:\n No acute change, OOB x mult,\n Plan:\n Cont to monitor, support, social work and psych following\n" }, { "category": "Nursing", "chartdate": "2140-01-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 651119, "text": "48 YOM last drink 4 PM - pt states\nI was at the library\n and called for an ambulance\n. EMD to ED- via report EMS found and pt\n requested Dilaudid and blanket. Initial ETOH level 272. In pt stated\n if he could not get pain medications he would go home and hang himself.\n Psych colsulted in ED 1:1 Sitter- may not leave AMA. Amitted for ETOH\n WD- + SI though has denied suicidal ideation since admission. CIWA\n consistently >20 in ED revieving total 20mg PO Valium, 6 PO Ativan, 4mg\n IV Atival and amitted to MICU for high CIWA.\n Events: Transferred to PO Valium. Sleeping throughout most of day w/o\n complaint- when waking\nve never been treated so bad, I\nm hooked up\n to monitor and getting no pain medication\n. Refusing blood work,\n monitoring, assessments. Acetaminphen for HA\nthe Tylenol and Valium\n help but only for 20 min-so you need to give it to me more often\n. C/O\n t floor v D/C to home. Current ETOH level neg.\n Alcohol abuse\n Assessment:\n States does not have regular drinking patter but denies any days\n without a drink, last drink pt stated what @ 4PM- CIWA never less\n than 10- pt sleeping most of day- waking to go to bathroom and have\n dinner\n Action:\n CIWA Q4hrs- PO Diazepam PRN CIWA >10\n Response:\n Agitated\nif I\nm not getting my pain meds what if the point of being\n here? You\nre doing nothing to fix me\n Plan:\n CIWA Q4hrs, known to social work, support for outpt detox program\n .H/O liver function abnormalities\n Assessment:\n -AM labs done @ 1500\n Action:\n Checking labs, monitoring for change in abd pain\n Response:\n No acute change\n Plan:\n Cont to monitor, ? inpt w/u- pt has had scheduled appointment as outpt\n in past\n .H/O pancreatitis, chronic\n Assessment:\n LUQ pain- pt states constant pain worse when talking, ambulating, touch\n 10.5/10 pain cont\n Action:\n Distraction, NPO\n Response:\n No acute change\n Plan:\n NPO, AM labs, monitor for change in pain\n Ineffective Coping\n Assessment:\n Agitated,\nm done talking to you because your not helping me, I have\n acute pancreatitis and afraid for my life\n, will not elaborate on\n patterns of drinking, detox, medical history of further pain\n assessment, bargaining for medications, occ shouting,\nI won\nt have\n blood work-they need to work me up for this pain, I can\nt leave the\n hospital with pancreatitis\n perseverates on pain control over formal\n workup,\nthey \nt know that they are doing- I can\nt leave until I get\n better- \n \n Action:\n Attempting emotional support, social work following\n Response:\n refuses\n Plan:\n Cont emotional support, information about detox, psych following\n regarding SI in ED\n Impaired Health Maintenance\n Assessment:\n Homeless w/ little support\n Action:\n Refusing information\n Response:\n Plan:\n Provide information for post hospital maintenance\n Risk for Suicide\n Assessment:\n Denies SI/HI on arrival to MICU,- currently will state\nif they \n fix me I won\nt leave, I\nll tell them I\nll end it if they try to make me\n leave without fixing my pain\n Action:\n Cont monitoring, ? 1:1 sitter if condition changes\n Response:\n Plan:\n psych F/U, - cleared to leave AMA w/ no current SI emotional support\n Risk for Injury\n Assessment:\n self harm, impulsive and agitated\n Action:\n Bed alarms, CIWA\n Response:\n No acute change, OOB x mult,\n Plan:\n Cont to monitor, support, social work and psych following\n Demographics\n Attending MD:\n F.\n Admit diagnosis:\n DEPRESSION\n Code status:\n Height:\n 70 Inch\n Admission weight:\n 77.6 kg\n Daily weight:\n Allergies/Reactions:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Precautions: No Additional Precautions\n PMH: ETOH, Hepatitis, Pancreatitis, Smoker\n CV-PMH:\n Additional history: Hepatitis C\n Surgery / Procedure and date: \"hand surgery\"\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:156\n D:101\n Temperature:\n 97.6\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 94 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n None\n O2 saturation:\n 100% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 110 mL\n 24h total out:\n 750 mL\n Pertinent Lab Results:\n Sodium:\n 132 mEq/L\n 03:18 PM\n Potassium:\n 3.8 mEq/L\n 03:18 PM\n Chloride:\n 99 mEq/L\n 03:18 PM\n CO2:\n 24 mEq/L\n 03:18 PM\n BUN:\n 6 mg/dL\n 03:18 PM\n Creatinine:\n 0.7 mg/dL\n 03:18 PM\n Glucose:\n 131 mg/dL\n 03:18 PM\n Hematocrit:\n 34.1 %\n 03:18 PM\n Valuables / Signature\n Patient valuables:\n Other valuables: 2x bag of clothing- on cash/wallet0 jeans, shirt,\n fleece, jacket, socks and white soes\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: MICU 6\n Transferred to: 2\n Date & time of Transfer: 12:00 AM\n ADD Pt ate dinner- ordering additional 2 dinners.\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 651050, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:00 PM\n URINE CULTURE - At 06:00 PM\n Pt refused AM labs\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:00 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 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 58 (58 - 103) bpm\n BP: 128/65(79) {128/65(79) - 187/127(131)} mmHg\n RR: 19 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 550 mL\n PO:\n 50 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 475 mL\n 500 mL\n Urine:\n 475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress, able to sit and move without obvious\n discomfort.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n PT refused AM labs\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n banana bag given in ED. Utox negative.\n - CIWA protocol\n - daily folate and thiamine\n - social work consult today\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO overnight, pt with good apetite and requesting food\n - IVF\n - trend labs\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Urine negative for UTI/pyelo. Clinically not suspicious for abdominal\n aneurysm or bowel ischemia. Pt with no peritoneal signs, able to sit,\n stand, move without discomfort when not being examined. Inconsistent\n exam for pain/tenderness.\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation: Pt generally calm, though uncooperative overnight.\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stools\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2139-12-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 650970, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2139-12-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 650971, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Noncontributory\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n As above.\n He experienced chills, ? warm,\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2139-12-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 650972, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Noncontributory\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n As above. Has pain everywhere but no chest pain.\n He experienced chills, fevers. Has headache. Has had nausea with\n movement. Denies SOB. Denies any bleeding including blood in stool,\n blood in urine, dysuria. No swelling. No sorethroat.\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2139-12-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 650973, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Noncontributory\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n As above. Has pain everywhere but no chest pain.\n He experienced chills, fevers. Has headache. Has had nausea with\n movement. Denies SOB. Denies any bleeding including blood in stool,\n blood in urine, dysuria. No swelling. No sorethroat.\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2139-12-31 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 650974, "text": "Chief Complaint: Alcohol intoxication/ withdrawl\n HPI:\n 48 y/o gentleman with history of alchohol abuse and multiple admission\n to ED with alcohol intoxication and abdominal pain presented to\n ED with alcohol intoxication. He was reportedly in a restaurant\n complaining of abdominal pain and refused to leave.\n In ED vitals were T 98.5 HR 115 BP 140/90 RR 18 98% RA. Intially\n he slept well in ED. However upon waking up he stated suicidal\n ideation. Psychiatry was consulted and recommended 1:1 sitter and not\n leave AMA. He has received 20 of PO valium, 4 total of IV ativan and 2\n po ativan. He also received banana bag in ED.\n In ICU vitals were T 97.7 HR 94 BP 158/100 RR 16 96% RA. He\n complained about left upperquadrant and flank pain. Patient has\n experienced nausea. This pain is consistent with his pancreative\n attacks. Patient is a poor historian and unable to obtain accurate\n reveiw of systems.\n .\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:10 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n 1)Chronic pancreatitis\n 2)Hepatitis C\n 3)Sciatica\n 4)EtOH abuse with h/o DTs\n 5)Prostatitis\n 6)? h/o \"aggressive behaviour\"\n 7)frequently leaves AMA\n Noncontributory\n Lives with friends. Active , unable to quantify. history of\n alcohol abuse. Denies any street drug use including IV drugs.\n Review of systems:\n As above. Has pain everywhere but no chest pain.\n He experienced chills, fevers. Has headache. Has had nausea with\n movement. Denies SOB. Denies any bleeding including blood in stool,\n blood in urine, dysuria. No swelling. No sorethroat.\n Flowsheet Data as of 07:40 PM\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: 78 (78 - 94) bpm\n BP: 163/86(102) {158/86(102) - 187/103(118)} mmHg\n RR: 17 (15 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 296 mL\n PO:\n TF:\n IVF:\n 296 mL\n Blood products:\n Total out:\n 0 mL\n 175 mL\n Urine:\n 175 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 121 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 96%\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n .\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2139-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650962, "text": "48 YOM last drink 4 PM - pt states\nI was at the library\n and called for an ambulance\n. EMD to ED- via report EMS found and pt\n requested Dilaudid and blanket. Initial ETOH level 272. In pt stated\n if he could not get pain medications he would go home and hang himself.\n Psych colsulted in ED 1:1 Sitter- may not leave AMA. Amitted for ETOH\n WD- + SI though has denied suicidal ideation since admission. \n consistently >20 in ED revieving total 20mg PO Valium, 6 PO Ativan, 4mg\n IV Atival and amitted to MICU for high .\n Events: On arrival to MICU agitated-\nnow that I\nm here I need you to\n give me pain meds\n, amb from stretcher to bed independently. Chief\n complaint\nm in the worst pain of my life and I need a blanket\n Concerned about getting pain meds\nm afraid for my life\n and\n requesting to watch TV. Denies any persons to contact. 18 while\n admitting. Denies thoughts of hurting himself/anyone else\nI just\n needs meds to make me better, then I can get better\n. 24 and given\n 1x dose 5mg IV Diazepam.\n Alcohol abuse\n Assessment:\n States does not have regular drinking patter but denies any days\n without a drink, last drink pt stated what @ 4PM\n Action:\n Q4hrs- IV Diazepam PRN >10\n Response:\n Agitated\nif I\nm not getting my pain meds what if the point of being\n here? You\nre doing nothing to fix me\n Plan:\n Q4hrs, known to social work, support for outpt detox program\n .H/O liver function abnormalities\n Assessment:\n Admitted labs Tbibi .5, AST/ALT 61/34, Lipase 65, albumin 4.6, benzo +,\n history of liver cirrhosis, Hep C\n Action:\n Checking AM labs, monitoring for change in abd pain\n Response:\n No acute change\n Plan:\n Cont to monitor\n .H/O pancreatitis, chronic\n Assessment:\n LUQ pain- pt states constant pain worse when talking, ambulating, touch\n 10.5/10 pain cont\n Action:\n Distraction, NPO\n Response:\n No acute change\n Plan:\n NPO, AM labs, monitor for change in pain\n Ineffective Coping\n Assessment:\n Agitated,\nm done talking to you because your not helping me, I have\n acute pancreatitis and afraid for my life\n, will not elaborate on\n patterns of drinking, detox, medical history of further pain assessment\n Action:\n Attempting emotional support\n Response:\n refuses\n Plan:\n Cont emotional support, information about detox, ? psych following\n regarding SI in ED\n Impaired Health Maintenance\n Assessment:\n Homeless w/ little support, intermittently employed\nas a fisherman\n Action:\n Refusing information\n Response:\n Plan:\n Provide information for post hospital maintenance\n Risk for Suicide\n Assessment:\n Denies SI/HI on arrival to MICU,\n Action:\n Cont monitoring, ? 1:1 sitter if condition changes\n Response:\n Plan:\n ? psych F/U, emotional support\n Risk for Injury\n Assessment:\n self harm, impulsive and agitated\n Action:\n Bed alarms, \n Response:\n No acute change, OOB x 1\n Plan:\n Cont to monitor, support, social work and psych following\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 651026, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:00 PM\n URINE CULTURE - At 06:00 PM\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:00 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 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 58 (58 - 103) bpm\n BP: 128/65(79) {128/65(79) - 187/127(131)} mmHg\n RR: 19 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 550 mL\n PO:\n 50 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 475 mL\n 500 mL\n Urine:\n 475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n ALCOHOL ABUSE\n .H/O LIVER FUNCTION ABNORMALITIES\n .H/O PANCREATITIS, CHRONIC\n INEFFECTIVE COPING\n IMPAIRED HEALTH MAINTENANCE\n RISK FOR SUICIDE\n RISK FOR INJURY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 651027, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:00 PM\n URINE CULTURE - At 06:00 PM\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:00 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 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 58 (58 - 103) bpm\n BP: 128/65(79) {128/65(79) - 187/127(131)} mmHg\n RR: 19 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 550 mL\n PO:\n 50 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 475 mL\n 500 mL\n Urine:\n 475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n Vitals: T 97.7 HR 94 BP 158/100 RR 16 96% RA.\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n - CIWA protocol\n - banana bag given in ED\n - will order for daily folate and thiamine\n - send utox\n - social work consult once sober\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO for now\n - IVF\n - trend labs\n - send for utox\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Will check for urine for possible UTI vs. pyelo. Clinically not\n suspicious for abdoinal aneurysm or bowel ischemia.\n - will check UA/UCx\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation:\n - 1:1 sitter\n - appreciate psych recs\n - may not leave AMA\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stool\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: ICU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2140-01-01 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 651113, "text": "48 YOM last drink 4 PM - pt states\nI was at the library\n and called for an ambulance\n. EMD to ED- via report EMS found and pt\n requested Dilaudid and blanket. Initial ETOH level 272. In pt stated\n if he could not get pain medications he would go home and hang himself.\n Psych colsulted in ED 1:1 Sitter- may not leave AMA. Amitted for ETOH\n WD- + SI though has denied suicidal ideation since admission. CIWA\n consistently >20 in ED revieving total 20mg PO Valium, 6 PO Ativan, 4mg\n IV Atival and amitted to MICU for high CIWA.\n Events: Transferred to PO Valium. Sleeping throughout most of day w/o\n complaint- when waking\nve never been treated so bad, I\nm hooked up\n to monitor and getting no pain medication\n. Refusing blood work,\n monitoring, assessments. Acetaminphen for HA\nthe Tylenol and Valium\n help but only for 20 min-so you need to give it to me more often\n. C/O\n t floor v D/C to home.\n Alcohol abuse\n Assessment:\n States does not have regular drinking patter but denies any days\n without a drink, last drink pt stated what @ 4PM- CIWA never less\n than 10- pt sleeping most of day- waking to go to bathroom and have\n dinner\n Action:\n CIWA Q4hrs- PO Diazepam PRN CIWA >10\n Response:\n Agitated\nif I\nm not getting my pain meds what if the point of being\n here? You\nre doing nothing to fix me\n Plan:\n CIWA Q4hrs, known to social work, support for outpt detox program\n .H/O liver function abnormalities\n Assessment:\n -AM labs done @ 1500\n Action:\n Checking labs, monitoring for change in abd pain\n Response:\n No acute change\n Plan:\n Cont to monitor, ? inpt w/u- pt has had scheduled appointment as outpt\n in past\n .H/O pancreatitis, chronic\n Assessment:\n LUQ pain- pt states constant pain worse when talking, ambulating, touch\n 10.5/10 pain cont\n Action:\n Distraction, NPO\n Response:\n No acute change\n Plan:\n NPO, AM labs, monitor for change in pain\n Ineffective Coping\n Assessment:\n Agitated,\nm done talking to you because your not helping me, I have\n acute pancreatitis and afraid for my life\n, will not elaborate on\n patterns of drinking, detox, medical history of further pain\n assessment, bargening for medications, occ shouting,\nI won\nt have\n bloodwork-they need to work me up for this pain, I can\nt leave the\n hospital with pancreatitis\n perseverates on pain control over formal\n workup\n Action:\n Attempting emotional support, social work following\n Response:\n refuses\n Plan:\n Cont emotional support, information about detox, ? psych following\n regarding SI in ED\n Impaired Health Maintenance\n Assessment:\n Homeless w/ little support\n Action:\n Refusing information\n Response:\n Plan:\n Provide information for post hospital maintenance\n Risk for Suicide\n Assessment:\n Denies SI/HI on arrival to MICU,- currently will state\nif they \n fix me I won\nt leave, I\nll tell them I\nll end it if they try to make me\n leave without fixing my pain\n Action:\n Cont monitoring, ? 1:1 sitter if condition changes\n Response:\n Plan:\n psych F/U, - cleared to leave AMA w/ no current SI emotional support\n Risk for Injury\n Assessment:\n self harm, impulsive and agitated\n Action:\n Bed alarms, CIWA\n Response:\n No acute change, OOB x mult,\n Plan:\n Cont to monitor, support, social work and psych following\n" }, { "category": "Physician ", "chartdate": "2140-01-01 00:00:00.000", "description": "Physician Resident/Attending Progress Note - MICU", "row_id": 651102, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 05:00 PM\n URINE CULTURE - At 06:00 PM\n Pt refused AM labs\n Allergies:\n Fiorinal (Oral) (Butalbital/Aspirin/Caffeine)\n Unknown;\n Ketorolac\n Unknown;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 05:00 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 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.4\nC (97.6\n HR: 58 (58 - 103) bpm\n BP: 128/65(79) {128/65(79) - 187/127(131)} mmHg\n RR: 19 (13 - 22) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 70 Inch\n Total In:\n 550 mL\n PO:\n 50 mL\n TF:\n IVF:\n 500 mL\n Blood products:\n Total out:\n 475 mL\n 500 mL\n Urine:\n 475 mL\n 500 mL\n NG:\n Stool:\n Drains:\n Balance:\n 75 mL\n -500 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ////\n Physical Examination\n General: Awake, agitated while answering questions, following\n commands, in no apparent distress, able to sit and move without obvious\n discomfort.\n HEENT: PERRL, EOM-I, oral thrush, MMM\n Heart: S1S2 RRR, no MRG\n Lungs: CTAB no wheezes, crackles\n Abdomen: BS positive, soft ND, no mass/organomegaly, patient states\n that he has pain on palpation diffusely, no involuntary guarding\n Ext: WWP, no edema\n Neuro: CN II-XII grossly intact, strength 5/5 bilaterally\n Labs / Radiology\n [image002.jpg]\n PT refused AM labs\n Assessment and Plan\n 48 y/o gentleman with history of alcohol abuse is admitted to ICU with\n high CIWA scale in the setting of acute alcohol intoxication.\n .\n # ETOH intoxication: ETOH level at 1 am was 272. Serum tox only\n positive for benzo and ETOH. He has a history of withdrawl seizures.\n banana bag given in ED. Utox negative. Pt refused AM labs.\n - continue CIWA protocol\n - daily folate and thiamine\n - social work consult today\n .\n # Hep C/chronic pancreatitis: Mildly Elevated AST/AP/Lipase. Most\n likely secondary to chronic alcohol abuse. Improved compared to\n baseline.\n - NPO overnight, pt with good apetite and requesting food, will ADAT\n - IVF until adequate PO intake.\n - trend labs\n - will strongly recommend out patient liver follow up to him\n .\n # Abdominal pain: Acute on chronic per patient. History of\n pancreatitis as above. Afebrile and hemodynamically stable currently.\n Urine negative for UTI/pyelo. Clinically not suspicious for abdominal\n aneurysm or bowel ischemia. Pt with no peritoneal signs, able to sit,\n stand, move without discomfort when not being examined. Inconsistent\n exam for pain/tenderness.\n - consider abd US if persistent or worsens\n .\n # Suicidal ideation: Pt generally calm, though uncooperative overnight.\n - appreciate psych recs\n - may not leave AMA until re-evaluated by Psych.\n .\n # Decreased white count: Unclear etiology. ? marrow suppression\n secondary to chronic alcohol abuse. No active signs of infection.\n - trend white count.\n .\n # Anemia: Stable HCT now at mid 30s. Borderline microcytic. Folate\n and vit B12 normal in the past. Poor nutritional status could play a\n part.\n - guaic stools\n - iron panel\n - will recheck b12 and folate given alcohol abuse\n .\n # Pulmonary Nodule: Needs out patient follow up.\n .\n # FEN: NPO for now; replete lytes prn\n .\n # Prophylaxis: sc heparin, PPI\n .\n # Code: Presumed full code\n .\n # Dispo: C/O to floor or d/c home pending pysch eval and labs\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 18 Gauge - 03:45 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: 48M EtOH abuse, multiple admits for\n intoxication / withdrawal / chronic pancreatitis and ? drug seeking\n behavior. Admitted to MICU after expressing suicidal ideation in the\n setting of acute intoxication follwed by early withdrawal symptoms.\n Stable in ICU overnight.\n Exam notable for Tm 97.9 BP 146/91 HR 61 RR 17 with sat 99 on RA.\n Refuses exam. Labs notable for WBC 3K, HCT 35, K+ 3.3, Cr 0.8, EtOH 272\n in ED.\n Agree with plan to manage objective evidence of ethanol withdrawal with\n valium per CIWA. Appreciate ongoing psych input for SI; currently on\n 1:1, can't leave AMA. Will ask for reevaluation today to assess\n capacity. No clear evidence of acute on chronic pancreatitis; hold\n narcotics and follow serial exams. Will advance diet today. Will work\n to coordinate outpatient management of multiple issues - anemia, hep C,\n SPN, alcohol abuse, etc. Remainder of plan as outlined above.\n Total time: 35 min\n ------ Protected Section Addendum Entered By: , MD\n on: 14:47 ------\n" } ]

[ { "category": "Echo", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 70050, "text": "PATIENT/TEST INFORMATION:\nIndication: Past history of breast cancer. Tachycardia and ?respiratory failure s/p extubation. Now re-intubated. Evaluation for LV / RV function fand to assess for pericardial effusion.\nHeight: (in) 63\nWeight (lb): 129\nBSA (m2): 1.61 m2\nBP (mm Hg): 98/45\nHR (bpm): 107\nStatus: Inpatient\nDate/Time: at 12:08\nTest: Portable TTE (Complete)\nDoppler: Full doppler and color doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No 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\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (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. No aortic regurgitation is seen.\nThe mitral valve appears structurally normal with trivial mitral\nregurgitation. The estimated pulmonary artery systolic pressure is normal.\nThere is a trivial/physiologic pericardial effusion. There are no\nechocardiographic signs of tamponade.\n\nIMPRESSION: Normal biventricular size and systolic function. Trivial\npericardial effusion. No significant valvular disease seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 853381, "text": " 11:25 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed or ischemia\n Admitting Diagnosis: LEFT BREAST CANCER/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 49 year old woman with agitation after extubation unclear etiology\n REASON FOR THIS EXAMINATION:\n eval for bleed or ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 49 y/o woman with agitation after extubation of unclear .\n Evaluate for bleed, ischemia or metastasis.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is no intracranial hemorrhage, mass lesion, hydrocephalus,\n shift of normally midline structures, minor or major vascular territorial\n infarct. Grey/white matter differentiation is preserved. Some opacification\n of the bilateral mastoid air cells is noted. The osseous and soft tissue\n structures are otherwise unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage, mass lesion, or other acute\n intracranial pathology.\n\n\n" }, { "category": "Radiology", "chartdate": "2153-02-26 00:00:00.000", "description": "O PORTABLE ABDOMEN IN O.R.", "row_id": 853306, "text": " 8:13 PM\n PORTABLE ABDOMEN IN O.R. Clip # \n Reason: ? FB S/P L MASTECTOMY & D/EP FLAP\n Admitting Diagnosis: LEFT BREAST CANCER/SDA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Post left mastectomy and flap.\n\n Two portable films from the O.R. lacking detail demonstrates surgical drains\n and tubes but not evidence of a radiopaque foreign body within the field of\n view.\n\n\n" }, { "category": "ECG", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 151098, "text": "Sinus tachycardia. Diffuse low voltage. Compared to the previous tracing\nof the rate is increased. Otherwise, no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2153-02-26 00:00:00.000", "description": "Report", "row_id": 151099, "text": "Sinus tachycardia.\nrSr'(V1) - probable normal variant\nPoor R wave progression with Late precordial QRS transition - is nonspecific\nModest diffuse nonspecific low amplitude T waves\nSince previous tracing of , sinus tachycardia low amplitude T waves\npresent\n\n" }, { "category": "Nursing/other", "chartdate": "2153-03-02 00:00:00.000", "description": "Report", "row_id": 1479409, "text": "NURSING NOTE 11A-7P Review of Systems:\nNEURO: Alert and oriented X3 follows commands well, transfers OOB to chair and toilet with minimal assist. Denies pain refuses percocet at this time.\nC/V: HR 90-110's no ectopy noted, BP stable. + doppler pulse to left breast, palpable pedal pulses.\nRESP: Lungs clear. Sat 100% on roomair.\nGI: Abd soft positive bowel sounds, no stools this shift OOB to toliet no results. Taking po diet well no complants of nausea or vomiting.\nGU: OOB to BR to void X2.\nSKIN: Abdominal incision intact 2 JP drains intact moderate amounts s/s fluid output recorded on flow sheet. Dresssing changed to left breast mupirocin cream applied oozing small amounts s/s fluid.\nSOCIAL: friend visited.\nPLAN: Transfer to floor when bed available. Monitor flap pules, JP drainage, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2153-02-28 00:00:00.000", "description": "Report", "row_id": 1479406, "text": "1030-\n\npatient returned from OR for left breast hematoma evacuation at 1030am, dozing on and off, but easily arousable to voice. tachycardic into the 130s, but with stable BP (120s), afebrile, +doppler pulses to left breast. 4 JP drains : 2 left axillary, 2 either side of ABD drain s/s fluid, O2 sat 96-98% on 50% cool neb mask\n\nROS:\nNEURO: alert, sleepy, follwoing all commands, very flat affect\n\nCV: continues to be tachycardic in the 110s, HO aware, no treatments at this time. BP stable 120s/60s, + pp, + flap pulse to left breast wtih doppler\nRESP: ls decreased at bases, able to wean off O2, O2 sat 98-100% on RA, +weak, non-productive cough\n\nGI: tolerating ice chips, no nausea/vomiting, hypoactive bowel sounds, abdomen soft slightly tender to palpation around incision\n\nGU: foley catheter draining clear yellow urine\n\nID: afebrile, vanco q12h\n\nskin: lower abdomen with horizontal incision with sutures intact, 2 jp drains on either side draining s/s fluids; left breast with nipple area incision with sutures intact, small amounts of serosang. drainage. 2 jp drains in left axillary draining serosang fluid.\n\nsocial: husband called or update. social work involved. patient having a hard time coping.\n\nPlan: continue with 1 hr flap checks as ordered, provide emotional support.\n" }, { "category": "Nursing/other", "chartdate": "2153-03-01 00:00:00.000", "description": "Report", "row_id": 1479407, "text": "T/SICU RN Progress Note\nNeuro: Alert and oriented, , denies pain.\n\nCV: HR 100-110 ST no ectopy noted. NBP 120's systolic. SQ Heparin and P-boots.\n\nResp: Lungs clear strong productive cough able to expectorate thick clear secretions. NARD on RA Sats 97-99% with RR 20's.\n\nGU/GI: Foley with clear yellow urine. Tolerating clear liquids without n/v, on pepcid. IVF changed to maint. D51/2NS@65cc/hr.\n\nSkin/Mobility: Moving well independently in bed and with min. assist. L breast with + doppler pulse still reddened and eccymotic with no change overnight. Abd incision intact. JPX4 with mod amouth of sang to s/s drainage no leaking around drain sites noted.\n\nID: Afebrile on vanco\n\nEndo/Lytes: No coverage for RISS, given 2gm MgSo4, K 3.4, needs repleation, no orders for K yet.\n\nSocial: No contact overnight.\n\nPlan: Monitor doppler pulses, monitor JP drainage, OOB in am, ? advance diet as tolerated, cont to monitor and support.\n" }, { "category": "Nursing/other", "chartdate": "2153-03-01 00:00:00.000", "description": "Report", "row_id": 1479408, "text": "\nneuro: alert and oriented, denies pain, moves all extremities, follows c0mmands\n\ncv: HR 90s-110s, no ectopy noted, BP stable, +doppler pulses to left breast, + palpable pedal pulse\n\nresp: lungs clear, good cough, O2sat 100%on Roomair\n\nGI: tolerating house diet, no nausea/vomiting,\n\nGU: foley catheter with large u/o\n\nSKIN: abdominal incision with sutures and 2 jp drains well approximated, drains putting out moderate amounts of s/s fluid, left breast incision around nipple with sutures well approximated, oozing small amounts of s/s fluid, 2 jps left axillary draining moderate amounts of s/s fluid\n\nsocial: husband into visit today, updated on plan.\n\nPLAN: monitor flap pulses, JP drain output. provide emotional support. jp drain teaching\n" }, { "category": "Nursing/other", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 1479401, "text": "admission note\n49 y/o female s/p total L mastectomy,breast reconstruction w/ flap.during anesthesia recovery,became very \"wild,\" hr 140-150s svt.given esmolol x 2.?seizure,emergence delirium,or cardiac event. neurology and cardiology consulted.in PACU,flap pulse undopplerable. returned to OR for re-exploration and revision of micro-anastamosis.bp unstable,very labile during 2nd case.started neo.troponin and ekg wnl. to tsicu-intubated,no pressors.total ebl 400ml,crystal in 9300ml,u/o 2860ml.received 1 unit prbc,1 unit autologous rbc.\npmh:hypothyroidism,seizure in childhood,breast ca.\nalg:cephelexin\n\nneuro:sedated on propofol.easily stimulated.opens eyes to voice, follows commands inconsistently.mae's.perrl.nods y/n.denies pain.given morphine 2mg x 1.\n\ncv:sbp low 100s upon arrival from OR.hypotensive to 80s w/ sedation and morphine.hr 90-140s,sr->st.rare pvc.labs pending.extremities cold,pale initially.warmed w/ bair hugger.pedal pulses 3+.\n\nresp:imv 600x9.5,5/5,100%.sxn'd for thick tan sputum.spec collected. sao2 100%.ls clear to coarse.\n\ngi:soft abd.+bs.\n\ngu:u/o brisk initially.urine clear,lt yellow.LR at 100ml/hr.\n\nskin:L breast flap pink,ecchymotic,ota.transverse abd incision approximated,ecchymotic,ota.jp x 2 to abd,jp x 1 to L chest.moderate bloody drng from L chest jp.\n\nid:afebrile.vanco given and scheduled.\n\nendo:covered x 1 per ss.\n\nheme:heparin sq,pneumatic boot to RLE only.\n\nsocial:has husband.updated by plastics.no contact since pt arrival.\n\na/p:s/p mastectomy,flap.monitor hemodynamics.check flap pulses q1hr.wean sedation and vent.extubate.provide adequate pain control, initiate pca when awake.\n" }, { "category": "Nursing/other", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 1479402, "text": "T/Sicu NSg Progress Note\n0700>>1900\n\n49 yo female admitted to ICU ~ 0300 s/p left modified radical mastectomy w/immediate reconstruction which reqired re-op for loss of flap pulse.\nProcedure reported as technically difficult and redo of microanastomosis was performed 40 minutes before conclusion of case. pt reportedly developed nodal rhthym and then SVT; she received esmolol and verapamil w/effect. Pt was extubated and became agitated; seizure like eye movement was observed off/on and pt was nonresponsive during these moments. To PACU @ 2100; received lopressor for st w/effect.Loss of flap pulse occured within 20 minutes. Pt received heparin & TPA & returned to the OR for revision of flap vasculature. Neurology & cardiology consults were requested & obtained. Hypotension equiring neo breifly during final OR; fluid & blood to resuscitate.\n\nEVENTS today- head CT >> negative\n cardiac echo >>negative\n EEG >> no seizure activity detected.\n Extubated w/o event\n Flap perfusion intact\n 2 units PC for hct drop\n\nNeuro- initially sedated on propofol and denying pain, following commands but not focused. Pt consistently more tachycardic with stimulation (see careview). Currently pt is alert & oriented but exhausted. MAE's with normal strength. Her speech is clear & she is appropriate. She is experiencing some breast & abdominal discomfort, , which was relieved with mso4 4mg ivp.\n\nCVS- NST w/o ectopy 110 >> 140. BP 90-100/systolic while on propofol, now 100-110/. EKG, 12 lead done; enzymes cycled.\n\nRENAL- auto-diuresing >200cc/hr. Potassium repleted; magnesium repleted. IVF remain @ 100cc/hr LR.\n\nRESP- weaned & extubated quickly after receiving haldol 5mg iv over 3/hr. Currently on RA with sats > 96%. RR in teens. Breath sounds are clear; pt is coughing effectively clearing blood tinged sputum.\nNo c/o resp distress.\n\nGI- soft abd with bowel sounds. Pepcid. Tolerating ice chips and sips of water w/meds.\n\nHeme- hct 24 >> 2u pc's>>30 post transfusion\n\nID- t.max 101.1 >> 99.1 now. Vanco as ordered.\n\nEndo- no coverage required.\n\nSkin- breast & abdominal incisions are approximated and dry; ecchymotic areas are noted & stable. Left breast tissue is warm, center graft skin is pale as expected but warm. Dopplerable flap pulse Q/hr; strong signal. JP drains x3- left axilla & 2 abdominal. Left axillary drainage is consistent @ 20-30cc/hr of serosanginous fluid. Abd JP's drain ~ 10-15cc/hr of blood tinged serous fluid.\nSkin is warm/dry with palpable peripheral pulses.\nCompression boots in use; sc heparin tid.\n\n husband & mother visited today; Surgeons spoke with husband & pt and provided detailed updates & POC.\n\nASSESS- s/p mod L radical mastectomy c/b agitation/tachycardia/ and loss of perfusion to flap requiring re-op. Now stable & extubated w/o recurrance of agitation BUT tachycardia persists.\nNeuro status appears to be at baseline now.\nPain is under control\nAuto-diuresing.\n\nPLAN- continue with q/hr flap \n" }, { "category": "Nursing/other", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 1479403, "text": "T/Sicu NSg Progress Note\n(Continued)\ncks; monitor for increase in bleeding from JP drains; check hct. Cont telemetry. Adequate pain mngmnt.\nCont current POC\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2153-02-27 00:00:00.000", "description": "Report", "row_id": 1479404, "text": "Patient went to CT Scan then extubated when she returned to unit. EEG done post extubation.patient alert,coop responding adequately to questions.BS with better gas exchange on L then R will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2153-02-28 00:00:00.000", "description": "Report", "row_id": 1479405, "text": "flap checks q1 hr. strong dopplar impulse, flap blanched until midnight. then turning pinkish at 4am flap noted to be mottled. no caprrefill seen by plastics will go to or this am at 730. beast getting increasingly engorged and ecchymotic. jp drain had been draining lg amts of bloody fld 250ccs from 11pm to 6am. pt also draining bloody drainage around insertion site in rt axilla.\nother 2 jp draining draining amts and more serous in nature.\nabd incision intct sl ecchymotic around edges.\npt has been hemodynamically stable with hr st 100 to 110 pt still gets tachy up to 12- 130 briefly with any exertion. temp max 100.5 now 99.4.\nivf lr at 100ccs per hr. uo qs clear yellow.\npt alert and oriented, given 2 mgs iv ms prn with good pain relief.\npt taking ice chips. abd sft with active bowel sounds. no stool\non sliding scale no insulin requirements.\n" } ]

[ { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797369, "text": " 7:20 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration pneumonia and NGT placement\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman w q about aspiration. Has new NG tube\n REASON FOR THIS EXAMINATION:\n aspiration pneumonia and NGT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Check tube placement. Suspected aspiration pneumonia.\n\n PORTABLE CHEST: A semierect view is compared to . The endotracheal\n tube has been withdrawn from the right main stem bronchus and now appears in\n good position with the tip 4.5 cm above the carina. The balloon may be\n slightly overinflated. The nasogastric tube extends down to the left upper\n quadrant of the abdomen, with the sideport well below the diaphragm. The\n heart size and pulmonary vasculature are normal. Patchy areas of density in\n the right perihilar region and left lung base are unchanged. This may be due\n to aspiration.\n\n IMPRESSION: ETT in satisfactory position. Possible slight overinflation of\n cuff.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-28 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 797437, "text": " 9:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: L SIDED WEAKNESS,FACIAL DROOP, VOMITING FOR 1.5 HOURS, BRAIN HEMORRHAGE, ? INCREASING EDEMA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with L sided weakness, facial droop, N/V for 1.5 hours\n\n REASON FOR THIS EXAMINATION:\n is there increasing edema?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n INDICATION: F/U intraparenchymal hemorrhage. Now with left-sided weakness\n and nausea and vomiting for 1 1/2 hours.\n\n COMPARISON IS made to prior exam of .\n\n TECHNIQUE: Non-contrast ct of the head.\n\n CT HEAD W/O CONTRAST: Allowing for differences in head position, and\n therefore, slice orientation, there is no significant interval change in the\n appearance of the right intraparenchymal and intraventricular hemorrhage. Mild\n shift of the normally midline structures toward the left is again appreciated.\n The degree of surrounding edema appears stable. The basal cisterns are\n visible and there is no evidence of herniation. No new areas of hemorrhage\n are identified. Again, the temporal horns are seen to be prominent, but\n ventricles are unchanged in size. A small amount of hemorrhage is again seen\n in the left occipital .\n\n The paranasal sinuses and the mastoids are well aerated.\n\n IMPRESSION: Allowing for differences in head position, and therefore slice\n orientation, no significant change in right-sided intraparenchymal hemorrhage\n and surrounding edema. No new areas of hemorrhage, hydrocephalus or increased\n shift identified.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2116-06-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 797360, "text": " 12:18 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: S/P TRAUMA\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with L sided weakness, facial droop, N/V for 1.5 hours\n REASON FOR THIS EXAMINATION:\n Is the bleed progressing?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n INDICATION: Nausea/vomiting for 1.5 hours, left sided weakness, and facial\n droop. Evaluate for progression of the previously identified hemorrhage.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: 6 hours earlier.\n\n FINDINGS: There has been no significant interval change in the appearance of\n the large right intraventricular and intraparenchymal hemorrhage. There is\n now a small amount of blood layering in the left lateral ventricle. The degree\n of cerebral edema and mass effect is not significantly changed. There may be\n minimal shift of normally midline structures toward the left. Again noted is\n effacement of the ambient cistern on the right, which may relate a degree of\n uncal herniation. No new areas of hemorrhage are appreciated. The visualized\n osseous structures and paranasal sinuses are unremarkable.\n\n IMPRESSION: No significant change in the appearance of the large right\n intraparenchymal and intraventricular hemorrhage.\n The temporal horns are mildly prominent raising a suspicion of early\n hydrocephalus\n A follow up CT is recomended in hours to assess interval change.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 797345, "text": " 6:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ET OPLACEMENT S/P RESP FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with\n REASON FOR THIS EXAMINATION:\n eval for ETT placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Respiratory failure.\n\n AP BEDSIDE CHEST RADIOGRAPH: There is an endotracheal tube with its distal\n tip in the right main stem bronchus. There is an NG tube passing beneath the\n diaphragm with its distal tip not visualized. The heart size and mediastinal\n contours are within normal limits. The pulmonary vasculature is within normal\n limits with no evidence of failure. The lungs are clear with no parenchymal\n consolidation or pulmonary nodules. There is no pneumothorax.\n\n IMPRESSION: Endotracheal tube within the right main stem bronchus.\n\n" }, { "category": "Radiology", "chartdate": "2116-06-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 797343, "text": " 5:48 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: assess for acute bleed\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old woman with L sided weakness, facial droop, N/V for 1.5 hours\n REASON FOR THIS EXAMINATION:\n assess for acute bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT HEAD WITHOUT CONTRAST:\n\n INDICATION: Left-sided weakness and facial droop.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is a large right-sided intrathalamic hemorrhage extending\n into the lateral, third and fourth ventricles. This is associated with mass\n effect and midline shift to the left. There is a small amount of\n opacification of the left mastoid air cells. Incidental note is made of\n calcification of the carotid arteries in the cavernous sinus.\n\n IMPRESSION: Large right intraparenchymal and intraventricular hemorrhage with\n associated mass effect and midline shift.\n\n" }, { "category": "ECG", "chartdate": "2116-06-28 00:00:00.000", "description": "Report", "row_id": 179396, "text": "Sinus rhythm\nSeptal+lateral T wave changes may be due to myocardial ischemia\nSince previous tracing, QRS changes in lead V2 -? position, left ventricular\nhypertrophy by voltage absent; T wave changes improved, sinus tachycardia is\nabsent\n\n\n" }, { "category": "ECG", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 179397, "text": "Sinus tachycardia\nConsider old septal infarct\n Anterolateral T wave changes may be due to myocardial ischemia\nLeft ventricular hypertrophy by voltage\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 1304548, "text": "NSICU NPN\nS: intubated/sedated\nO: see carevue for all objective data\nneuro: eyes not opening spontaneously. Will follow simple commands re: right side, ie: lifting hand, squeezing hand, letting go, lifting foot. Moving right hand in purposeful manner, tries to pull at ETT. withdraws to deep pain on left side. PERRL, sluggish, Started on dilantin.\ncv: nipride d/c and pt now on labatelol gtt at .5mg/min. bp 125-150/60-70. hr 85-115 sr, st, no vea. Had been given lopressor 5mg iv w/ transient drop in bp, now d/c.\nresp: vent changed to ps5/peep 5 this am, w/ good abg, plan not to extubate until at least . sx q 3-4 hr for scant amts white, bl tinged sputum. lungs cta.\ngi: Impact w/ fiber started at 1700 at 10cc/hr. no stool\ngu: foley draining sm amts dk amber urine. ns w/ 40meq kcl infusing at 100cc/hr x 1000cc.\nid: tm 100.4 PO,sputum and urine sent.\nend: bs 123-167, covered per RISS.\nsocial: both daughters here most of afternoon. Spoke at great length w/ Dr. (neurology), pt is now DNR.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 1304549, "text": "NSICU NPN addendum\nIV in pt's r arm noted to be very reddened, with streaking. iv pulled, hot packs applied, Dr. notified.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-28 00:00:00.000", "description": "Report", "row_id": 1304550, "text": "Respiratory Care:\n\nPatient intubated on Psv. Vent settings Psv 5, Cpap 5, Fio2 40%. Spont vols 350-400's. RR 20-mid 20's. Sx'd for sm amounts of thick yellow sputum. Abg results within normal limits. RSBI 72.9. Improved from yesterday. SBT not done. No plans to extubate. Watching for further signs of increased brain swelling. Patient remains intubated for airway protection. Continue with Psv as tolerated and re assess for extubation as neuro status improves.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-28 00:00:00.000", "description": "Report", "row_id": 1304551, "text": "Fio2 set at 50% not 40%.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-28 00:00:00.000", "description": "Report", "row_id": 1304552, "text": "ccu nsg progress note-nsicu border.\no:neuro=unchged. see care view.\n pulm=remains on cpap. am abg-wnl. breath sounds=clear. sx-tannish secretions. sats upper 90's.\n cv=hemody stable w spb 120's on labatolol @ 0.5mg/min.\n gi=tf-impact @ 10ml/hr-off 2hrs before & after dilantin.\n gu=positive i&o. urine very dark.\n id=low grade t.\n labs=am sent.\n\na:unchged.\n\np:contin present managemnt.\n\n" }, { "category": "Nursing/other", "chartdate": "2116-06-28 00:00:00.000", "description": "Report", "row_id": 1304553, "text": "NSICU NPN\nPt's daughter's met w/ neurology attending Dr. . The decision was made to withdraw treatment and make her comfort measures only. Mrs was extubated at 1315 w/o difficulty, all med except dilantin, tylenol and morphine drip were d/c. RA sat 88%, rr 22. hr 80's, sr, bp 115-130/50-70.\nFamily has been with pt all afternoon.\nA: CMO s/p lg intracranial bleed.\nP: titrate mso4 to comfort. Emotional support to family.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-29 00:00:00.000", "description": "Report", "row_id": 1304554, "text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\nO:CMO! MSO4 GTT TITRATED FROM 3 TO 9MG/HR TO MAINTAIN ADEQ SEDATION/COMFORT. DAUGHTER & NEICE INTO VISIT-SUPPORT GIVEN.\n\nA:CMO!\n\nP:CONTIN CMO CARE. SUPPORT FAMILY AS INDICATED.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-29 00:00:00.000", "description": "Report", "row_id": 1304555, "text": "CCU NSG PROGRESS NOTE-NSICU BORDER.\n0530-PRONOUNCED BY NSICU RESIDENT. FAMILY NOTIFIED BY RN. NEURO MED RESIDENT NOTIFIED. PT TO MORGUE.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 1304545, "text": "CCU NSG ADMIT NOTE-NSICU BORDER.\n75 YO FEMALE ADMITTED TO CCU FROM THE EW S/P R BASAL GANGLIA HEMMORHAGE W EXTENSION INTO VENTRICLES.\n\nPMH:NONE. HAS NOT SEEN A PHYSICIAN IN # OF YEARS.\n\nALLERGIES:NONE.\n\nMEDS:NONE.\n\nSOCIAL:LIVES ALONE-HUSBAND PASSED AWAY >20 YRS AGO. 2 DAUGHTERS-BOTH VERY SUPPORTIVE. VERY ACTIVE PRIOR TO ADMISSION.\n\nPRESENT HX: @ HOME DEVELOPED HA W FELLING OF WEAKNESS. EMTS CALLED- NOTED L-SIDED HEMIPARESIS. EW-INITIALLY ABLE TO CONVERSE, BUT DEVELOPED NAUSEA/VOMITING-INTUBATED FOR AIRWAY PROTECTION. CT SCAN- R- BASAL GANGLIA HEMMORHAGE W EXTENSION INTO VENTRICLES. EVALUATED BY NEUR0 & NEURO -NON @ PRESENT. ADMITTED TO CCU-NSICU BORDER.\n\nO:NEURO=SEE CARE VIEW. UNRESPONSIVE. NON-PURPOSEFUL MOVEMENT R-SIDE ONLY! L-SIDE SL FLINCHING L-HAND W BL DRAW. REDO CT SCAN-WO CHG.\n PULM=INTUBATED & VENTED. SETTINGS-SEE CARE VIEW. VENT CHG TO CPAP W GAOL EXTUBATION IF TOLERATES. BREATH SOUNDS=CLEAR. INITIALLY SX FOR BL TINGED SECRETIONS. SEDATED W PROPOFOL GTT-TO BE DCED 0630.\n CV=HEMODY STABLE. W SBP 120'S ON LOW DOSE NIPRE.\n GI=NPO. OGT-BILIOUS. OGT/STOOL GUIAC NEG.\n ID=LOW GRADE T.\n LABS=AM SENT.\n SOCIAL=DAUGHTERS PRESENT. HEALTH CARE DIRECTIVE PLACED IN CHART.\n\nA:L-SIDED HEMIPARESIS NEW ONSET.\n\nP:CONTIN PRESENT MANAGEMENT. ?EXTUBATE IF TOLERATES CPAP. SUPPORT PT/FAMILY AS NEEDED.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 1304546, "text": "Respiratory Care:\n75 Y.O F., with no significant PMH, presenting now w/lg. Rt. ICH. CXR showed #7 OET, secured 20@ lip, was into Rt. mainstem>>pulled OET back to 16cm @ lip. ETS for small amount of red/yellow mixed secretions. No A-line>>ABG drawn X 2 showing essentially normal range acid-base, with adequate oxygenation. RSBI done this a.m., was 78>>Pt. started on spontaneous breathing trial, with PS=5, peep=0, and FIO2 50%. RR low 20's, spont. VT ~ 350cc, SPO2=97%. Will evaluate for extubation.\n" }, { "category": "Nursing/other", "chartdate": "2116-06-27 00:00:00.000", "description": "Report", "row_id": 1304547, "text": "Resp. Care Note\nPt remains intubated and vented on settings PSV 5 peep 5 and 50%. TV 300 range and RR 20. Pt with good RSBI this morning and a successful breathing trial but no plans to extubate today. Neuro concerned about potential of ^ brain edema and compromise to airway. Plan to keep intubated for airway protection, follow neuro exam and assess for readiness for extubation.\n" } ]

[ { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "ABDOMEN (SUPINE ONLY)", "row_id": 875662, "text": " 9:46 AM\n ABDOMEN (SUPINE ONLY) Clip # \n Reason: r/o SBO\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with fevers, vomiting and abd distension.\n REASON FOR THIS EXAMINATION:\n r/o SBO\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fevers, vomiting and abdominal distention. Evaluate for SBO.\n\n COMPARISON: CT of the abdomen and pelvis dated .\n\n SUPINE ABDOMEN: On this single view of the abdomen, the upper abdomen\n including the hemidiaphragms is not imaged. The patient was imaged in the\n supine position. Given these limitations, there appears to be air and stool\n within the colon, with large stool bolus in the rectum. There is a rounded\n calcified structure in the right upper portion of the image, which corresponds\n to a calcified renal cyst on the prior CT. There are degenerative changes of\n the hips and spine. No dilated small bowel loops are seen. No free air is\n seen within the abdomen in the area imaged, though the hemidiaphragms were not\n imaged.\n\n IMPRESSION:\n 1) No definite evidence of obstruction.\n 2) Calcified renal cyst.\n 3) The upper abdomen including the hemidiaphragms were not imaged. There is\n no free air seen in the portion of the abdomen imaged.\n\n" }, { "category": "Radiology", "chartdate": "2178-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876335, "text": " 3:34 AM\n CHEST (PORTABLE AP) Clip # \n Reason: new infiltr, effusions\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with asprtn pna, desatting\n REASON FOR THIS EXAMINATION:\n new infiltr, effusions\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old man with aspiration pneumonia, desaturation.\n\n COMMENTS: Portable erect AP radiograph of the chest is reviewed and compared\n with the previous study of .\n\n There is continued mild congestive heart failure with cardiomegaly and small\n bilateral pleural effusion. There is continued opacity in both lower lobes\n indicating aspiration pneumonia. The patient has been extubated. The right\n jugular IV catheter remains in place. The nasogastric tube terminates in the\n gastric antrum. No pneumothorax is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 875676, "text": " 11:09 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval ett placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sob, s/p intubation\n\n REASON FOR THIS EXAMINATION:\n eval ett placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Intubation.\n\n PORTABLE SUPINE AP CHEST: Comparison is made to the study from one hour\n earlier. The newly inserted endotracheal tube tip is in satisfactory position\n in the mid trachea. The NG tube tip is below the diaphragm. Note is made of\n diffuse gaseous distention of multiple bowel loops. Heart size and appearance\n of the lungs are unchanged in the short interval since the prior study.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 875684, "text": " 12:33 PM\n CHEST PORT. LINE PLACEMENT; -76 BY SAME PHYSICIAN # \n Reason: s/p line placement\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sob, s/p central line placement\n\n REASON FOR THIS EXAMINATION:\n s/p line placement\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST 12:40 P.M.\n\n COMPARISON: , at 11:14 a.m.\n\n INDICATION: Line placement.\n\n There has been interval placement of a right subclavian vascular catheter,\n terminating in the superior vena cava. There is no pneumothorax.\n Endotracheal tube remains in satisfactory position. Cardiac and mediastinal\n contours are difficult to assess due to patient rotation, but are stable,\n accounting for this factor. Bilateral pleural effusions appear slightly\n increased in the interval. There is otherwise no significant change since the\n recent radiograph of approximately 1 hour earlier.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-07 00:00:00.000", "description": "P ABDOMEN (SUPINE ONLY) PORT", "row_id": 875827, "text": " 1:00 PM\n ABDOMEN (SUPINE ONLY) PORT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Eval for interval change of colonic distension\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with fevers, vomiting and abd distension.\n\n REASON FOR THIS EXAMINATION:\n Eval for interval change of colonic distension\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fevers, vomiting and abdominal distention. Evaluate for interval\n change in colonic distention.\n\n COMPARISON: at 07:21.\n\n SUPINE AP ABDOMEN: The colon is once again air-filled and dilated. The\n degree of dilation may be minimally improved from earlier today. However,\n there has been no significant interval change. The cecum is largely excluded\n from the image, limiting evaluation. The findings may represent colonic\n ileus. The calcified cystic structure associated with the right kidney is\n again noted. Degenerative changes of the spine are again noted.\n\n IMPRESSION: No significant change in the moderately dilated air-filled colon,\n which may represent a colonic ileus. Please note that the cecum is not imaged\n and this thus limits evaluation.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-07 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 875783, "text": " 6:51 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for SBO, dilated loops, air in rectum\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sepsis, constipation, dilated colon on previous eval\n REASON FOR THIS EXAMINATION:\n eval for SBO, dilated loops, air in rectum\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Sepsis, constipation, and dilated colon on previous evaluation.\n Evaluate for small-bowel obstruction, dilated loops and air in rectum.\n\n COMPARISON: .\n\n SUPINE ABDOMEN: Once again, colon is moderately dilated and air filled, to a\n similar degree of that seen yesterday. The cecum is largely excluded from the\n image. Large amount of stool is again seen in the rectum. There are no\n dilated small bowel loops to suggest a small- bowel obstruction. The findings\n may represent colonic ileus. There is a calcified cystic structure associated\n with the right kidney. Degenerative changes of the spine are again noted.\n\n IMPRESSION: Unchanged moderately dilated air-filled colon, which may\n represent a colonic ileus.\n\n" }, { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 875668, "text": " 10:06 AM\n CHEST (PA & LAT) Clip # \n Reason: aspiration PNA vs. effusion.\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with acute hypoxia in setting of vomiting/\n REASON FOR THIS EXAMINATION:\n aspiration PNA vs. effusion.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Acute hypoxia after vomiting.\n\n AP AND LATERAL CHEST RADIOGRAPHS: Comparison is made to the study from 2\n hours earlier. The lateral radiograph is extremely limited due to patient\n positioning ability. There is stable mild cardiomegaly. The lung volumes are\n low, causing crowding of pulmonary vessels. There is linear opacity in the\n right middle-to-lower lung zone, which could be atelectasis. Also noted are\n minimal interstitial opacities in both lower lobes, which could be due to\n aspiration or CHF.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-07 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 875799, "text": " 8:30 AM\n RENAL U.S. PORT Clip # \n Reason: INCREASE CREATININE,EVAL FOR OBSTRUCTION\\\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with ARF (creatinine 1.2 -> 6.7)\n\n REASON FOR THIS EXAMINATION:\n Eval for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n EXAMINATION: Renal ultrasound.\n\n MEDICAL HISTORY: 78-year-old man with acute renal failure.\n\n INDICATION: Rule out obstruction.\n\n Comparison is made to CT of .\n\n This exam is markedly limited secondary to the patient's body habitus.\n\n The right kidney measures 10.7 cm. The left kidney measures 11.7 cm. There\n is no evidence of hydronephrosis. The calcified cystic structure in the upper\n pole of the right kidney visualized on CT scan was not visualized secondary to\n body habitus.\n\n\n IMPRESSION:\n\n 1. No evidence of hydronephrosis on this limited exam.\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 876024, "text": " 7:16 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate, effusion\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sob, intubated, aspr pna\n\n REASON FOR THIS EXAMINATION:\n eval for infiltrate, effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, aspiration pneumonia, to evaluate for\n infiltrate or effusion.\n\n CHEST X-RAY AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: The tip of the right subclavian catheter overlies the SVC. The ET\n tube is at the thoracic inlet. The NG tube projects beyond the film. There\n appear to be bilateral pleural effusions, however, the lower part of the chest\n is not included in the film and this is very difficult to evaluate. A repeat\n film would be required to evaluate the lung bases.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-08 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 876025, "text": " 7:16 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval for obstr\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sob, intubated, aspr pna, obstipation\n\n REASON FOR THIS EXAMINATION:\n eval for obstr\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath, aspiration pneumonia and intubated. Evaluate\n for obstruction.\n\n COMPARISON: .\n\n AP SUPINE ABDOMEN: There has been interval resolution of colonic dilation.\n The bowel gas pattern is within normal limits of today's exam with a small\n amount of air still noted within the colon. There are no dilated loops of\n small bowel to suggest obstruction. The calcified cystic structure of the\n right kidney is again noted. Degenerative changes are again noted.\n\n IMPRESSION:\n Interval improvement in the colonic dilation. Normal bowel gas pattern.\n\n" }, { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 875647, "text": " 8:06 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: eval for pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with sob\n REASON FOR THIS EXAMINATION:\n eval for pna\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE SEMI-UPRIGHT CHEST @ 11:49:\n\n No prior films for comparison.\n\n The examination is technically limited due to extreme apical lordotic\n projection, as well as degree of patient rotation. This limits the assessment\n of the cardiac and mediastinal contours. The cardiac silhouette appears\n prominent. The aorta is tortuous. Pulmonary vascularity is within normal\n limits for technique. There is increased opacity in the lower left\n hemithorax, which appears to be due to both a pleural effusion and a\n parenchymal process. Within the right lung, there is patchy opacity at the\n right base with otherwise clear appearance. No definite right pleural\n effusion is evident. Within the imaged portion of the upper abdomen, there\n are mildly distended loops of colon measuring up to 7 cm in diameter.\n\n IMPRESSION: 1) Technically limited chest radiograph for which a dedicated PA\n and lateral chest radiographs in the department are recommended for more\n complete assessment when the patient's condition permits.\n\n 2) Small left pleural effusion.\n\n 3) Bibasilar opacities, left greater than right, which may be related to\n atelectasis, aspiration or infectious pneumonia.\n\n 4) Mildly distended loops of colon in the imaged portion of the upper\n abdomen, for which dedicated obstruction series could be obtained if warranted\n clinically.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-07-06 00:00:00.000", "description": "CT ABDOMEN W/O CONTRAST", "row_id": 875687, "text": " 12:47 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DISTENDED ABD,FEVER,AND ABDOMEN,INFILTRATE,EFFUSION,EVAL FOR OBSTRUCTION\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old man with distended abd, fever and vomiting\n REASON FOR THIS EXAMINATION:\n r/o obstruction.\n CONTRAINDICATIONS for IV CONTRAST:\n renal failure;ARF\n ______________________________________________________________________________\n WET READ: EEZ MON 1:59 PM\n bilateral lower lobe consolidations with dense material in lungs, likely from\n aspiration. No free intraperitoneal air. Dilated stool filled colon with\n likely wall thickening in rectum. 5 mm right renal stone, tiny 1 mm left renal\n stone. No hydro. Calcified right renal cyst.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Distended abdomen, fever and vomiting. Assess for obstruction.\n\n TECHNIQUE: Biometric CT imaging of the abdomen was performed without oral or\n IV contrast. This was done at the request of the referring service.\n\n COMPARISON: Abdominal radiographs from earlier the same day.\n\n CT OF THE ABDOMEN WITHOUT CONTRAST: Study is severely limited due to beam\n hardening artifact from the patient's arms, which were not able to be raised\n above his head. There are dense areas of consolidation in both lower lobes\n and the lingula. Multiple punctate areas of high attenuation are seen within\n the collapsed lung parenchyma, suggestive of aspiration. There are likely\n small bilateral pleural effusions. Evaluation of the aerated portion of the\n lung shows no intralobular septal thickening or definitely ground glass\n opacities to suggest fluid overload. Dense coronary arterial calcifications\n are seen in both the right and left coronary arteries.\n\n Assessment of the liver was severely limited due to extensive beam hardening\n artifact, resulting in diffusely heterogeneous hepatic attenuation. The\n spleen, gallbladder, and pancreas are grossly unremarkable. The adrenal\n glands, stomach, are within normal limits. All small bowel loops are\n decompressed. Arising from the upper pole of the right kidney is a 4.5 x 4.5\n cm calcified cystic lesion which demonstrates internal Hounsfield units above\n that expected for a simple cyst. This cannot be fully assessed without IV\n contrast. Two additional exophytic cystic structures are seen in the lower\n pole of the right kidney, one which measures 3.3 x 4.0 cm and demonstrates\n slightly higher Hounsfield units than expected, the other which measures 3.9 x\n 4.2 cm, and is likely a cyst. These are all incompletely assessed.\n Additionally, there is a 7 mm non-obstructing right renal stone, and a 1 mm\n non-obstructing stone in the lower pole of the left kidney. Extensive beam\n hardening artifact is seen through the left kidney. There are focal areas\n which appear darker than the adjacent abdominal fat, but this is only seen in\n relation to extreme beam hardening artifact from the patient's arms. The\n (Over)\n\n 12:47 PM\n CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip # \n Reason: DISTENDED ABD,FEVER,AND ABDOMEN,INFILTRATE,EFFUSION,EVAL FOR OBSTRUCTION\n Admitting Diagnosis: HYPOXIA, ACUTE RENAL FAILURE\n Field of view: 50\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n descending aorta is diffusely calcified.\n\n CT OF THE PELVIS WITHOUT CONTRAST: Stool is seen throughout the colon,\n and there is a large amount of stool within the rectosigmoid, with the\n sigmoid colon being dilated, measuring 8 cm. There is a suggestion of rectal\n wall thickening. The bladder is collapsed about a Foley catheter. There is no\n free fluid in the pelvis or pathological inguinal or pelvic nodal enlargement.\n\n Degenerative changes are seen throughout the spine and in both hips. No\n suspicious osseous lesions.\n\n IMPRESSION:\n 1) Dilated stool filled colon, particularly the rectosigmoid. There is also\n apparent rectal wall thickening. The findings are consistent with a fecal\n impaction.\n\n 2) Dense consolidation in both lower lobes which contain high attenuation\n material, suspicious for aspiration.\n\n 3) Extremely limited assessment of the abdomen due to respiratory motion and\n beam hardening artifact from the patient's arms.\n\n 4) Peripherally calcified cystic structure in the upper pole of the right\n kidney with Hounsfield units not consistent with a simple cyst. This is\n inadequately assessed without IV contrast. Further evaluation with MRI could\n be considered. Two additional likely cysts in the lower pole of the right\n kidney.\n\n 5) 7 mm non-obstructing right renal stone and tiny 1 mm non-obstructing left\n renal stone.\n\n\n\n" }, { "category": "ECG", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 196875, "text": "Sinus rhythm with atrial premature beats. Non-specific inferolateral T wave\nflattening. Compared to tracing #1, atrial premature beats are new and\nST segment depressions are improved.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 196876, "text": "Sinus rhythm. Non-specific inferolateral ST-T wave changes. Compared to the\nprevious tracing of ST-T wave changes are new and bradycardia is absent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 196877, "text": "Sinus bradycardia\nNormal ECG except for rate\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 196878, "text": "Sinus bradycardia\nNormal ECG except for rate\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 196879, "text": "Sinus rhythm\nFirst degree AV block\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 196880, "text": "Sinus rhythm\nFirst degree A-V block\nLeft atrial abnormality\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 196881, "text": "Sinus rhythm\nFirst degree A-V block\nNo previous tracing\n\n" }, { "category": "Nursing/other", "chartdate": "2178-07-12 00:00:00.000", "description": "Report", "row_id": 1457248, "text": "pmicu npn 7p-7a\n\n\n although still hypertensive, the pt did tolerate a decrease in the ntg rate. the insulin qtt was titrated off while he remained npo pnding a speech and swallow study.\n\nreview of systems\n\nrespiratory-> the pt continues to do well s/p extubation on . lung sounds cta while maintaining sats >95% on 4 liters nasal cannula. denies c/o sob.\n\ncardiac-> hr 60-70's, sr w/rare pvc's. sbp generally 150-160's thru most of the shift but transiently as high the 180's when awake.\n\nneuro-> alert and more interactive tonoc, oriented x2. he is mae with some difficulty d/t parkinson's as well as + peripheral edema. since the pt is taking po meds w/o incident, the tylenol/oxycodone combination was changed to his usual oxycontin dosing. he requested and received fentanyl x1 for ^discomfort with good effect.\n\ngi-> abd is soft, nontender w/+bs. ogt tongued out by pt last evening was not replaced since he was able to take po meds with water w/o incident. he continues to pass liquid, brown, ob+ stool via a mushroom catheter.\n\nheme-> steady, daily decline in hct. stool remains ob +.\n\ngu-> daily improvement in creat values continues with an increase in his hourly output. awaiting autodiuretic effect while remaining grossly tfb positive for her los. foley reinserted last noc d/t retention.\n\nendocrine-> while npo, insulin qtt on hold since last evening and fingersticks checked q2hrs overnoc.\n\nid-> afebrile with a persistently elevated wbc. surveillence blood cxs were sent again this morning.\n\naccess-> left areadial a-line and right ij tlcl are both patent and intact.\n\nsocial-> pt's wife called last noc and was updated on her husband's condition.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-12 00:00:00.000", "description": "Report", "row_id": 1457249, "text": "NPN 0700-1900:\n\nEVENTS: Hypertension continues to be his major barrier to leaving the ICU; he is otherwise much improved.\n\nROS:\nNEURO: Pt is A&O X 3, though HOH. Pleasant and cooperative. OOB to chair X 8 hours. Able to stand and pivot with assist X . Denies pain on current regimen. Sinemet being slowly increased towards outpatient dose of 6 tabs/day.\nRESP: Remains on NC 4L with sats in 90's. Slight DOE. No resp complaints. LS CTA. Occasional strong cough; appears to be swallowing secretions.\nC-V: BP via a-line 180's or higher all day. Early in shift when pt was getting OOB he c/o HA; BP 220's at the time. NTG gtt increased to 1.6mcg/kg/min with little effect. PO Isordil added, then increased; Lopressor increased, and given Lasix 20mg IV. No response to any of these interventions. At 1700 NBP was checked bilaterally and found to be ~140/45 in both arms with a-line 180's/60's. Question if vasospasm may be causing elevated BP from a-line. Decision made to pull a-line and follow NBP. Will wean NTG with goal SBP 150's-160's.\nGI: Belly remains benign with active BS. Passing flatus and small amts stool via mushroom. Bowel regime scaled back a bit. Remains NPO except H2O and meds which he is tolerating very well.\nGU: Fair diuretic response to Lasix 20mg IV.\nENDO: FSBS well-controlled on SSRI.\nID: Low-grade temp; WBC decreasing. Levoquin and Flagyl D/C'd after today's doses. Vanco to continue for total of 14 days. Pt did recieve dose of Vanco this afternoon for level of 14.3.\nHEME: Slow Hct drop over past several days; PPI changed to Protonix .\nSKIN: Heels slowly improving; pressure reduction methods utilized.\nSOCIAL: Wife, son and dtr visiting all afternoon; encouraged by his progress.\n\nA: continues to make good progress\n\nP: Wean NTG to off using NBP; goal SBP 150's-160's; check with team regarding dosing of anti-hypertensives tonight. Anticipate adding back ace-inhibitor when renal function improves. Monitor response to Lasix; goal is even to slightly negative. Check with team regarding ? check lytes this evening. Follow for evidence of infection off Levoquin and Flagyl. Continue to increase activity and work w/PT. Anticipate pt will be off NTG and ready to transfer to floor tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-13 00:00:00.000", "description": "Report", "row_id": 1457250, "text": "pmicu npn 7p-7a\n\n\n the pt continued to do well overnoc and was more alert and interactive. anticipate transfer to medicine later today.\n\nreview of systems\n\nrespiratory-> lung exam cta, maintaining sats >96% on room air. denies c/o sob.\n\ncardiac-> hr 60's, sr w/rare pvc's. improved blood pressure management sbp generally ranging 150-160's overnoc. lopressor dose was reduced and the hydralazine was changed to prn. repleted w/20meq po kcl x1 last noc.\n\nneuro-> a&o x3, very pleasant and interactive. mae x4 although rom limited by significant + peripheral edema in addition to parkinson's. oob to chair daily for several hours.\n\ngi/heme-> abd is soft, distended w/+bs. remains npo except for water w/meds while awaiting speech and swallow study today. passing liquid, brown, ob+ stool via mushroom catheter. of note, hct 29 this am; team is aware but has no immediate plans to transfuse.\n\ngu-> foley is patent and intact. received 20mg iv lasix last noc w/excellent results. since mn, the pt is ~700cc tfb negative. uop tapering to ~50cc/hr at the present time.\n\nid-> tmax 98 orally. steady decline in wbc, now 13 this morning. however, bc from growing out yeast. please f/u on random vanco level drawn this am.\n\nendocrine-> fs ranging 114-154. pt received riss coverage x1 only.\n\naccess-> right sc tlcl is patent and intact.\n\nsocial-> no contact w/family overnoc.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 1457247, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Numerous changes made to pain and antihypertensive medications. Oob to chair for most of shift.\n\n Neuro: Alert and oriented to person and day, not always sure of date or location. Short term memory intact. Speach is soft and garbled by ogt but is able to make needs known Moving all extrem. weakly. Oob to chair for most of shift and tolerated well. Stood at chairside with pt for very short period and tolerated well. Temperature max. 98.5 oral.\n\n Respiratory: Lung sounds are clear in all fields, diminished in lt base, rare crackle in rt base. RR 10-24 and non labored. O2 saturation on 3l nc 94-100% No congested cough noted.\n\n CV: Sinus brady to sinus rhythm with rare to occn pvc, rate 58-72. Abp 130's to 180's systolic. Ntg drip presently at 1.5 mcg/kg/min, weaned down from 3 mcg/kg/min. Multiple antihypertensives are having moderate effect on bp. Potassium repleation was completed this am. Hct 31.8 down from 32.5 this am.\n\n GI/GU: Abdomen softly distended with + bs. Ogt in good placement, tf criticare hn at goal of 60cc/hr. Minimal residuals. Mushroom catheter patent and draining dark liquid stool. Foley catheter d/c'd this pm after terazosin started. Bowel regimen increased to meet pain control medication needs.\n\n ID: Wbc down from 20 to 17. Vancomycin held this am d/t vanco level of 19. Levaqiun changed to po every 24 hrs for 2 days.\n\n Social: Wife, daughter and son in room most of afternoon. Met with team briefly, appeared to be satisfied with icu stay.\n\n Endocrine: Remains on insulin gtt at 6 units hr, fs average 120's to 150's.\n\n Plan: Monitor bp and effect of antihypertensives and pain control medications. Blood sugar every hour. Full code. ? c/o tomm. if weaned of gtts.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 1457242, "text": "MICU NURSING PROGRESS NOTE. 0700-1900\n SEE CAREVIEW FOR OBJECTIVE DATA.\n\n Events: Sedation to be changed r/t bradycardia caused by propofol. Changed antihypertensives. Son arrived from .\n\n Neuro: Sedated on propofol at present but will be changed to fentanyl and versed. With propofol off pts heartrate becomes wnl but becomes hypertensive to 190's. With propofol on at 20 mcg/kg/min bp comes to 170's but hr drops to low 40's. Opens eyes to verbal stimulus. Moving all extrem. with purpose and did follow simple commands. Pupils 3mm and brisk. Upper extrem. restrained for safety. Temperature max. 98.8 oral.\n\n Respiratory: Lung sounds are clear in upper fields, diminished in bilat bases. Ventilator settings are unchanged a/c/.40/550/20/5. Abg to be drawn. O2 saturation on present settings 95-100%. Suctioned every 3-4 hrs for thick tan secretions in sm to large amts.\n\n CV: Sinus brady to sinus rhythm with rare pvc's, rate 50's to 60's with several episodes of significant bradycardia down to mid 30's. Team aware. Ekg done, labs drawn. Ekg appears to be sinus. No significant lab values. Potassium repleated with 40 meq kcl iv. Hct stable.\n\n GI/GU: Abdomen softly distended with + bs. Large liquid brown stools x 2. Mushroom catheter placed and draining good amts liquid brown heme+ stool. Tf criticare hn via ogt infusing at goal rate 10 cc/hr. Foley catheter patent and draining clear yellow urine 40-60cc/hr.\n\n Endocrine: Riss inuse, fs 200.\n\n Social: Daughter,son and wife into sit with pt this pm. Asking approp. questions and are very concerned but cooperative.\n\n ID: Continue on levo,vanco and flagyl.\n\n Plan: Wean ventilator settings as tolerated. Sedate for comfort. Monitor urine output. Monitor cardiac status, atropine at bedside.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-10 00:00:00.000", "description": "Report", "row_id": 1457243, "text": "RESPIRATORY CARE NOTE: Pt remains intubated and ventilated. Changed pt from PS 5/5 to A/C to rest pt for the night. Pt was feeling a little short of breath. Pt on A/C 10/550/.40/+5 tolerating well..Breath sounds diminished throughout. Suctioned small to moderate amount thick yellow sputum. Will do RSBI and change back to PS if tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-10 00:00:00.000", "description": "Report", "row_id": 1457244, "text": "NPN 1900-0700:\n\nEVENTS: Returned to CMV mode of ventilation as he was tiring. Otherwise stable night.\n\nROS:\nNEURO: Fentanyl and Versed gtts initiated for general discomfort and to allow pt to rest on vent. Currently running at 50mcg/hr Fent and 4mg/hr Versed with good effect. He is lightly sedated, opens eyes when name called, f/c (though inconsistent). Nods/shakes head appropriately. Wrists restrained for safety.\nRESP: Pt c/o feeling SOB at start of shift. Suctioned for copious thick yellow secretions and placed on CMV .4/550/10/5. Pt cont to c/o subjective SOB until he was more sedated. Suctioned several times for thick yellow secretions. ABG on above settings: 7.38/33/118/19/-3.\nC-V: HR 60's, NSR, occ PVC's. BP running on the high side, 170's-180's. Minimal if any response to 10mg IV Hydralazine; dose increased to 30mg q6 hours with better effect. BP dropped to 150's-160's for about 3 hours. Nifedipine then added back (will give 1st dose at 0600). Lytes WNL.\nID: Afebrile, WBC WNL; con'ts on vanco, flagyl. Surveillance BC sent this AM.\nGI: Cont's to pass liquid brown stool vis mushrom catheter. TF's advance to 40cc/hr thus far. They continue to be well-tolerated.\nGU: ADequate UO: BUN/CREAT cont to normalize.\nHEME: Hct stable at 28.9; no evidence of active bleed.\nENDO: FSBS/SSRI; serum glucose running higher than FS by almost 40 points.\nSKIN: scrotum, penis edematous, scrotum reddened. Barrier cream applied. Bilateral heels w/stage 1 ulcers; elevated off bed and multi-podus boot alternated R/L. Skin otherwise intact.\nSOCIAL: Wife, son and dtr visited till ; asking appropriate questions and pleased with his progress.\n\nA: steady improvement cont's; unable to tolerate CPAP/PS overnight\n\nP: continue pulmonary hygeine and wean vent as able. Follow BP closely to assess response to anti-hypertensives. TF goal 60cc/hr. Fent/Versed for comfort and vent synchrony. Consider insulin gtt of sugars remain high. Continue all supportive care as we are doing.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-10 00:00:00.000", "description": "Report", "row_id": 1457245, "text": "NPN 0700-1900\nResp: Pt extubated at 1445, placed on face tent at 50% fio2. Sats 94-98, RR 10-15, no sob. Occ cough, expectorates sm amt, swallowed it, yank given, but pt's arms weak, difficult to use. LS clear with sl diminished/sl crackles at bases. Sputum yellow, very sm amt.\n\nCV: SBP high all day, 170s to 180s. D/c'd nifedipine and hydralazine, then restarted hydralazine again at 30mg q6hr. Goal BP 150-160. Team waiting for pt to self diuresis, so does not want to be aggressive with antihypertensives. CVP 7-9. HR stable 62-70. K repleted c 20meq po.\n\nNeuro: A&O x3. Communicative and pleasant. After tube out, c/o abd pain at #4. Dr. to pt it was probably cramps. Midaz d/c'd at 1300. Fentanyl weaned off. Will monitor for pain. Pt transiently c/o dizziness and sl nausea ~ 1/2 hr post extubation. No change in BP or HR. Asp ~ 10mls bilious from OG tube. Pt reported dizziness gone after ~ 10mins. Pt feels extremely weak. Says at baseline he can barely use R arm, he lifts and holds L arm but weakly. Pt uses walker but is mostly in w/c. Pt visited, will work with pt am and get oob.\n\nGI: TF d/c'd for extubation at 1200. IV fld run during that time, D5 1/2 NS at 85mls/hr. Restarted TF ~ 1445, IV flds d/c'd. Tol TF well earlier in day c minimal residuals. Loose, brown stool from mushroom cath, ~ 300mls for shift. Cont on Senna and colace only.\n\nEndo: RISS- FS > 200. Team had d/c'd steroids, waited for BS to go down, but didn't so started on Insulin gtt c hrly FS.\n\nGU: Cr cont to decline, now 2.5. u/o 35-80mls/hr. Pt positive >800mls thus far today, still positive many liters c edema U and L extrem.\n\nSkin: Rotating Multipodus boot. Heels stage 1, keeping pressure off.\nScrotum edematous.\n\nID: Vanco increased to 1500mg q 24 hrs. Cont on Flagyl and Levoflox. Afebrile.\n\nSocial: Family in today, very supportive. Pt's 50th wedding anniv is .\n\nPlan: Hrly FS, titrate insulin. Monitor BP for need for further meds. Encourage C&DB. Giving pt ice chips - swallowing well. Pt to have swallow study prior to feeding. Monitor u/o and stool output.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-11 00:00:00.000", "description": "Report", "row_id": 1457246, "text": "pmicu npn 7p-7a\n\n\n events overnoc include significant hypertension (sbp's 180-200) despite the addition of iv nitrates. at 0300, the pt awoke c/o \"not feeling well\" and eventually admitted to a h/a, leg, worsening abd, and chest pain. he received a total of 100mcqs of fentanyl and 6mg iv morphine w/o subjective improvement in his chest pain. per micu resident, an ekg was unrevealing. pt was at maximum dose ntg and continued to be hypertensive w/sbps 180-190's. after approx 1 hour, the narcotics appeared to take effect, and the pt's blood pressure fell to the 150-160's. of note, the pt was receiving oxycontin for his chronic back pain pta.\n\nreview of systems\n\nrespiratory-> pt was successfully extubated yesterday and was eventually weaned to a nasal cannula early last evening. he began to desaturate, however, when his pain status deteriorated ~0300. he was subsequently placed on 100% cn and is maintaining sats >95%. rr teens and nonlabored.\n\ncardiac-> hypertensive thru most of the shift but dramatically improved w/the addition of narcotics to manage his chronic pain. currently weaning ntg qtt slowly and maintaining sbp 150-160's. hr 60-70's, sr with rare pvc's. pt received a total of 60meq kcl repletion this morning.\n\nneuro-> the pt appears alert and oriented although very hoh. he denies any subjective improvement in his pain status despite falling back to sleep after receiving narcotics. a prn order for fentanyl was written although the pt would likely benefit from a consistent dosage rtc.\n\ngi-> abd is soft, nontender w/+bs. he is tolerating tube feedings at goal rate and passing moderate amts of brown, liquid stool via a mushroom catheter.\n\ngu-> creat levels continue to trend downward on a daily basis. uop >30cc/hr although the pt continues to be grossly tfb positive (approx 9.5 liters for his los).\n\nid-> wbc doubled to 20K from yesterday. bc x2/urine cx and ua sent. the pt has been afebrile. no change in abx regimen to cover for an asp pnx.\n\nendocrine-> insulin qtt titrated frequently to maintain fs <150.\n\naccess-> right sc tlcl and a left radial a-line are both patent and intact.\n\nsocial-> pt's wife called last noc and was updated on his condition at that time.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 1457240, "text": "NPN 7p-7a:\n Neuro: Pt opens eyes to voice, follows commands. Squeezes both hands, and wiggles toes. Lightly sedated on Propofol, increased to 35mcg/kg/min. Pt med with MSO4 1mg iv x 2 for penile pain. penis is very swollen and painful.. team aware.\n RESP: Vent changes made overnight as such: RR decreased to 20 from 25, and peep decreased from 8 to 5. TV's 550, fio2 40%. ABG: 7.42/28/115/19. sx for small amts yellow secretions. LS crackles L base.\n CV: HR 50's-70's SB/NSR. Pt very hypotensive o/n, sbp 160's-170's, up to 180's-190's sustained. Several calls placed to dR. . Pt med with 10mg iv hydralazine x 2, 1 hr apart per Dr. without effect. then pt med with mso4 as noted above to see if pain was causing hypertension. Propofol gtt increased without effect. Then pt med with 10mg nifedipine pogt x 1, with sbp down to 150's-160's. CVP running .\n Gi: pt with enormous bm x 1, which blew off butt bag, which was left off as seemed ineffective. pt with smaller bm x 1. cont on rigorous bowel regime. xray done last noc, bowel appears much less full of stool. remains npo.\n GU: foley intact, uo 60-160cc's/hr.\n Integ: heels with stage 1 pressure sores, elevated off bed.\n Social: wife called x 1 o/n. updated.\n FE: fsbs high 100's, treated x 2 o/n with 2units regular insulin.\n ID: received dose vanco yesterday. Cont on flagyl.\n A/p: 78 yr old pt s/p SBO/aspiration, with LLL infiltrate. pt s/p bowel clean out, now tolerating some weaning to vent settings. Bun/Creat slowly returning to baseline. Pt requiring treatment o/n for hypertension. will need more effective regime. follow temp/cx.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 1457241, "text": "the pt remained stable beside occasionnal bradycardia 2 to propofolol.\nhydralazine to manage his bp and fentanyl and versed for neuro.\nbs:occa wheezes .suctionned a moderate amount of thick yellow secretions.no vent changes made and no abg.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-08 00:00:00.000", "description": "Report", "row_id": 1457237, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. See resp flowsheet for specific vent settings/data/changes. PEEP weaned down today to good effect. ABG WNL. BLBS slightly coarse anteriorly, suctioned for small amounts of thick whitish clear sputum. SpO2 remained 90s. ETT remains secure/patent & in good position.\n\nPlan: maintain support; continue to wean as tolerated\n" }, { "category": "Nursing/other", "chartdate": "2178-07-08 00:00:00.000", "description": "Report", "row_id": 1457238, "text": "NPN 0700-1900\nNeuro: Pt sedated on Propofol 25mcg. Awakens to voice, follows commands. Lifts and holds all extremities. No c/o pain. Grimaces with nsg care = 2ml boluses for nsg care.\n\nCV: HR55-67, sb/nsr no ectopy. BP higher today 150/52 - 168/67. Team will grad add back antihypertensives, but wanted to watch BP today. Was on Levophed 24 hrs ago. CVP down to 11-12 from 15 early this am. Pt receiving 75mls/hr D5 1/2NS. Repeat chems drawn this eve, pending.\n\nResp: Cont on AC 550x25, fio2 dropped from 50 to 40 early this am. Peep dropped from 14 to 12, later to 10. Last ABG was at 10 peep - very good, see careview. LS mostly clear, diminished at bases. Minimal secretions.\n\nGi: +BS. Abd much less distended, even from this am to pm. Pt had 4 stools, 2 huge, 1 lge, 1med. Had 1 SSE, 1 Dulcolax supp, and cont lactulose and colace. Stool mostly formed, soft. Last few stools had more loose stool.\n\nGU: U/o improved. >45mls/hr. Pt fld bal negative so far today, still 6.8L up los.\n\nID: Afebrile. Zosyn d/c'd and Flagyl iv started. Vanco and Levoflox cont.\n\nSkin: Intact\n\nSocial: Wife and dtr here most of day as well as neice.\n\nPlan: Continue to monitor resp status/ abgs. RT just dropped peep down to 8, f/u. Monitor u/o hrly, need for further bowel meds and enemas. Cont abx.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-09 00:00:00.000", "description": "Report", "row_id": 1457239, "text": "RESPIRATORY CARE NOTE:: Pt remains intubated and on A/C decreased RR 20/550/.40/+5 decreased from 8. Breath sounds diminished and clear throughout, suctioned moderate amount thick tan sputum. Will do RSBI. Wean as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-07 00:00:00.000", "description": "Report", "row_id": 1457233, "text": "MICU NURSING PROGRESS NOTE 0700-1900\nNEURO--REMAINS SEDATED ON PROPOFOL BUT WAKES TO NAME AND NODS HEAD APPROPRIATELY TO SIMPLE QUESTIONS. MOVES BILATERAL HANDS AND FEET TO COMMAND AND WILL GRASP FOR SIDE RAIL WHEN TURNED ON SIDE. PEARL AT 2-3 MM.\n\nPAIN--WHEN ASKED IF IN PAIN, PT NODDED AFFIRMATIVE. WHEN ASKED WHERE PAIN IS, PT WAS UNRESTRAINED AND POINTED TO BELLY. REPOSITIONED AND FELT BETTER.\n\nCARDIAC--LEVO WEANED OFF. HR SB/SR WITH OCCASIONAL APC'S. MAP >60. RECIEVING FLUID BOLUSES OF NS FOR HYPOTENSION, LOW CVP AND DECREASED UO.\n\nRESP--PT ON 50% AND FULLY VENTILLATED. SPONT RESP . LUNGS COARSE IN UPPER AIRWAYS AND CRACKLES IN BASES BILATERALLY. SAO2 >96%. SX Q2-3 HRS FOR THICK BROWN SPECKLED SPUTUM.\n\nGI--UO POOR. RECEIVING NS BOLUSES IN 500 CC INCREMENTS. AFTER RECIEVING 500 CC, HIS UO FOR THE FOLLOWING 1HR HAS BEEN 30CC. UO HAS BEEN Q1HR. KUB DONE, FILLED WITH STOOL. 2 SEPARATE SSE GIVEN 4 HRS APART. PT HAS ENORMOUS AMTS OF SOFT FORMED STOOL IN RESPONSE TO BOTH OF THESE ENEMAS. REPEAT KUB SHOWED IMPROVEMENT.\n\nGU--FOLEY CATH PATENT DRAINING POOR AMTS OF AMBER CLOUDY STOOL.\n\nENDO--HYPOGLYCEMIC TO 51. RECEIVED AMP D50. REPEAT SUGARS HAVE BEEN 90-110. STARTED ON HYDROCORTISONE.\n\nSKIN--INTACT WITHOUT BREAKDOWN. R SIDED TRIPLE LUMEN SITE CLEAR.\n\nID--AFEBRILE. REMAINS ON ABX. BLOOD CX AND URINE CX SENT.\n\nCOPING--FAMILY IN AT BEDSIDE . THEY HAVE BEEN UPDATED REGARDING PROGRESS OF THEIR LOVED ONE. THEY ARE HAPPY THAT HE HAS NO FEVER AND THAT THE BP MED IS OFF. THEY ARE CONCERNED ABOUT RESULTS OF BLOOD CX AND URINE CX.\n\nA--MAINTAINING ADEQUATE BP. RESPONDING TO ENEMAS.\n\nP--CON'T TO MONITOR. ENEMAS AS ORDERED. MONITOR BS. OFFER SUPPORT TO PT AND FAMILY. CON'T ABX .\n" }, { "category": "Nursing/other", "chartdate": "2178-07-07 00:00:00.000", "description": "Report", "row_id": 1457234, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. Currently on A/C w/ settings per resp flowsheet. PIP/Pplat = 27/24. Weaned FiO2 today w/ PaO2 in adequate range. ABG shows compensated metabolic acidosis w/ PaCo2 in high 20s. SpO2 remained 90s. BLBS slightly coarse, suctioned for small amounts of thick creamy sputum. See resp flowsheet for specific vent data/changes.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2178-07-08 00:00:00.000", "description": "Report", "row_id": 1457235, "text": "RESP CARE: Pt remains intubated/on vent per carevue. Lungs dim RLL, sxd scant amount of sputum. ABGs pending this am. No RSBI due to high PEEP\n" }, { "category": "Nursing/other", "chartdate": "2178-07-08 00:00:00.000", "description": "Report", "row_id": 1457236, "text": "npn\nneuro: pt continues sedated with propofol at 25 mcg, pt is comfortable, awakens to voice, follows commands, squeeezes wiht both hands and moves both legs. perrla\npain: pt c/o abd and throat pain pt repositioned for comfort\n\ncad sb/sr 50 to 60's no ecotpy noted. abp range 134/46 to 156/59 with maps 70 to 80's. cvp 17 to 20. pt given one 500cc bolus of ns. levophed remains off\n\nresp ls clear with diminished bases, vent fio2 was supposed to been changed to 40% but was not decreased until 5am. sats 98 to 100%,\n\ngu: uo 70 to 130cc/hr of amberish clear. bun/creat 106/4.7 ionized ca+ 1.14. negative 360 cc at 5am but overall 6500cc++ for los.\n\ngi: abd firm /distended, sse given with some results, lactulose also given, see .\n\nendo: bs all under 150 no ssi coverage needed.\n\nid: continues with temp in 99 range, blood cx sent off rsc.\n\nplan: continue with bowel regime, continue to wean vent settings, continue to monitor vs, labs etc..\n" }, { "category": "Nursing/other", "chartdate": "2178-07-07 00:00:00.000", "description": "Report", "row_id": 1457231, "text": "MICU NURSING PROGRESS NOTE. 2300-0700\n SEE CAREVIEW FOR OBJECTIVE DATA\n\n EVENTS: Abdomen noted to be firmer, team aware. Levophed decreased slightly.\n\n Neuro: Arouses to verbal stimulus by opening eyes, moving all extrem. in purposeful manner. Is not following commands as of this time. Remains moderatly sedated on propofol at 15 mcg/kg/min. Pupils are 3 mm and brisk. Temperature max. 98.4 oral.\n\n Respiratory: Lung sounds are clear in upper fields, diminished in lll. Ventilator setting remains unchanged ac/.80/550/28/14. O2 saturation on present ventilator settings 96-100%. Occn. difficult to obtain sao2. Suctioned every 3-4 hrs for thick white/ thick green sputum. Abg on present settings 7.33/161/33. Team aware of last abg.\n\n CV: Sinus brady with rare pvc, rate 50's. Abp high 90's to low 110's systolic. CVp 14-20. No fluid bolus's required. Levophed reduced to .04 mcg/kg/min. A line site wnl, waveform sharp. Awaiting am lab results.\n\n GI/GU: Abdomen firmly distended with hypoactive bs. Fleets enema given this am with very minimal reults. Dulcolax supp. given, awating results. Was lightly disempacted on previous shift with good results. Abd. film pending. Foley catheter patent and draining cloudy amber urine 25-40cc/hr.\n\n Endocrine: Insulin gtt off at present, awaiting 5 am fs. Fs have been varied, 60-114.\n\n Social: No social contacts as of this time.\n\n Integ: Skin appears grossly intact. Waffle boot applied to protect heels, appear bruised.\n\n Plan: Wean ventilator as tolerated. Wean levophed as tolerated, cvp goal > 14, map > 65.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-07-07 00:00:00.000", "description": "Report", "row_id": 1457232, "text": "Resp Care, pt remains intubated and sedated. Pt was bronched last noc for minimal secretions. Plan to wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 1457228, "text": "Respiratory Care: Patient admitted with severe hypoxemia and metabolic acidosis. He is on full vent support. CXR with LLL collapse. Suctioned for greenish grey sputum. Plan for bronchoscopy and wean FIO2 as tolerated.\n\n" }, { "category": "Nursing/other", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 1457229, "text": "MICU Admission NPN:\n78y.o. male admitted today from EW with aspiration pneumonia/acute on chronic renal failure, creat 6.7 and K+ 6.2, and ?SBO.\n\n Pt resides at Rehab along with his wife. had some abdominal pain and distension and vomited last Tuesday and choked and had possible aspiration at that time. Since then wife reports changes in mental status. Today pt developed acute resp distress, fevers 101.8. Brought to EW and had low sat on RA and was put on 100% NRB. Did poorly and required intubation for increasing hypoxia/acidosis. CXR showed Left infiltrate, KUB showed ?SBO. Abdominal CT ruled out SBO but pt noted to be full of stool. Pt dropping BP in EW, received 3000cc's IVF. Foley was inserted and pt had 800cc's urine in bladder and also put out 1000cc's urine after insertion. Pt brought to MICU-A after central line and A-line was inserted in EW.\n\nPMH: Parkinson's disease, spinal stenosis with partial paraplegia, uses walker/wheelchair as needed, CRI, Chronic MSRA UTI, Bilateral renal cysts, recent dental abcess, GIB, Gallstones s/p chole , Anxiety disorder, chronic constipation, HTN, CAD, NQWMI, Melanoma\n\nAllergies: Amoxicillin\n\nI sent home pt's wedding ring with his wife.\n\nNeuro: Sedated on propofol drip at 15mcg/kg/min. Shaking head/arms/legs with stimulation noted. Pt very HOH. Opens eyes to commands. MAE. Pupils 5mm react to light bilaterally.\n\nCV: Hypotensive upon admission and started on levophed drip. Remains on low dose at this time. Sat difficult to obtain due to low perfusion. Given bicarb drip 1000cc's once for acidosis/fluid bolus for low UO. HR low at times and due to renal failure felt to have atenolol toxicity and has responded to two doses of glucogon IV 10mg run over 10minutes. Currently HR 51 sinus brady. BP 120/60. Goal MAP>60.\n\nResp: Very acidotic ?due to sepsis and renal failure. Using vent to help correct acidosis. Currently on AC 28, TV 550, FIO2 weaned to 80%. 14cm peep. Last ABG on 90% with some improvement. pH improved after fluid bolus. Pt with deminished breath sounds left lower lobe. Suctioned initally for what looked like fecal material. Quick bronch done at bedside which did not reveal much. CXR showed aspiration pna.\n\nGI: Abdomen large obese with faint, infrequent hypo BS. OGT in place by auscultation. Getting bowel meds. Given dulcolax suppository, passed small brown stool, awaiting further results. benefit from disimpaction. Team planning to see how effective the suppository is before this. Hct 30. Blood clot sent to BB on hold.\n\nGU: UO low but has picked up after fluid bolus. Urine now concentrated/cloudy. Creat improved slightly with fluids and renal involved on consult. Please that urine has picked up and K+ has come down to 5.4\n\nID: Sputum sent as well as urine. Blood had been sent from EW. Pt given levo/flagyl in EW as well as vanco and here has started on zosyn Q8hrs. Pt is afebrile. WBC 9.2\n\nEndo: Started on insulin drip and titrated to get blood sugars 80-130 goal. Have not obtained this as yet\n" }, { "category": "Nursing/other", "chartdate": "2178-07-06 00:00:00.000", "description": "Report", "row_id": 1457230, "text": "MICU Admission NPN:\n(Continued)\nand he currently is on 10u/hr with last glucose 280 at 8PM. Will continue to titrate and get glucose under control.\n\nIV: Right SC triple lumen as well as two peripherla IV's in place. A-line right radial artery.\n\nSocial: Wife and daughter updated and aware of the plan. Telephone numbers are in nursing admission note.\n" } ]

[ { "category": "Radiology", "chartdate": "2190-06-20 00:00:00.000", "description": "CT ABD & PELVIS WITH CONTRAST", "row_id": 1238666, "text": " 6:33 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for infection\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 60M with fever, prior episode of cholangitis\n REASON FOR THIS EXAMINATION:\n evaluate for infection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: TXCf SUN 9:39 PM\n 1. moderate left pleural effusion of intermediate density, adjacent pleura is\n enchaning suggesting of superimposed infection.\n 2. bibasilar consolidation, atelectasis, aspiration or infection.\n 3. heterogeneous liver enhancement; multiple hypoattenuating lesions, some of\n which are well defined likely cysts. However, some are less well defined with\n peripheral hyperenhancement, the largest measuring 1.4cm, in setting of recent\n biliary tract infection, developing/resolving abcesses are concerning.\n Infrahepatic fluid collection.\n 4. compression deformities of L1, L3, L5 of indeterminate chronicity.\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, RUQ pain. Recent cholangitis, ERCP with stent placement.\n\n COMPARISONS: Abdominal ultrasound exam of the same date.\n\n TECHNIQUE: MDCT-acquired contiguous images through the abdomen and pelvis\n were obtained with intravenous contrast at 5-mm slice thickness. Coronally\n and sagittally reformatted images were displayed.\n\n FINDINGS:\n\n CT OF THE ABDOMEN:\n\n Moderate left pleural effusion is noted. There is apparent enhancement of\n overlying pleura. Adjacent small left lung base consolidation is noted.\n Small right lung base consolidation is also seen. No left pleural effusion.\n Heart is top normal in size without pericardial effusion.\n\n The liver demonstrates heterogeneous enhancement. There are numerous focal\n hypodensities scattered throughout the hepatic parenchyma, most of which are\n too small to characterize while others are compatible with cysts. Other\n lesions however are not so well defined. For example the largest of these\n hypodense lesions is in segment V/VI measures 1.2 x 1.3 cm (2:30) and\n demonstrates hyperenhancement of the surrounding liver parenchyma. A biliary\n stent is in place, which appears appropriately positioned. There is no\n evidence of intrahepatic or extrahepatic biliary ductal dilatation. There is\n no pneumobilia. Hepatic vasculature appears patent. The gallbladder is\n incompletely distended. There is no gallbladder wall thickening. Trace\n pericholecystic fluid collection is seen. Small amount of sludge and tiny\n stones are better seen on the ultrasound exam of the same day. There is\n (Over)\n\n 6:33 PM\n CT ABD & PELVIS WITH CONTRAST Clip # \n Reason: evaluate for infection\n Contrast: OMNIPAQUE Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n small amount of infrahepatic fluid measuring intermediate density up to 26\n Hounsfield units in attenuation. The fluid collection measures 6.5 x 5.4 cm\n (2:43).\n\n The spleen is unremarkable. The pancreas enhances homogeneously without\n ductal dilatation or peripancreatic fluid collection. The adrenal glands are\n normal. Kidneys enhance and excrete contrast symmetrically without\n hydronephrosis or renal masses. Small and large bowel loops are normal in\n caliber without bowel wall thickening or obstruction. There is no free air\n within the abdomen. Intra-abdominal aorta and its branches are normal in\n caliber. A gastrostomy tube is in place.\n\n CT OF THE PELVIS: The bladder is collapsed around a Foley catheter. The\n prostate gland, seminal vesicles, rectum and sigmoid colon are unremarkable.\n There is no free air or free fluid within the pelvis. No pathologically\n enlarged pelvic or inguinal lymph nodes are seen.\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesion is seen. Diffuse\n osteopenia and muscle atrophy is noted. Multiple compression deformities of\n L5, L3 and L1 vertebral bodies are of indeterminate chronicity.\n\n IMPRESSION:\n\n 1. Moderate left pleural effusion with enhancement of the adjacent pleural\n raising concern for empyema. Small basilar consolidations, may represent\n atelectasis, aspiration or infection in the appropriate clinical setting.\n\n 2. Heterogeneous liver enhancement with numerous focal hypodensities, some of\n which\n appear simple in nature however there are several ill defined hypodensities\n with surrounding hyperenhancing parenchyma. In the setting of recently\n reported ascending cholangitis, hepatic abscesses would be of concern.\n Obtaining recent outside CT to evaluate for interval change may help further\n characterize.\n\n 3. No evidence of acute cholecystitis. Sludge and numerous tiny stones.\n Gallbladder stones are better seen on the ultrasound exam of the same date.\n\n 4. L1, L3, and L5 compression deformities of indeterminate chronicity.\n\n" }, { "category": "Radiology", "chartdate": "2190-06-24 00:00:00.000", "description": "PICC W/O PORT", "row_id": 1239240, "text": " 3:45 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place picc\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 15\n ********************************* CPT Codes ********************************\n * PICC W/O FLUORO GUID PLCT/REPLCT/REMOVE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with ALS and liver abscess\n REASON FOR THIS EXAMINATION:\n place picc\n ______________________________________________________________________________\n FINAL REPORT\n PICC LINE PLACEMENT\n\n CLINICAL INDICATION: 60-year-old man with ALS and liver abscess. Needs PICC\n line for antimicrobial therapy.\n\n The patient was placed on the fluoroscopic table in supine position. The\n initial efforts were focused on the right upper extremity where the IV team\n initially attempted placement of a PICC line, the tip of which was coiled in a\n chest wall vein. The skin of the right upper extremity around the insertion\n site was prepped and draped in a sterile fashion. Local anesthesia around the\n insertion site was effected by 1% lidocaine. Existing PICC line was removed\n over a guidewire. A 0.018 guidewire was successfully advanced into the\n superior vena cava. A single-lumen PICC line was unable to be advanced over\n the guidewire past the axillary vein. Limited right upper extremity venogram\n demonstrated abrupt axillary vein occlusion and extensive collateral framework\n of veins draining the right upper extremity through the intercostal venous\n collaterals of the chest wall.\n\n The attention was diverted to the left upper extremity. The skin of the left\n upper extremity was prepped and draped in a sterile fashion. Local anesthesia\n was effected by 1% lidocaine. Patent and fully compressible left brachial\n vein was punctured under direct ultrasound visualization using 21-gauge\n micropuncture needle. A 0.018 guidewire was advanced into the superior vena\n cava. Micropuncture needle was exchanged for a 4-French micropuncture sheath.\n A 4-French single-lumen PICC line was then advanced into the distal superior\n vena cava through the appropriate peel-away sheath which was subsequently\n removed.\n\n CONCLUSION:\n\n 1. Successful placement of a single-lumen PICC line into the distal superior\n vena cava via the left brachial vein.\n 2. The line is ready to use.\n (Over)\n\n 3:45 PM\n PICC LINE PLACMENT SCH Clip # \n Reason: place picc\n Admitting Diagnosis: ABDOMINAL PAIN\n Contrast: OPTIRAY Amt: 15\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2190-06-23 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1239009, "text": " 10:17 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 44 cm left Picc \n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with new Picc\n REASON FOR THIS EXAMINATION:\n 44 cm left Picc \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old man with new 44 cm left PICC.\n\n COMPARISONS: Portable AP radiograph from .\n\n FINDINGS: A new left PICC catheter is malpositioned and remains within the\n lateral chest wall. Recommend repositioning. Since the prior radiograph,\n bibasilar opacities and large bilateral pleural effusions are unchanged. The\n upper lungs are clear. Cardiomediastinal silhouette is unchanged.\n\n IMPRESSION:\n 1. Malpositioned right PICC catheter in the lateral chest wall, recommend\n repositioning.\n 2. Stable large bilateral pleural effusions.\n\n Findings regarding PICC line were discussed , IV nurse by Dr. \n via telephone at 10:50 a.m.\n\n" }, { "category": "Radiology", "chartdate": "2190-06-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238848, "text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old man with increasing white count and GNR in sputum\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Increasing white count.\n\n FINDINGS: In comparison with the study of , there are again areas of\n increased opacification at the bases with poor definition of the\n hemidiaphragms, more prominent on the left. This is consistent with layering\n pleural effusion and underlying atelectasis. In the appropriate clinical\n setting, the possibility of supervening pneumonia would have to be considered.\n\n\n Tracheostomy tube remains in place and there is no evidence of vascular\n congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-06-20 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 1238657, "text": " 4:21 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN) Clip # \n Reason: evaluate for evidence of CBD obstruction\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 60M with ALS vent dependent presents w/ fevers and RUQ pain\n REASON FOR THIS EXAMINATION:\n evaluate for evidence of CBD obstruction\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: MRAf SUN 5:57 PM\n CBD stent resulted in improvment of previously seen ductal dilitation.\n Heterogenous liver. Decompressed gallbladder filled with sludge and stones.\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: ALS, vent dependent, presents with fevers and right upper\n quadrant pain.\n\n COMPARISONS: .\n\n FINDINGS: The liver echotexture is heterogeneous. There are no focal liver\n lesions identified. The gallbladder is decompressed but contains stones and\n sludge as previously seen. A stent is in place within the common bile duct\n and which has resulted in a decompression of the biliary ductal dilatation\n seen on previous ultrasound. To the extent visualized, the pancreas is\n normal. The main portal vein demonstrates normal hepatopetal flow. The\n spleen is minimally enlarged measuring 13.8 cm. There is no ascites.\n\n IMPRESSION:\n 1. Common bile duct stent with decompression of the previously seen biliary\n ductal dilatation.\n 2. Decompressed, sludge and stone-filled gallbladder, without evidence of\n cholecystitis.\n\n\n" }, { "category": "Radiology", "chartdate": "2190-06-20 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1238654, "text": " 3:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o pna\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 60M with ALS, vent dependent, fevers, abdominal pain, adventitious\n breath sounds\n REASON FOR THIS EXAMINATION:\n r/o pna\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fever, labored breathing. Assess for pneumonia.\n\n COMPARISONS: Chest radiographs dated and .\n\n FINDINGS:\n\n AP view of the chest demonstrates moderate left pleural effusion, unchanged\n since prior. Left lung base consolidation is again noted. Right pleural\n effusion has improved. Right lung base opacities likely represent\n atelectasis. Hilar and mediastinal silhouettes are unchanged. Heart size is\n normal. There is no pulmonary edema. Tracheostomy tube is noted with its tip\n terminating 3.9 cm above the carina.\n\n IMPRESSION:\n\n In comparison to exam, moderate left pleural effusion is unchanged.\n Persistent left lung base consolidation may represent atelectasis or infection\n in appropriate clinical setting.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2196-04-28 00:00:00.000", "description": "Report", "row_id": 1402807, "text": "CCU NPN 1400-2300\nS/O:\n\nCV: PT ADMITTED FROM CATH LAB AT 1400. SHEATHS PULLED AT 1630 FROM RIGHT GROIN, DSD APPLIED AND NO HEAMOTOMA OR OOZE. HEP STARTED AT 2100 AT 700U/HR, TO CONT UNTIL 0300 AND THEN D/C. PLAVIX STARTED AND GIVEN AT . ALL CARDIAC MEDS FROM HOME GIVEN. HR 70'S-90'S SR WITHOUT VEA. SBP STABLE. K 3.7 AT 2130, WILL REPLETE TONIGHT. 1/2 NS AT 100CC/HR, SECOND LITER UP. PT 80 LASIX IV IN BETWEEN LITERS WITH GOOD DIURESIS. REPEAT K 4.1.\n\nRESP: SATS STABLE ON RA. LUNGS CLEAR TO BILAT.\n\nID: AFEB.\n\nGI: ATE LATE LUNCH AND DINNER. BS 219 AT 1800, REC'D 6U REGULAR INSULIN, NEED TO INC SLIDING SCALE UNLESS BS .\n\nGU: URINE CLEAR WITH GOOD DIURESIS.\n\nMS: A/O, PLEASANT. NEURO CHECKS STABLE WITH , , NO C/O DIZZINESS OR H/A.\n\nA/P: STABLE POST CATH LAB, D/C HEP AT 0300, CONT TO FOLLOW NEURO VS Q2H. CHECK FS AT 0000.\n" }, { "category": "Nursing/other", "chartdate": "2196-04-29 00:00:00.000", "description": "Report", "row_id": 1402808, "text": "CCU NPN 1900-0700\nafeb.\nHR 80-90 SR. no VEA. BP 100-110/50.\nK+ 3.7 and repleted with 40meq po.\nright groin site D/I. pulses 1+ bilat.\nheparin off at 0300 per order. IVF completed post angio.\nu/o 50cc/hr. (-) 400cc for .\nFS 233- covered with 4Ureg.\nA/O x3. dozing short naps during night. MAE. pt. states she had a bad reaction to a sleeping med. (unsure which one) in past and is now hesitant to take any.\nLS clear. RA sat 92-95%. sleeping with HOB up >30deg.\nA: stable s/p angio. no neuro changes.\nP: OOB today. follow lytes. ? start usual insulin dose.\n" }, { "category": "Nursing/other", "chartdate": "2196-04-29 00:00:00.000", "description": "Report", "row_id": 1402809, "text": "ccu nursing progress note\ns: i only walk 20ft\no: pls see carevue flowsheet for complete vs/data/events\nneuro: intact. no s/s.\noob amb w rn this am. tol well\nr fem site d/i. pulses palp.\ndc'd to home this afternoon w family. only new med plavix.\na: s/p carotid stent attempt\np: dc home\n" }, { "category": "ECG", "chartdate": "2196-04-28 00:00:00.000", "description": "Report", "row_id": 299366, "text": "Poor quality tracing. Probable atrial sensed and ventricular paced rhythm.\nSince the previous tracing of probably no significant change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2197-08-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 976177, "text": " 6:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: SEIZURES\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with seizure\n REASON FOR THIS EXAMINATION:\n please eval for new hemorrhage\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Recent subarachnoid hemorrhage, now with seizure.\n\n NON-CONTRAST HEAD CT: This study is limited by motion, despite several\n attempts.\n No hydrocephalus, shift of midline structures, or gross intra- or extra-axial\n hemorrhage is seen. There is no definite acute major vascular territorial\n infarct, though again, due to the limited nature of the study, a small one\n cannot be excluded. Osseous structures are unchanged. The imaged paranasal\n sinuses and mastoid air cells are clear.\n\n IMPRESSION: Limited study; no gross hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-25 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 975368, "text": " 10:20 AM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: swallow evaluate\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with CVA right sided weakness\n REASON FOR THIS EXAMINATION:\n swallow evaluate\n ______________________________________________________________________________\n FINAL REPORT\n ORAL VIDEO OROPHARYNGEAL SWALLOW\n\n HISTORY: 55-year-old woman with CVA and dysphagia.\n\n ORAL AND PHARYNGEAL VIDEO FLUOROSCOPIC EXAMINATION: An oral and pharyngeal\n video fluoroscopic swallowing evaluation was performed today in collaboration\n with the Speech and Language Pathology Division. Various consistencies of\n barium were administered.\n\n The oral phase demonstrated decreased bolus control with piecemeal handling of\n the bolus and mild premature spillover. The pharyngeal phase demonstrates\n mild- to- moderate delay in swallow initiation. Laryngeal elevation, valve\n closure, and epiglottic deflection were within normal limits. There was no\n aspiration or penetration seen. However, with self-administered thin liquids,\n there is moderate filling of the piriform sinuses. This was decreased with a\n chin tuck maneuver.\n\n IMPRESSION: There is no evidence of aspiration. However, with thin liquids,\n there was moderate filling of the piriform sinuses, which may potentially lead\n to aspiration. A chin tuck maneuver was effective in decreasing this.\n\n" }, { "category": "Radiology", "chartdate": "2197-08-24 00:00:00.000", "description": "P CAROTID SERIES COMPLETE PORT", "row_id": 975231, "text": " 10:31 AM\n CAROTID SERIES COMPLETE PORT Clip # \n Reason: LEFT HEMIPARESIS, S/P RT CEA\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with L hemiparesis, s/p R CEA\n REASON FOR THIS EXAMINATION:\n please eval carotids\n ______________________________________________________________________________\n FINAL REPORT\n CAROTID SERIES COMPLETE.\n\n REASON: Stroke.\n\n FINDINGS: Duplex evaluation was performed of both carotid arteries. Moderate\n plaque was identified on the right.\n\n On the right, peak systolic velocities are 190, 113, 114 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 1.7. This is consistent with 60-69%\n stenosis.\n\n On the left, peak systolic velocities are 106, 91, 246 in the ICA, CCA, ECA\n respectively. The ICA to CCA ratio is 1.2. This is consistent with less than\n 40% stenosis.\n\n There is antegrade flow in both vertebral arteries.\n\n IMPRESSION: Moderate plaque with a right 60-69% and a left less than 40%\n carotid stenosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-24 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 975287, "text": " 5:53 PM\n MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST Clip # \n Reason: please eval for infarct, sinus venous thrombosis, occlusion,\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with h/a, SAH on head CT, sx concerning for R infarct\n REASON FOR THIS EXAMINATION:\n please eval for infarct, sinus venous thrombosis, occlusion, aneurysm, vasc\n malformation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Headache, left-sided symptoms, recent left-sided subarachnoid\n hemorrhage on head CT.\n\n TECHNIQUE: Multiplanar T1 and T2-weighted images without administration of IV\n contrast. 3D time-of-flight images obtained for MR angiography, 2D time-of-\n flight images for venography.\n\n FINDINGS: Small linear foci of T2 and FLAIR prolongation in the sulci of the\n left frontal lobe correspond with the known area of subarachnoid hemorrhage on\n the CT scan of , and represent a small amount of\n chronic subarachnoid blood. No new areas of hemorrhage are identified. No\n masses or mass effect are seen. Ventricles and sulci are normal in\n configuration.\n\n MR angiography and MR venography were also performed, and show no aneurysms or\n vascular malformations.\n\n There is no evidence of infarction.\n\n IMPRESSION: Small amount of linear high T2 signal in the left frontal lobe\n corresponding with the known area of subarachnoid hemorrhage. No aneurysms or\n other vascular malformation. No evidence of infarction.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-26 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 975500, "text": " 11:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: additional SAH\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with L SAH now with acute onset thunderclap headache\n REASON FOR THIS EXAMINATION:\n additional SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old female with left subarachnoid hemorrhage, now new\n onset headache.\n\n COMPARISON: .\n\n TECHNIQUE: Non-contrast head CT scan.\n\n FINDINGS: A small amount of subarachnoid blood in the left frontal sulci is\n resolving. There are no new areas of subarachnoid hemorrhage. There is no\n shift of the normally midline structures or major vascular territorial\n infarct. There is no hydrocephalus. Osseous structures and paranasal sinuses\n are unchanged.\n\n IMPRESSION:\n\n 1. Resolving left frontal subarachnoid hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-24 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 975177, "text": " 5:14 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: CTA, CTV to evaluate for embolic stroke, venous sinus thromb\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with L hemiparesis severe HA, L-side intracranial blood. Did\n not tolerate MRI despite sedation.\n REASON FOR THIS EXAMINATION:\n CTA, CTV to evaluate for embolic stroke, venous sinus thrombosis\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 7:20 AM\n No evidence of arterial occlusion or venous sinus thrombosis. Small SAH better\n seen on prior noncontrast CT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Subarachnoid hemorrhage in left, left-sided neurologic signs.\n\n TECHNIQUE: CT head and neck before and after uneventful administration of 80\n mL of Optiray IV contrast. Images were processed on a separate workstation\n with displayed curved reformats, volume rendered images, and maximum intensity\n projection images.\n\n COMPARISON: CT scan.\n\n CT ANGIOGRAM HEAD: A small amount of blood is seen in the left superior\n frontal region, less apparent than on the previous examination. Ventricles\n and sulci are normal in caliber and configuration. No fractures are seen. The\n circle of and major branches appear normal, without evidence of\n stenosis or aneurysm. CT venogram images demonstrate large cerebral veins\n along the right parietal lobe, and just inferior to the straight sinus, and\n a focally small left transverse sinus. No large arteries are seen connected\n to the large veins.\n\n CT ANGIOGRAM NECK: The carotid and vertebral arteries and their major\n branches are patent without evidence of stenosis. Lung apices are normal.\n\n IMPRESSION:\n\n 1. Large veins along the right parietal cerebral convexity and along the\n straight sinus, without definite feeding arteries, most likely representing\n anomalous venous drainage of doubtful clinical significance. The possibility,\n though small, exists that the right parietal veins could represent a dural AV\n malformation with nonvisualization of a feeding epidural artery closely\n applied to the dura. If a high flow lesion such as a dural AV malformation is\n suspected, catheter angiography should be performed.\n\n 2. Resolving left frontal subarachnoid hemorrhage. No aneurysm identified.\n\n Findings and recommendations discussed with Dr of Vascular Neurology by\n phone on .\n (Over)\n\n 5:14 AM\n CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS Clip # \n Reason: CTA, CTV to evaluate for embolic stroke, venous sinus thromb\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2197-08-24 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 975169, "text": " 4:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: please eval for infxn, mass\n Admitting Diagnosis: SUBARACHNOID HEMORRHAGE;STROKE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with SAH\n REASON FOR THIS EXAMINATION:\n please eval for infxn, mass\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE PORTABLE SUPINE FILM OF THE CHEST ON AT 0429 HOURS.\n\n No previous studies are available for comparison. Surgical clips overlie the\n left upper chest whether intra- or extra-thoracic undetermined. Poor\n inspiratory effort is taken and the diaphragms are high. There is slight\n prominence of vascular shadows. At this point in time this could just be due\n to poor respiratory motion. Follow up films are indicated to further evaluate\n the chest. No definite mass lesions are seen.\n\n CONCLUSION: Poor aeration, evidence of surgery in the left upper chest area.\n Possible early vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2197-08-24 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 975166, "text": " 1:28 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: left sided paralysis- head CT from OSH (neg) but looks like\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 55 year old woman with\n REASON FOR THIS EXAMINATION:\n left sided paralysis- head CT from OSH (neg) but looks like SAH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 3:31 AM\n Small left frontal SAH. Otherwise unremarkable study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 55-year-old woman with paralysis - head CT from outside hospital\n negative, but looks like SAH.\n\n CT HEAD WITHOUT CONTRAST:\n No prior comparison studies are available. There is a small amount of\n subarachnoid blood in left superior frontal sulci (2:24). There is a second\n focus of small amount of hemorrhage overlying a left frontal gyrus (2:19). No\n mass effect or shift of normally midline structures. Ventricles and cisterns\n are normal in size. No evidence of major vascular territorial infarct.\n\n Partially visualized is an interrupted tooth projecting into the left\n maxillary sinus. The sinus and mastoid air cells are clear. Bony structures\n and surrounding soft tissue structures are unremarkable.\n\n IMPRESSION:\n 1. Small amount of subarachnoid hemorrhage in the superior left frontal\n region.\n 2. Small amount of acute hemorrhage overlying a left frontal gyrus, most\n likely also representing subarachnoid hemorrhage.\n\n\n" }, { "category": "Echo", "chartdate": "2197-08-24 00:00:00.000", "description": "Report", "row_id": 83817, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate for thrombus, endocarditis, Left ventricular function, valve function, PFO by Bubble study.\nHeight: (in) 66\nWeight (lb): 238\nBSA (m2): 2.16 m2\nBP (mm Hg): 131/52\nHR (bpm): 55\nStatus: Inpatient\nDate/Time: at 13:23\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: Saline\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No ASD or PFO by 2D, color\nDoppler or saline contrast with maneuvers.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). No LV mass/thrombus. 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. Mildly dilated aortic arch.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Trivial MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Contrast study was performed with 3 iv injections of 8 ccs\nof agitated normal saline, at rest, with cough and post-Valsalva maneuver.\nSuboptimal image quality - poor echo windows.\n\nConclusions:\nThe left atrium is normal in size. No atrial septal defect or patent foramen\novale is seen by 2D, color Doppler or saline contrast with maneuvers (images\nafter cough and Valsalva maneuver are technically suboptimal). Left\nventricular wall thickness, cavity size and regional/global systolic function\nare normal (LVEF >55%) No masses or thrombi are seen in the left ventricle.\nRight ventricular chamber size and free wall motion are normal. The aortic\narch is mildly dilated. The aortic valve leaflets (3) appear structurally\nnormal with good leaflet excursion and no aortic regurgitation. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. The estimated pulmonary artery systolic\npressure is normal. There is no pericardial effusion.\n\nIMPRESSION: No cardiac source of embolism identified. Normal global and\nregional biventricular systolic function.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-24 00:00:00.000", "description": "Report", "row_id": 1641418, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT A&O X2, DIFFICULTY W/WORD FINDING, LEFT FACIAL DROOP NOTED. NORMAL STRENGTH TO RU/RLE, WEAK GRASP NOTED TO LEFT, NO MV,T TO LLE. IMPAIRED SENSATION AT BASELINE TO ALL EXTREMS. PERRLA, 3MM, BRISK. C/O HEADACHE/BACK PAIN, IV DILAUDID GIVEN W/RELIEF.\n\nCVS: HR 40S-50S, SB, DR. AWARE. SBP 110S-130S, AFEBRILE. HCT STABLE, K 3.6, NA 147. CARDIAC ECHO/CAROTID US/EKG DONE.\n\nRESP: O2 SATS 95-99% ON 2L N/C, DOWN TO 92% ON RA. LUNGS CLEAR, SL DIMINISHED AT BASES, NARD/SOB.\n\nGI/GU: ABD S/NT, HYPO+BS, CONT NPO, NO N/V. SPEECH & SWALLOW WENT POORLY, PT WILL NEED VIDEO SWALLOW. HUO 25-115, CYU\n\nINTEG: PT TURNED FREQUENTLY, NO AREAS OF BREAKDOWN NOTED. UP OOB W/PT TO CHAIR, SIG LEFT-SIDED WEAKNESS, TOL TRANSFER OK.\n\nSOCIAL: PT HUSBAND/DTR IN TO VISIT. DTR PLANS TO STAY THE WEEKEND, SOCIAL WORK NOTIFIED-WILL SPEAK W/DTR .\n\nPLAN: CONT FREQUENT NEURO CHECKS, F/U MRI, HEMODYNAMIC MONITORING. PAIN MGMT, ACT AS TOL, ?VIDEO SWALLOW. PAIN MGMT, FAMILY SUPPORT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2197-08-25 00:00:00.000", "description": "Report", "row_id": 1641419, "text": "NURSING PROGRESS NOTE\nNEURO:PT EASILY AROUSED AWAKE, ALERT OX2(\"HOSPITAL AND NAME BUT YESR IS OFF ) RT HEMIPARESIS AND LT ARM AND LEG FLACCID. PERRLA, SPEECH GARBLED. MRI ON EVES DONE.\nCV:VSS, TMAX 99.1 PO, SINUS BRADY 43-54, NO ECTOPICS. BIL DP PALP. K 3.8 TO BE REPLETED. BLOOD CULTURES OBTAINED. IV RT ARM LEAKING AND D/C'D #20 IV RESTARTED BY IV RN. IVF KVO NOW.\nRESP O2SAT 99% ON 2L NP. BIL BREATH SOUNDS PRESENT CLEAR.\nGI:NPO. VIDEO SWALLOW STUDY TO BE DONE TODAY. NO N/V. NO STOOL, BOWEL SOUNDS PRESENT. BLOOD SUGARS IN THE 80'S NO INSULIN REQUIRED PER SLIDING SCALE.\nGU:ADEQ HUO.\nPSYCHOSOCIAL:PT CALM, APPROPRIATE, NO CALLS FROM FAMILY OVERNIGHT.\nPLAN:VIDEO SWALLOW TODAY\nHYPERCOAGS PENDING, CHECK FOR RESULTS AND CHECK IF HEPARIN TO BE STARTED TODAY.\nREPLETE K FOR 3.8\nKEEP SBP<180 AND MAP<130 (LABETOLOL ORDERED PRN)\nPROVIDE INFORMATION TO PT AND FAMILY. PROVIDE EMOTIONAL SUPPORT AND COPING STRATEGIES.\n\n\n" }, { "category": "ECG", "chartdate": "2197-08-26 00:00:00.000", "description": "Report", "row_id": 219169, "text": "Sinus bradycardia. The limb leads are misattached. Compared to the prior\ntracing of no diagnostic interim change.\n\n" }, { "category": "ECG", "chartdate": "2197-08-24 00:00:00.000", "description": "Report", "row_id": 219170, "text": "Sinus bradycardia\nConsider left atrial abnormality\nOtherwise normal ECG\nSince previous tracing of the same date, sinus bradycardia present\n\n" }, { "category": "ECG", "chartdate": "2197-08-24 00:00:00.000", "description": "Report", "row_id": 219171, "text": "Sinus bradycardia\nConsider left atrial abnormality\nOtherwise normal ECG\nSince previous tracing of the same date, no significant change\n\n" }, { "category": "ECG", "chartdate": "2197-08-24 00:00:00.000", "description": "Report", "row_id": 219172, "text": "Sinus bradycardia\nConsider left atrial abnormality\nOtherwise normal ECG\nNo previous tracing available for comparison\n\n" } ]

[ { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394264, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. A/A/0x3, pleasant and cooperative, oxygenating well on room air,\n lungs clear, anuric, comfortable s/p dialysis previous shift, denies\n abdominal pain or discomfort\n Action:\n Labs sent previous shift , am labs sent\n Response:\n BUN/CREAT 23/5.3 post dialysis, am pnd\n Plan:\n Follow up with am labs\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR, 1degree AV block with PR\n 0.21-0.22 by monitor. BP ranges 130-140\ns/60-70\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate, closely monitored\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104\n Plan:\n Follow up with am labs and EKG\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394265, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. A/A/0x3, pleasant and cooperative, oxygenating well on room air,\n lungs clear, anuric, comfortable s/p dialysis previous shift, denies\n abdominal pain or discomfort\n Action:\n Labs sent previous shift , am labs sent\n Response:\n BUN/CREAT 23/5.3 post dialysis, am pnd , last CPK 31\n Plan:\n Follow up with am labs\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR, 1degree AV block with PR\n 0.21-0.22 by monitor. BP ranges 130-140\ns/60-70\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate, closely monitored\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104\n Plan:\n Follow up with am labs and EKG\n" }, { "category": "ECG", "chartdate": "2196-12-17 00:00:00.000", "description": "Report", "row_id": 274608, "text": "Sinus bradycardia with first degree A-V block. Possible anteroseptal\nmyocardial infarction, age indeterminate. Non-specific lateral ST-T wave\nchanges. Compared to tracing #3 bradycardia is new. Lateral ST-T wave changes\nare more pronounced. The QRS change in lead V3 is probably positional.\nTRACING #4\n\n" }, { "category": "ECG", "chartdate": "2196-12-17 00:00:00.000", "description": "Report", "row_id": 274609, "text": "Sinus rhythm with first degree A-V block. Non-specific intraventricular\nconduction delay. Non-specific ST-T wave changes. Compared to tracing #2\nthe QRS change in lead V3 is probably positional.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2196-12-17 00:00:00.000", "description": "Report", "row_id": 274610, "text": "Sinus rhythm with first degree A-V block. Non-specific intraventricular\nconduction delay. Possible anteroseptal myocardial infarction, age\nindeterminate. Non-specific ST-T wave changes. Compared to tracing #1\nsinus rhythm is now present. Peaked T waves are less pronounced.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2196-12-17 00:00:00.000", "description": "Report", "row_id": 274607, "text": "Baseline artifact is present. Sinus rhythm. There is a late transition with\nQ waves in the anterior leads consistent with probable prior myocardial\ninfarction. Non-specific ST-T wave changes. Compared to the previous tracing\nthe P-R interval is shorter.\n\n" }, { "category": "ECG", "chartdate": "2196-12-17 00:00:00.000", "description": "Report", "row_id": 274822, "text": "Sinus bradycardia with pauses and junctional escape beats. Possible blocked\npremature atrial contractions. Also, evidence for retrograde conduction in\nlead V1. Tall T waves suggesting hyperkalemia. Probable anteroseptal\nmyocardial infarction. Compared to the previous tracing of sinus\nbradycardia, first degree A-V block, junctional beats and tall peaked T waves\nare new.\nTRACING #1\n\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394246, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. A/A/0x3, pleasant and cooperative, oxygenating well on room air,\n lungs clear, anuric, comfortable s/p dialysis previous shift, denies\n abdominal pain or discomfort\n Action:\n Labs sent previous shift\n Response:\n BUN/CREAT 23/5.3 post dialysis\n Plan:\n Follow up with am labs\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR, 1degree AV block with PR\n 0.21-0.22 by monitor. BP ranges 130-140\ns/60-70\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate, closely monitored\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104\n Plan:\n Follow up with am labs and EKG\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394239, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Action:\n Labs sent previous shift\n Response:\n Repeat k+\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394240, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Labs sent previous shift\n Response:\n BUN/CREAT 23/5.3\n Plan:\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR with BP ranges\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394241, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. A/A/0x3, pleasant and cooperative, oxygenating well on room air,\n lungs clear, anuric,\n Action:\n Labs sent previous shift\n Response:\n BUN/CREAT 23/5.3 post dialysis\n Plan:\n Follow up with am labs\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR with BP ranges\n 130-140\ns/60-70\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104\n Plan:\n Follow up with am labs and EKG\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 394327, "text": "Pt is a 62 woman w/ h/o PAF, IgA nephropathy and CKD who presented to\n outpatient HD yesterday with epigastric pain, hypotension (SBP 70s),\n and bradycardia (~30 bpm). Sent to the ED where BP 107/61, HR 30s, also\n noted to be Mobitz II heart block with K+ 7.3 and peaked T\ns on ECG.\n Treated with insulin/glucose/bicarb/Calcium Gluconate\n repeat 6.2 then\n 6.7. To CCU for immediate dialysis. Initial glucose 57\nreceived\n apple juice and crackers\n subsequent FS 140-150\ns. Pt last dialysis\n was Wed\n a day early secondary to holiday on Thurs.\n HR throughout CCU course 60\ns SR with 1^st degree AVB, BP stable\n 118-150\ns/systolic.\n c/o pain across lower rib cage on admission\nreproducible on palpation\n began after straining for bowel movement yesterday AM, has slowly\n subsided\n now pain-free.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Tolerated dialysis run yesterday\n 2 liters off, post-K+ 4.0 now back\n to 5.o this am\n Action:\n Following labs, HR/Ryhthm, BP; holding some cardiac meds\n captopril,\n amlodipine\n Response:\n Remains stable - VSS\n Plan:\n c/o to medical floor, follow labs overnight - ? need for extra dialysis\n in AM prior to D/C\n usual dialysis days are Tues-Thurs-Sat; ? restart\n usual cardiac meds and assess toleration prior to discharge.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n HYPERKALEMIA, HEART BLOCK\n Code status:\n Full code\n Height:\n Admission weight:\n 48 kg\n Daily weight:\n Allergies/Reactions:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Unknown; fever;\n Precautions:\n PMH: Renal Failure\n CV-PMH: Arrhythmias, Hypertension\n Additional history: Afib/flutter since ; off coumadin since \n sec UGI bleed; s/p ablation\n ESRD secondary to IgA nephropathy s/p cadaveric kidney transplant\n which eventually failed - Tues-Th-Sat dialysis via LUE AVF; last\n dialysis Wed sec to holiday\n UGI Bleed- esophagitis, gastric ulacer, bleeding duodenal vessel -\n s/p clipping, cauterization, PPI\n diastolic heart failure dx'd by echo \n - malignant hypertension w/seizure\n ddepression - celexa\n rheumatic fever as child\n Social: s/p smoker quit 25 years ago, rare etoh, sister with breast CA\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:145\n D:62\n Temperature:\n 98\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 71 bpm\n Heart rhythm:\n 1st AV (First degree AV Block)\n O2 delivery device:\n None\n O2 saturation:\n 97% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 138 mEq/L\n 05:39 AM\n Potassium:\n 5.0 mEq/L\n 05:39 AM\n Chloride:\n 94 mEq/L\n 05:39 AM\n CO2:\n 35 mEq/L\n 05:39 AM\n BUN:\n 38 mg/dL\n 05:39 AM\n Creatinine:\n 6.9 mg/dL\n 05:39 AM\n Glucose:\n 91 mg/dL\n 05:39 AM\n Hematocrit:\n 33.7 %\n 05:39 AM\n Finger Stick Glucose:\n 98\n 06:00 AM\n Valuables / Signature\n Patient valuables: clothes, glasses\n Other valuables:\n Clothes: Sent home with:\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: 624 \n Transferred to: 2\n Date & time of Transfer: 1230pm\n" }, { "category": "Physician ", "chartdate": "2196-12-17 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 394232, "text": "Chief Complaint: Hypotension, bradycardia, chronic renal failure.\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n Patient awoke this AM with abdominal pain. No N/V. No blood per rectum.\n Went to dialysis and didn't feel right. Was sent to the ED for\n evaluation without getting dialysis.\n In ED, BP 107 systolic with HR 30's. Initial potassium was 7.6. ECG\n shows long pauses with junctional escape beats. Admitted to CCU. Went\n for dialysis. BP was stable. Now in NSR.\n Patient admitted from: ER\n History obtained from Medical records\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Unknown; fever;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n CRF\n Peptic ulcer disease.\n Afib\n Esophagitis\n Rheumatic fever as child\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems:\n Flowsheet Data as of 07:02 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 64 (62 - 66) bpm\n BP: 139/65(83) {126/61(77) - 151/70(94)} mmHg\n RR: 18 (9 - 18) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///34/\n Physical Examination\n General Appearance: Well nourished, No acute distress, No(t) Overweight\n / Obese, Thin, No(t) Anxious, No(t) Diaphoretic\n Eyes / Conjunctiva: PERRL, No(t) Pupils dilated, No(t) Conjunctiva\n pale, No(t) Sclera edema\n Head, Ears, Nose, Throat: Normocephalic, No(t) Poor dentition, No(t)\n Endotracheal tube, No(t) NG tube, No(t) OG tube\n Cardiovascular: (PMI Normal, No(t) Hyperdynamic), (S1: Normal, No(t)\n Absent), (S2: Normal, No(t) Distant, No(t) Loud, No(t) Widely split ,\n No(t) Fixed), No(t) S3, No(t) S4, No(t) Rub, (Murmur: Systolic, No(t)\n Diastolic), II/VI systolic murmur at lower left sternal border.\n Continuous sound at suprasternal notch radiating from fistula\n Peripheral 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, No(t) Paradoxical), (Breath\n Sounds: Clear : Anteriorally and laterally, No(t) Crackles : , No(t)\n Bronchial: , No(t) Wheezes : , No(t) Diminished: , No(t) Absent : ,\n No(t) Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender: , No(t) Obese\n Extremities: Right lower extremity edema: Absent edema, Left lower\n extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing\n Musculoskeletal: No(t) Muscle wasting, No(t) Unable to stand\n Skin: Warm, No(t) Rash: , No(t) Jaundice\n Neurologic: Attentive, Follows simple commands, Responds to: Verbal\n stimuli, Oriented (to): X 3, Movement: Purposeful, No(t) Sedated, No(t)\n Paralyzed, Tone: Not assessed\n Labs / Radiology\n 248 K/uL\n 36.0 %\n 11.4 g/dL\n 119 mg/dL\n 5.3 mg/dL\n 23 mg/dL\n 34 mEq/L\n 95 mEq/L\n 4.0 mEq/L\n 139 mEq/L\n 6.6 K/uL\n [image002.jpg]\n 10:18 AM\n 05:22 PM\n WBC\n 6.6\n Hct\n 36.0\n Plt\n 248\n Cr\n 11.9\n 5.3\n TropT\n 0.05\n Glucose\n 98\n 119\n Other labs: PT / PTT / INR:16.0/27.7/1.4, CK / CKMB /\n Troponin-T:31//0.05, Differential-Neuts:71.4 %, Lymph:20.8 %, Mono:5.3\n %, Eos:1.7 %, Ca++:9.5 mg/dL, Mg++:1.8 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n RENAL FAILURE, CHRONIC (CHRONIC RENAL FAILURE, CRF, CHRONIC KIDNEY\n DISEASE)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n HYPERKALEMIA (HIGH POTASSIUM, HYPERPOTASSEMIA)\n BRADYCARDIA\n ===========================\n Patient with hyperkalemia probably related to the extra day between\n dialysis sessions. Bradycardia likely secondary to hyperkalemia. Now\n much better following dialysis. Monitor overnight.\n Abdominal pain resolved. Benign exam now. Would check\n LFTs/amylase/lipase for evidence of possible bilary stone.\n Electrolytes and acid-base status improved following dialysis.\n ICU Care\n Nutrition: Oral\n Glycemic Control:\n Lines / Intubation:\n 20 Gauge - 05:46 PM\n Comments:\n Prophylaxis:\n DVT: (Systemic anticoagulation: Coumadin)\n Stress ulcer: PPI\n VAP:\n Comments: Not applicable.\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: Transfer to floor\n Total time spent: 40 minutes\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 394313, "text": "Pt is a 62 woman w/ h/o PAF, IgA nephropathy and CKD who presented to\n outpatient HD yesterday with epigastric pain, hypotension (SBP 70s),\n and bradycardia (~30 bpm). Sent to the ED where BP 107/61, HR 30s, also\n noted to be Mobitz II heart block with K+ 7.3 and peaked T\ns on ECG.\n Treated with insulin/glucose/bicarb/Calcium Gluconate\n repeat 6.2 then\n 6.7. To CCU for immediate dialysis. Initial glucose 57\nreceived\n apple juice and crackers\n subsequent FS 140-150\ns. Pt last dialysis\n was Wed\n a day early secondary to holiday on Thurs.\n HR throughout CCU course 60\ns SR with 1^st degree AVB, BP stable\n 118-150\ns/systolic.\n c/o pain across lower rib cage on admission\nreproducible on palpation\n began after straining for bowel movement yesterday AM, has slowly\n subsided\n now pain-free.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Tolerated dialysis run yesterday\n 2 liters off, post-K+ 4.0 now back\n to 5.o this am\n Action:\n Following labs, HR/Ryhthm, BP; holding some cardiac meds\n captopril,\n amlodipine\n Response:\n Remains stable - VSS\n Plan:\n c/o to medical floor, follow labs overnight - ? need for extra dialysis\n in AM prior to D/C\n usual dialysis days are Tues-Thurs-Sat; ? restart\n usual cardiac meds and assess toleration prior to discharge.\n" }, { "category": "Physician ", "chartdate": "2196-12-18 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 394297, "text": "TITLE:\n Chief Complaint: tolerated HD, no more bradycardia\n 24 Hour Events:\n NASAL SWAB - At 10:00 AM\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Unknown; fever;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 08:01 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.7\nC (99.8\n Tcurrent: 36.8\nC (98.3\n HR: 66 (62 - 68) bpm\n BP: 152/79(97) {126/61(77) - 152/79(97)} mmHg\n RR: 18 (9 - 22) insp/min\n SpO2: 96%\n Heart rhythm: 1st AV (First degree AV Block)\n Total In:\n 80 mL\n PO:\n 30 mL\n TF:\n IVF:\n 50 mL\n Blood products:\n Total out:\n 2,000 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n -1,920 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 96%\n ABG: ///35/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 269 K/uL\n 11.2 g/dL\n 91 mg/dL\n 6.9 mg/dL\n 35 mEq/L\n 5.0 mEq/L\n 38 mg/dL\n 94 mEq/L\n 138 mEq/L\n 33.7 %\n 6.3 K/uL\n [image002.jpg]\n 10:18 AM\n 05:22 PM\n 05:39 AM\n WBC\n 6.6\n 6.3\n Hct\n 36.0\n 33.7\n Plt\n 248\n 269\n Cr\n 11.9\n 5.3\n 6.9\n TropT\n 0.05\n 0.07\n Glucose\n 98\n 119\n 91\n Other labs: PT / PTT / INR:16.0/27.7/1.4, CK / CKMB /\n Troponin-T:31//0.07, ALT / AST:55/44, Alk Phos / T Bili:96/0.4, Amylase\n / Lipase:90/42, Differential-Neuts:71.4 %, Lymph:20.8 %, Mono:5.3 %,\n Eos:1.7 %, Albumin:4.1 g/dL, LDH:199 IU/L, Ca++:10.0 mg/dL, Mg++:2.7\n mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n 62 year old woman with atrial fibrillation and end stage renal disease\n status post failed transplant and currently on HD who presented with\n epigastric pain, hyperkalemia, and sinus bradycardia.\n # Hyperkalemia: Secondary to ESRD. She has a history of hyperkalemic\n episodes in the past, that required MICU admission and emergent\n dialysis. Her baseline K is in the 5-6 range. Currently status post\n calcium gluconate, bicarb and insulin, and now HD.\n - follow K (5.0) this AM and monitor ECG\n - urgent dialysis\n - kayexalate if dialysis delayed\n # Rhythm: Sinus bradycardia with 1st degree AV delay with junctional\n escape beats at presentation, currently sinus. The patient was\n bradycardic on admission with peaked T's on ECG from hyperkalemia. We\n do not have a longer rhythm strip that suggest Mobitz II or CHB on\n admission. For now, will monitor patient on telemetry. Hold nodal\n agents for now. On discharge, can consider holding, or redosing nodal\n agents.\n - monitor ECG/tele\n - atropine at bedside\n - continue amiodarone\n - hold metoprolol/nodal agents for now\n # Atrial fibrillation: currently in sinus rhythm.\n - on amiodarone; add back metoprolol as tolerated.\n - on warfarin, follow INR\n # Epigastric pain: Ddx includes anginal equivalent/CAD vs viral\n gastroenteritis vs renal failure vs gastritis. Currently pain is\n improved.\n - contiunue home PPI\n # ESRD on HD: secondary to IgA nephropathy, s/p failed transplant.\n - HD today\n .\n # HTN:\n - On CCB, ACEi (on captopril and lisinopril at home - unclear why; will\n hold both for now and restart once stable BP)\n - Will plan to d/c captopril indefinitely on discharge\n .\n FEN: replete lytes, renal diet\n ACCESS: PIV's\n PROPHYLAXIS: warfarin, PPI\n CODE: Full Code (confirmed).\n DISPO: MEDICINE SERVICE TODAY\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 05:46 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": "2196-12-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 394303, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 394308, "text": "Pt is a 62 woman w/ h/o PAF, IgA nephropathy and CKD who presented to\n outpatient HD today with epigastric pain, hypotension (SBP 70s), and\n bradycardia (~30 bpm). Sent to the ED where BP 107/61, HR 30s, also\n noted to be Mobitz II heart block with K+ 7.3 and peaked T\ns on ECG.\n Treated with insulin/glucose/bicarb/Calcium Gluconate\n repeat 6.2 then\n 6.7. To CCU for immediate dialysis. Initial glucose 57\nreceived\n apple juice and crackers\n subsequent FS 140-150\ns. Pt last dialysis\n was Wed\n a day early secondary to holiday onThurs.\n HR throughout CCU course 60\nsSR with 1^st degree AVB, BP stable\n 118-150\ns/systolic.\n c/o pain across lower rib cage on admission\nreproducible on palpation\n began after straining for bowel movement yesterday AM, has slowly\n subsided\n now pain-free.\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Tolerated dialysis run yesterday\n 2 liters off, post-K+ 4.0 now back\n to 5.o this am\n Action:\n Following labs, HR/Ryhthm, BP; hoolding some cardiac meds\n Response:\n Remains stable\n Plan:\n c/o to medical floor, follow labs overnight - ? need for extra dialysis\n in AM prior to D/C\n usual days are Tues-Thurs-Sat; ? restart usual\n cardiac meds and assess toleration prior to discharge.\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394205, "text": "Hyperkalemia (high Potassium, Hyperpotassemia)\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 Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-12-17 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 394199, "text": "Chief Complaint: Epigastric pain\n HPI:\n 62 F w/ h/o PAF, IgA nephropathy and CKD who presented to HD today with\n epigastric pain, hypotension (SBP 70s), and bradycardia (~30 bpm). Sent\n to the ED In the ED, BP 107/61, HR 30s, also noted to be Mobitz II\n heart block, although these strips are not available. Also found to\n have a K 7.3. Now s/p HD.\n Epigastric pain\n 24 Hour Events:\n History obtained from Patient\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Unknown; fever;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 02:51 PM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.4\nC (97.6\n Tcurrent: 36.4\nC (97.6\n HR: 64 (62 - 64) bpm\n BP: 126/64(77) {126/62(77) - 151/70(94)} mmHg\n RR: 14 (9 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 100%\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 11.4 g/dL\n 248 K/uL\n 98 mg/dL\n 11.9 mg/dL\n 26 mEq/L\n 6.7 mEq/L\n 92 mg/dL\n 95 mEq/L\n 137 mEq/L\n 36.0 %\n 6.6 K/uL\n [image002.jpg]\n 10:18 AM\n WBC\n 6.6\n Hct\n 36.0\n Plt\n 248\n Cr\n 11.9\n TropT\n 0.05\n Glucose\n 98\n Other labs: PT / PTT / INR:16.0/27.7/1.4, CK / CKMB /\n Troponin-T:34//0.05, Differential-Neuts:71.4 %, Lymph:20.8 %, Mono:5.3\n %, Eos:1.7 %, Ca++:12.1 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 62 F w/ h/o PAF, IgA nephropathy and CKD\n # Bradycardia\n likely hyperkalemia in the setting of multiple\n nodal agents. No evidence of heart block on available strips.\n -continue Amiodarone for rhythm control given that she remains in\n sinus.\n -hold metoprolol for now, likely will need lower dose at discharge\n given that this is the second episode.\n # Hyperkalemia\n # Atrial fibrillation\n Other issues per HO note.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 09:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :\n Total time spent:\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394206, "text": "62 F w/ h/o PAF, IgA nephropathy and CKD who presented to HD today with\n epigastric pain, hypotension (SBP 70s), and bradycardia (~30 bpm). Sent\n to the ED In the ED, BP 107/61, HR 30s, also noted to be Mobitz II\n heart block, although these strips are not available. Also found to\n have a K 7.3. Now s/p HD.\n Hyperkalemia (high Potassium, Hyperpotassemia)\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 Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2196-12-17 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 394207, "text": "TITLE:\n Chief Complaint:\n HPI:\n This is a 62 year old woman with atrial fibrillation and end stage\n renal disease presenting with epigastric pain and bradycardia from\n dialysis suite.\n She was scheduled to have HD today and while in the suite she\n complained of epigastric pain. This pain started at 4 am while\n straining to have a BM, was not associated with nausea or vomiting and\n is reproducable. At the time she was noted to be bradycardic in the\n 30s and hypotensive in 90s/40s and refered to the ED.\n In the ED he presenting vitals were VS 97.4, HR 30s, 107/61 18, 97% RA.\n Her ECG showed second degree AVB and peaked t waves. Her K was 7.0 and\n she was given calcium gluconate, 1 amp D50, 10 units of insulin and 1\n amp of HCO3. Subsequently she returned in sinus rhythm with first\n degree AV. Prior to transfer her vitals were 139/64, 60, 18 100 RA. She\n was alert and oriented. Guaiac negative. The dialysis fellow has been\n notified and they plan to dialyse urgently.\n Of note she has a history of a similar admission with hyperkalemia and\n bradycardia in , which was treated with dialysis. On arrival to\n floor, patient states that abdominal pain has improved.\n On review of systems, s/he denies any chest pain, dyspnea on exertion,\n paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations,\n syncope or presyncope, myalgias, joint pains, cough, hemoptysis, black\n stools or red stools. S/he denies recent fevers, chills or rigors. S/he\n denies exertional buttock or calf pain. All of the other review of\n systems were negative.\n Allergies:\n Dilantin (Oral) (Phenytoin Sodium Extended)\n Unknown; fever;\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 12:00 PM\n Other medications:\n MEDICATIONS:\n AMIODARONE - (Prescribed by Other Provider: /c from hosp) -\n 200 mg Tablet - 1 Tablet(s) by mouth daily\n AMLODIPINE - 10 mg Tablet - 1 (One) Tablet(s) by mouth once a day\n Hold on dialysis days\n CALCIUM ACETATE - 667 mg Capsule - 3 Capsule(s) by mouth three\n times a day\n CAPTOPRIL - 12.5 mg Tablet - 1 Tablet(s) by mouth at bedtime\n CINACALCET [SENSIPAR] - 60 mg Tablet - 2 Tablet(s) by mouth DAILY\n (Daily)\n CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth qam\n LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) pt\n holds on dialysis days\n METOPROLOL SUCCINATE - 50 mg Tablet Sustained Release 24 hr - 1\n Tablet(s) by mouth DAILY (Daily)\n PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s)\n by mouth once a day Name Brand Only, No Substitutions - No\n Substitution\n SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 3 Tablet(s) by\n mouth three times a day\n SODIUM POLYSTYRENE SULFONATE - Powder - 15grams Powder(s) by\n mouth daily\n WARFARIN - 1 mg Tablet - Take up to 4 tablets (4mgs) a day or as\n directed by Clinic\n Past medical history:\n Family history:\n Social History:\n 1. Atrial fibrillation/flutter: first diagnosed in . She\n has not been on Coumadin until very recently due to history of upper GI\n bleeding. On of this year, she was admitted to with chest\n pain and shortness of breath in the setting of atrial flutter with\n rapid ventricular response and hyperkalemia. She was treated for\n hyperkalemia and subsequently her atrial flutter was converted to sinus\n rhythm. Myocardial infarction was ruled out based EKG and biomarkers.\n Thereafter, she underwent right-sided isthmus ablation of clockwise\n atrial flutter, and was started on quinidine and Coumadin.\n 2. End-stage renal disease on hemodialysis secondary to IgA\n nephropathy. She underwent cadaveric kidney transplant in which\n has eventually failed, and started on hemodialysis in .\n 3. History of upper GI bleeding on with evidence of\n esophagitis, gastric ulcer, and bleeding duodenal vessel. She was\n treated by clipping, cauterization and PPI. Repeated endoscopy in \n revealed mild inflammation and healing ulcer. She has not had any\n recurrent episodes of GI bleeding since then.\n 4. Diastolic heart failure supported by an echocardiography from\n . Clinically, she is stable and fairly asymptomatic on her\n current medical regimen.\n 5. History of malignant hypertension, which was complicated by seizure\n on . Not on antiepileptic meds. Denies h/o CVA.\n 6. Depression.\n 7. Rheumatic fever in childhood\n No family history of early MI, arrhythmia, cardiomyopathies, or sudden\n cardiac death; otherwise non-contributory. Her father died at the age\n of 80. Her mother died at the age of 64 from lung CA. She has a sister\n with breast CA. MI in uncle in his 60s.\n She is single, lives by herself in , and has no children. She\n quit smoking 25 years ago (10-pack-years). She rarely drinks alcohol,\n and denies illicit drug use. She used to work part-time in a coffee\n shop, but currently does not work.\n Review of systems:\n Flowsheet Data as of 04:46 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 65 (62 - 66) bpm\n BP: 143/64(84) {126/61(77) - 151/70(94)} mmHg\n RR: 15 (9 - 16) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n PO:\n TF:\n IVF:\n Blood products:\n Total out:\n 0 mL\n 0 mL\n Urine:\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 0 mL\n Respiratory\n O2 Delivery Device: None\n SpO2: 100%\n ABG: ///26/\n Physical Examination\n GENERAL: 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 6cm.\n CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR,\n normal S1, S2. II/VI at apex. No thrills, lifts. No S3 or S4.\n LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were\n unlabored, no accessory muscle use. CTAB, no crackles, wheezes or\n 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. Thrill over LUE AV Fistula.\n SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.\n PULSES:\n Right: Carotid 2+ DP 2+ PT 2+\n Left: Carotid 2+ DP 2+ PT 2+\n Labs / Radiology\n 248 K/uL\n 11.4 g/dL\n 98 mg/dL\n 11.9 mg/dL\n 92 mg/dL\n 26 mEq/L\n 95 mEq/L\n 6.7 mEq/L\n 137 mEq/L\n 36.0 %\n 6.6 K/uL\n [image002.jpg]\n \n 2:33 A11/28/ 10:18 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 6.6\n Hct\n 36.0\n Plt\n 248\n Cr\n 11.9\n TropT\n 0.05\n Glucose\n 98\n Other labs: PT / PTT / INR:16.0/27.7/1.4, CK / CKMB /\n Troponin-T:34//0.05, Differential-Neuts:71.4 %, Lymph:20.8 %, Mono:5.3\n %, Eos:1.7 %, Ca++:12.1 mg/dL, Mg++:2.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n 62 year old woman with atrial fibrillation and end stage renal disease\n status post failed transplant and currently on HD who presented with\n epigastric pain, hyperkalemia, and sinus bradycardia.\n # Hyperkalemia: Secondary to ESRD. She has a history of hyperkalemic\n episodes in the past, that required MICU admission and emergent\n dialysis. Her baseline K is in the 5-6 range. Currently status post\n calcium gluconate, bicarb and insulin.\n - follow K and monitor ECG/tele\n - urgent dialysis\n - kayexilate if dialysis delayed\n # Rhythm: Sinus bradycardia with 1st degree AV delay with junctional\n escape beats. The patient was bradycardic on admission with peaked T's\n on ECG from hyperkalemia. We do not have a longer rhythm strip that\n suggest Mobitz II or CHB on admission. For now, will monitor patient\n on telemetry. Hold nodal agents for now. On discharge, can consider\n holding, or redosing nodal agents.\n - monitor ECG/tele\n - atropine at bedside\n - continue amiodarone\n - hold metoprolol/nodal agents for now\n # Atrial fibrillation: currently in sinus rhythm.\n - on amiodarone; add back metoprolol as tolerated.\n - on warfarin, follow INR\n # Epigastric pain: Ddx includes anginal equivalent/CAD vs viral\n gastroenteritis vs renal failure vs gastritis. Currently pain is\n improved.\n - contiunue home PPI\n # ESRD on HD: secondary to IgA nephropathy, s/p failed transplant.\n - HD today\n .\n # HTN:\n - On CCB, ACEi (on captopril and lisinopril at home - unclear why; will\n hold both for now and restart once stable BP)\n - Will plan to d/c captopril indefinitely on discharge\n .\n FEN: replete lytes, renal diet\n ACCESS: PIV's\n PROPHYLAXIS: warfarin, PPI\n CODE: Full Code (confirmed).\n DISPO: CCU for now\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 22 Gauge - 09:29 AM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2196-12-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394210, "text": "Pt is a 62 woman w/ h/o PAF, IgA nephropathy and CKD who presented to\n outpatient HD today with epigastric pain, hypotension (SBP 70s), and\n bradycardia (~30 bpm). Sent to the ED where BP 107/61, HR 30s, also\n noted to be Mobitz II heart block with K+ 7.3 and peaked T\ns on ECG.\n Treated with insulin/glucose/bicarb/Calcium Gluconate\n repeat 6.2 then\n 6.7. To CCU for immediate dialysis. Initial glucose 57\n team aware\n received apple juice and crackers\n subsequent FS 140-150\n Hr on admission 60\ns SR, Bp stable 118-130\ns/systolic, pt in NAD on\n admission except for complaints of mild pain across rib cage.\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hyperkalemic after receiving Thursday treatment 1 day early secondary\n to holiday\n K+ after treatment in ED 6.2 then 6.7\n Action:\n Repeat ECG peaked T\ns improved; dialysis treatment done\n 2L off\n Response:\n Repeat labs to be drawn at 530pm\n 4 hours post-dialysis; HR and rhythm\n have remained stable SR 60\ns since admission\n Plan:\n Await post-dialysis labs and treat accordingly; cont follow blood\n sugars, Follow CPK\ns, ECG\n Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt tolerated normal dialysis treatment\n 2L taken off with stable HR\n 60\ns SR and BP 120-130\n Action:\n Treatment done\n Response:\n stable HR 60\ns SR and BP 120-130\ns/ during and after treatment\n Plan:\n Cont to follow and return to regular dialysis schedule.\n Pain control (acute pain, chronic pain)\n Assessment:\n Pt admitted with epigastric pain\n described by pt as\npain across my\n lower rib cage\n states it began at 0400 after straining to have bowel\n movement; pain was reproducible upon palpation and increased with\n coughing or movement; pain on admission, felt it was tolerable and\n did not want to take meds for pain; has gradually subsided over course\n of day now and comfortable; initial CPK neg, troponin slightly\n elevated\n Action:\n Positioned for comfort\n Response:\n Pain spontaneously resolving\n Plan:\n Cont to assess pain and need for medication; follow CPK\ns, Position for\n comfort, Emotional support.\n" }, { "category": "Nursing", "chartdate": "2196-12-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 394281, "text": "Renal failure, Chronic (Chronic renal failure, CRF, Chronic kidney\n disease)\n Assessment:\n Pt. A/A/0x3, pleasant and cooperative, oxygenating well on room air,\n lungs clear, anuric, comfortable s/p dialysis previous shift, denies\n abdominal pain or discomfort, slept well most of night\n Action:\n Labs sent previous shift , am labs sent\n Response:\n BUN/CREAT 23/5.3 post dialysis, am pnd , last CPK 31\n Plan:\n Follow up with am labs\n Hyperkalemia (high Potassium, Hyperpotassemia)\n Assessment:\n Hemodynamically stable with HR 60\ns NSR, 1degree AV block with PR\n 0.21-0.22 by monitor. BP ranges 130-140\ns/60-70\n Action:\n Labs sent previous shift , Magnesium repleted with 2gms IV Magnesium\n sulfate, closely monitored, am labs sent\n Response:\n Repeat k+ 4.0, Magnesium 1.8, glucose 104, am labs pnd\n Plan:\n Follow up with am labs and EKG\n" } ]

[ { "category": "Radiology", "chartdate": "2120-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 769729, "text": " 7:37 PM\n CHEST (PORTABLE AP) Clip # \n Reason: post intubation/tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 26 year old woman with polysubstance OD\n REASON FOR THIS EXAMINATION:\n post intubation/tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post intubation for overdose.\n\n COMPARISONS: None.\n\n FINDINGS: An endotracheal tube is present with tip 4 cm above the carina. A\n nasogastric tube projects with tip below the diaphragm in region of stomach.\n\n The cardiopericardial silhouette is normal and the lungs and costophrenic\n angles are clear. No acute bony abnormalities are seen.\n\n IMPRESSION:\n\n 1) Endotracheal tube 4 cm above the carina. Otherwise no evidence of acute\n cardiopulmonary disease.\n\n" }, { "category": "Radiology", "chartdate": "2120-10-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 769847, "text": " 10:01 AM\n CHEST (PA & LAT) Clip # \n Reason: R/O PNEUMONIA\n ______________________________________________________________________________\n CLINICAL INFORMATION & QUESTIONS TO BE ANSWERED:\n R/O PNEUMONIA\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Clinical suspicion for pneumonia.\n\n Compared to previous study of two days earlier.\n\n There has been interval extubation. Cardiac and mediastinal contours are\n within normal limits. The lungs reveal patchy increased opacity in the left\n retrocardiac region, new in the interval. No pleural effusions are evident.\n Skeletal structures of the thorax are unremarkable.\n\n IMPRESSION: New patchy left lower lobe opacity, most prominent in the\n retrocardiac region. Given recent intubation, this may be due to a focal area\n of aspiration. Early pneumonia is not excluded in the appropriate clinical\n setting.\n\n" }, { "category": "ECG", "chartdate": "2120-10-15 00:00:00.000", "description": "Report", "row_id": 171026, "text": "Sinus tachycardia\nBifid T wave with Q-T interval prolongation or less likely at 2:1\nblock\nEarly R wave progression\nClinical correlation is suggested\n\n" }, { "category": "ECG", "chartdate": "2120-10-15 00:00:00.000", "description": "Report", "row_id": 171027, "text": "Sinus rhythm\nInferior ST-T changes\nQ-T interval prolongation for rate\nEarly R wave progression\nConsider metabolic derangements at this age\nSince previous tracing, ST-T wave abnormalities are new\nClinical correlation is suggested\n\n" }, { "category": "Nursing/other", "chartdate": "2120-10-16 00:00:00.000", "description": "Report", "row_id": 1446572, "text": "S/MICU Nursing Progress Note\n A26y/o woman admitted from EW after ingesting an a number of meds, including valium,resperdal,paxil,caritin and ,, intubated for airway protection. Received charcoal and mucomyst in the Ew Transported to MISU for closer observation.\n\n Resp: remained intubated overnight until overnight lab values were available. on IMV rate of 12 Tv 600cc 45 Fio2 suctioned for sm amt white sputum, sedated on propofol\n\n Cardaic: Hr 90-100's NO VEA but ? prolongation of QT interval by EKG Are repeating the 12 lead this morning. Serum K 2.8 replacing via OGT Bp stable 100-120/70's\n\n Neuro: sedated on arrival, then restless at times, sedated with propofol overnight, easily arousable this morning, following commands, opening eyes to name, mvoing all extermites. +gag,+ cough.\n\n Plan: wean to off propofol once drug levels have normalized, extubated and psych evaluate.\n" }, { "category": "Nursing/other", "chartdate": "2120-10-16 00:00:00.000", "description": "Report", "row_id": 1446573, "text": "NPN See careview for details\n\nNeuro: AXOX3 ,sleeping intermittently.Arousable and follows commands.Diffaculty tol mucomyst although no doses missed as yet. Received 25mg phenergan for nausea ,sedative effect noted.Mucomyst is ordered IV as well ,but PO is prefered.withdrawn, but affect appropriate.\n Denies suicidal ideation,but states disappointed attempt failed. Pt seen by Psych and will be inpatient psych as soon as bed available. 1:1 sitter at bedside at all times.\n\nC/V: SR-ST no ectopy,BP stable. Serum CK slightly elevated but MB WNL.EKG unchanged.\n\nRESP: RA sats 93-97% .LCTA\n\nF/E/N: UO 75-100cc/hr.Repleted AM K+ and MGSo4 PO, able to swallow,although nauseated at times , stool X 2 black charcol\n\nPLAN: cont 1:1 suicide watch, bed on floor w/ sitter or psych unit when available.\n" } ]

[ { "category": "Radiology", "chartdate": "2160-02-11 00:00:00.000", "description": "CVL/PICC", "row_id": 812323, "text": " 7:44 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: PICC line placement, unable to obtain PICC line on floor\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ********************************* CPT Codes ********************************\n * CVL/PICC 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * UD GUID FOR NEEDLE PLACMENT C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with Liver transplant with elevated LFTs\n REASON FOR THIS EXAMINATION:\n PICC line placement, unable to obtain PICC line on floor\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Liver transplant. Infection. Requiring antibiotics.\n\n PROCEDURE: The procedure was performed by Drs. and with Dr.\n supervising. The left upper arm was prepped in sterile fashion. Since\n no suitable superficial veins were visible, ultrasound was used for\n localization of a suitable vein. The brachial vein was patent and\n compressible. After local anesthesia with 2 cc of 1% Lidocaine, the brachial\n vein was entered under ultrasonographic guidance with a 21-gauge needle. A\n .018 guide wire was advanced under fluoroscopy into the superior vena cava.\n Based on the markers on the guide wire, it was determined that a length of 31\n cm would be suitable. The PIC line was trimmed to length and advanced over a\n 4-French Introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final chest x-ray\n was obtained. The film demonstrates the tip to be in the superior vena cava\n just above the atrium. The line is ready for use. A Stat-lock was applied\n and the line was hep-locked.\n\n IMPRESSION: Successful placement of a 31 cm total length 4-French single\n lumen PIC line with tip in the superior vena cava, ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-04 00:00:00.000", "description": "TRANSCATHETER INFUSION FOR LYSIS", "row_id": 811758, "text": " 6:45 PM\n HEPATIC Clip # \n Reason: patency for liver transplant hepatic arterial x 3\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 100\n ********************************* CPT Codes ********************************\n * TRANSCATHETER INFUSION FOR LYS INITAL 2ND ORDER ABD/PEL/LOWER *\n * -51 MULTI-PROCEDURE SAME DAY EA 1ST ORDER ABD/PEL/LOWER EXT *\n * -59 DISTINCT PROCEDURAL SERVICE CVL/PICC *\n * TRANSCATHETER INFUSION VISERAL SEL/SUPERSEL A-GRAM *\n * VISERAL SEL/SUPERSEL A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with living related liver transplant on with 3\n arterial ( left and rt hepatic and gastroduodenal arterial anastam) now\n alk phos/ t. bili and us/cta un able to demon flow in liver\n transplant\n REASON FOR THIS EXAMINATION:\n patency for liver transplant hepatic arterial x 3\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 48-year-old woman with living-related liver transplant on\n with three arterial anastomosis. Now with increasing alk. phos.,\n total bili and ultrasound CTA unable to discern hepatic arterial patency.\n\n RADIOLOGIST PERFORMING THE PROCEDURE: Dr. ; Dr. \n , the staff radiologist present throughout the entire procedure.\n\n PROCEDURE/TECHNIQUE: Informed written consent was obtained. Through an\n anesthetized skin approach and utilizing fluoroscopic guidance, access was\n obtained to the right common femoral artery using a 19-gauge single-wall\n puncture needle. wire was then advanced into the abdominal aorta.\n The puncture needle was then exchanged for a 5-French angiographic sheath. The\n inner dilator was removed. A 5-French C-II glide catheter was advanced over\n the wire. The wire was removed. The C-II glide catheter was\n placed in the superior mesenteric artery origin and a superior mesenteric\n arteriogram was performed.\n\n A superior mesenteric arteriogram was performed with the catheter well seated\n in the superior mesenteric artery. This demonstrated a completely replaced\n hepatic arterial system arising off the proximal SMA. A large-caliber vessel\n was seen traversing superiorly which corresponds to the ... ? gastropopulic\n ... artery seen on CTA. The run was carried out to include the portal vein\n which was widely patent without area of stricture.\n\n The catheter was then placed in the celiac axis and a celiac arteriogram was\n then performed. This demonstrated a left gastric and a splenic artery. No\n hepatic arterial branches were seen. The run was also carried out to confirm\n the portal vein was patent and that there was no stenosis from the portal\n vein.\n\n Then, the catheter was replaced in the superior mesenteric artery and then\n (Over)\n\n 6:45 PM\n HEPATIC Clip # \n Reason: patency for liver transplant hepatic arterial x 3\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n placed in the replaced hepatic artery using an 035 angled glide wire. The\n arteriogram demonstrated a large-caliber hepatic artery arising from the\n proximal superior mesenteric artery with single small-caliber intrahepatic\n artery arising off the medial aspect of the distal tip of the large-caliber\n hepatic artery. This was felt to represent a single one of the three\n anastomoses described by the transplant surgeons. Neither the gastroduodenal\n anastomosis or the second hepatic arterial anastomosis along the distal aspect\n of the hepatic artery was visualized. This suggested occlusion of two of the\n three hepatic arterial branches.\n\n The catheter was then replaced in the celiac axis and a celiac arteriogram was\n performed with a high injection rate in order to reflux contrast in the aorta.\n This again demonstrated only a splenic artery and a left gastric artery. No\n suggestion of hepatic arterial branches was seen arising from the celiac axis.\n\n Then, access was obtained to the replaced hepatic arterial system using the 5-\n French C-II glide catheter and the 035 angled glide wire. With the glide wire\n placed in the hepatic artery, the 5-French C-II catheter was exchanged for a\n 4-French C-II catheter. The catheter was removed. At this point, a triple-\n lumen catheter was placed in the right common femoral vein. This was done\n after anesthetizing the skin and using a 19-gauge needle to gain access to the\n femoral vein. The wire was then advanced into the inferior vena cava\n and the puncture needle was exchanged for the triple-lumen catheter. Good\n flush and aspiration were seen in all three ports. The catheter was secured\n to the skin using 0-silk.\n\n The 5-French sheath was secured to the skin using 0-silk. The 5-French\n sheath, 4-French C-II glide catheter and triple-lumen central venous catheter\n were then covered with a Tegaderm. At this point, 4 mg of TPA was slowly\n infused into the 4-French C-II glide catheter under fluoroscopic\n visualization. The catheter was then secured to the skin using a combination\n of Steri-Strips, tongue depressors and Tegaderm. The catheter was then hooked\n up to an infusion of TPA. The patient was sent to an intensive care unit for\n monitoring. The patient is to return at 7:30 in the morning on for\n followup evaluation.\n\n COMPLICATIONS: None.\n\n CONTRAST/MEDICATIONS: 4 mg of TPA infused intra-arterially with the catheter\n selected in the replaced hepatic artery. IV conscious sedation consisted of\n incremental doses of Versed and Fentanyl. 8 cc of 1% Lidocaine for local\n anesthetic. 140 cc of Optiray contrast.\n\n IMPRESSION:\n 1. Occlusion of two of the three anastomotic hepatic arteries of the donor\n (Over)\n\n 6:45 PM\n HEPATIC Clip # \n Reason: patency for liver transplant hepatic arterial x 3\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n liver. A single patent hepatic arterial vessel was seen arising from a\n replaced hepatic arterial system (arising from the proximal SMA). TPA was\n infused selectively into the hepatic artery (4 mg) and the patient was hooked\n up to a TPA drip and sent to the intensive care unit for monitoring. Followup\n is scheduled for 7:30 in the morning on .\n\n" }, { "category": "Radiology", "chartdate": "2160-02-05 00:00:00.000", "description": "F/U STATUS INFUSION/EMBO", "row_id": 811788, "text": " 7:22 AM\n HEPATIC Clip # \n Reason: 12 HRS P/TPA CHECK\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 40\n ********************************* CPT Codes ********************************\n * F/U STATUS INFUSION/EMBO F/U STATUS INFUSION/EMBO *\n * NON-IONIC LESS THAN 100CC *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post hepatic arteriogram and 12 hours of tissue\n plasminogen activator infusion.\n\n REFERRING PHYSICIAN: . .\n\n CONTRAST: 40 cc Optiray-320 at 60%.\n\n PROCEDURE/TECHNIQUE/FINDINGS: With the catheter in the replaced common\n hepatic artery, a repeat arteriogram was performed. This demonstrated no\n significant change in the amount of perfusion into the liver relative to the\n previous study. Multiple obliquities were obtained, demonstrating the two\n other anastomotic vessels stumps. Also noted was a diffuse vasospasm\n throughout the replaced common hepatic and the right posterior hepatic artery.\n We then attempted, using an 0.018 Tracker catheter and wire, to cross the two\n other anastomoses, but were unsuccessful. The findings suggest that there are\n intimal flaps which are occluding both anastomoses.\n\n Due to the diffuse vasospasm, 100 mcg of nitroglycerin was infused intra-\n arterially. A repeat arteriogram demonstrated vaso dilation of the vessels,\n without further evidence for vasospasm. The catheter and sheath were then\n removed, and compression was applied over the groin until hemostasis was\n achieved.\n\n COMPLICATIONS: None.\n\n IMPRESSION: Followup thrombolysis demonstrates no significant change in the\n perfusion to the liver. Attempts to cross the two other anastomoses were\n unsuccessful. Findings discussed directly with Dr. .\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-02-04 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 811749, "text": " 4:05 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY; CT RECONSTRUCTION\n Reason: CTA LIVER TRANSPLANT - STATEVALUATE ARTERIAL, VENOUS FLOW .\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant. elevated LFTS, U/S today could not view\n arterial blood flow\n REASON FOR THIS EXAMINATION:\n CTA LIVER TRANSPLANT - STATEVALUATE ARTERIAL, VENOUS FLOW . 3 VESSEL\n ANASTOMOSIS\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: This is a 48 y/o female status post liver transplant on ,\n with increasing liver function tests. Ultrasound today failed to visualize\n hepatic arterial flow.\n\n PROCEDURES: Utilizing the GE CT scanner, 5 mm contiguous images were obtained\n throughout the abdomen prior to the IV administration of 150 cc Optiray\n contrast. Following IV contrast, 5 mm contiguous images were obtained\n throughout the abdomen in the arterial and portal venous phases with\n additional 5 mm contiguous images through the abdomen and pelvis following a\n 3-minute delay.\n\n CT OF THE ABDOMEN W/O & W/CONTRAST:\n\n FINDINGS: Comparison is made to the previous study dated , a\n pretransplant study. The lung bases are clear bilaterally. There has been\n interval right lobe liver transplant with an apparent Roux-en-Y procedure\n involving the proximal gastrointestinal tract. Three percutaneous surgical\n drains are noted, as well as multiple surgical skin staples. There is a fluid\n collection between the blind end of the Roux-en-Y and the transplanted liver,\n which measures 4.75 cm in width x 5.7 cm anteroposterior on a single axial\n image. There are some air bubbles located throughout this collection as well.\n Several other intrabdominal fluid collections are also noted in the\n perisplenic region, in the mesenteric root, as well as both pericolic gutters.\n No free air is noted in the left abdomen. Visible loops of small bowel are\n normal in appearance. The ascending colon is poorly distended and appears to\n contain residual stool. The pancreas and enlarged spleen are stable.\n Bilateral adrenal glands are grossly normal in appearance. The kidneys\n enhance symmetrically without mass or hydronephrosis.\n\n CT OF THE PELVIS W/CONTRAST:\n\n FINDINGS: There is extensive free fluid in the pelvis. The visible loops of\n large and small bowel are grossly normal in appearance. The urinary bladder\n and rectum are normal. No significant lymphadenopathy is noted in the pelvis.\n There is diffuse edema in the subcutaneous tissues.\n\n CTA: The aorta, celiac axis and SMA origins are normal in appearance and\n (Over)\n\n 4:05 PM\n CT ABD W&W/O C; CT PELVIS W/CONTRAST Clip # \n 200CC NON IONIC CONTRAST SUPPLY; CT RECONSTRUCTION\n Reason: CTA LIVER TRANSPLANT - STATEVALUATE ARTERIAL, VENOUS FLOW .\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Field of view: 40 Contrast: OPTIRAY Amt: 200\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n widely patent. There is an apparent replaced right hepatic artery, which\n terminates in the region of the porta hepatis. Very tiny hepatic arteries are\n visualized; however, these are apparent only after a delay and do not opacify\n simultaneously with the splenic artery. No focal stenosis is visualized.\n\n BONE WINDOWS: No suspicious lytic or sclerotic lesions are seen.\n\n IMPRESSION:\n\n 1. Hepatic arteries are visualized; however, they are very small in caliber\n and do not opacify simultaneously with the splenic artery; rather they enhance\n during the portal venous phase or later. This is suspicious for very\n restricted and/or delayed flow through the hepatic arteries.\n\n 2. Extensive fluid is seen throughout the abdomen. There is a fluid\n collection with scattered bubbles of air in the right upper quadrant between\n the blind loop of the Roux-en-Y and the transplanted liver, which may\n represent surgicell material. An infectious process cannot be excluded.\n\n Other findings including surgical skin staples and percutaneous drains\n consistent with recent hepatic transplant. These findings were discussed and\n the images reviewed in person with Dr. .\n\n" }, { "category": "Radiology", "chartdate": "2160-02-05 00:00:00.000", "description": "PERITONEAL ABSCESS DRAINAGE US", "row_id": 811848, "text": " 3:30 PM\n PERITONEAL ABSCESS DRAINAGE US Clip # \n Reason: ultrasound guided peritoneal fluid aspiration for analysis\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p LRLT with HAT 2 of 3 anastamoses.\n REASON FOR THIS EXAMINATION:\n ultrasound guided peritoneal fluid aspiration for analysis\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post living related liver transplant. Perihepatic fluid\n collection.\n\n TECHNIQUE: Alternatives, benefits and risks including infection and bleeding\n were explained to the patient and informed consent was obtained. At the\n bedside, with ultrasound guidance, the fluid collection medial to the\n transplanted liver was localized. An 18 gauge spinal needle was inserted.\n Upon aspiration, sanguineous and slightly purulent material returned. The\n fluid appeared to be infected and therefore a 8 french pigtail catheter was\n inserted. Approximately 300 cc of fluid returned immediately. The patient\n tolerated the procedure without immediate complications. The specimen was\n sent to microbiology and cytology.\n\n The staff radiologist, Dr. , was present during the entire procedure.\n\n IMPRESSION: Successful aspiration and placement of 8 french catheter into\n perihepatic fluid collection.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-07 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 812059, "text": " 9:44 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: eval ileus vs acites\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman with liver transplant now distended abdomen.\n REASON FOR THIS EXAMINATION:\n eval ileus vs acites\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN 2 VIEWS:\n\n HISTORY: Liver transplant and abdominal distention.\n\n There are a few gas filled loops of non-dilated small bowel with gas present\n in the colon and no evidence for intestinal obstruction. There is some free\n gas under the right diaphragm and an air fluid level in this location.\n Catheter overlies right upper quadrant. Vascular access catheter overlies\n right common iliac vessel. There is some retained contrast in the right colon.\n\n IMPRESSION: Air fluid level in right subphrenic region in addition to free\n gas. Significance is uncertain. An abscess in the right subphrenic region\n cannot be ruled out. Correlate clinically and with CT scan if indicated.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-04 00:00:00.000", "description": "DUPLEX DOP ABD/PEL LIMITED", "row_id": 811738, "text": " 3:01 PM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: DUPLEX TRANSPLANT LIVER3 vessel anastomosis. evaluate hepati\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p living related liver transplant with elevated\n alk phos, bilirubin\n REASON FOR THIS EXAMINATION:\n DUPLEX TRANSPLANT LIVER3 vessel anastomosis. evaluate hepatic artery , vein,\n portal vein. r/o hepatic stenosis. please page Dr. # with any\n questions regarding the study.\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: Status post liver transplant with three arterial\n anastomosis. Elevated alk phos and bilirubin.\n\n COMPARISON: Ultrasound of .\n\n FINDINGS: The transplanted right lobe of the liver is located in right upper\n quadrant. The liver is normal in echogenicity. The main portal vein is patent\n with normal hepatopedal flow. Normal intrahepatic portal and hepaticvenous\n waveforms are visualized. No intrahepatic arterial waveform was detected\n despite multiple attempts. There is no biliary ductal diltation. Medial to\n the liver, there is a large heterogeneous collection which may represent a\n resolving hematoma.\n\n IMPRESSION: No detectable intrahepatic arterial flow. This finding is new\n since the previous examination, when three intrahepatic arterial vessels were\n identified. This change may be seen if the liver is edematous or if the flow\n is severely dampened. CTA is recommended for further evaluation. The findings\n were discussed with Dr. of the transplant service.\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2160-02-11 00:00:00.000", "description": "LIVER OR GALLBLADDER US (SINGLE ORGAN)", "row_id": 812366, "text": " 9:36 PM\n LIVER OR GALLBLADDER US (SINGLE ORGAN); DUPLEX DOPP ABD/PEL Clip # \n Reason: please assess for doppler flows/ patency - 2 arteries known\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 47 year old woman with s/p living related liver transplant with elevated\n alk phos, bilirubin, known to have 2 arteries thrombosed - please assess for\n change\n REASON FOR THIS EXAMINATION:\n please assess for doppler flows/ patency - 2 arteries known to be thrombosed\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 47 y/o female with liver transplant and elevated alk-phos and\n bilirubin. Evaluate for hepatic arterial patency.\n\n COMPARISON: .\n\n FINDINGS: There is a transplant liver within the right upper quadrant of the\n abdomen, which demonstrates normal hepatic echogenicity. The main portal vein\n is patent with flow in an appropriate direction. The hepatic vein is patent.\n Arterial waveforms are identified near the portal bifurcation. There is no\n evidence of biliary ductal dilatation.\n\n IMPRESSION: Limited examination with hepatic arterial waveforms identified\n centrally, near the portal bifurcation. A repeat ultrasound should be\n performed in ultrasound during the day on given the\n limited nature of this exam.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-15 00:00:00.000", "description": "CHALNAGIOGRAPHY VIA EXISTING CATHETER", "row_id": 812737, "text": " 7:37 AM\n CATH CHEK/REMV Clip # \n Reason: Gravity cholangiogram only. Please for th\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 20\n ********************************* CPT Codes ********************************\n * CHALNAGIOGRAPHY VIA EXISTING C 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * CHALNAGIOGRAPHY VIA EXISTING C 79 UNRELATED PROCEDURE/SERVICE DURIN *\n * -59 DISTINCT PROCEDURAL SERVICE CHALNAGIOGRAPHY VIA EXISTING C *\n * 79 UNRELATED PROCEDURE/SERVICE DURIN -59 DISTINCT PROCEDURAL SERVICE *\n * TUBE CHOLANGIOGRAM TUBE CHOLANGIOGRAM *\n * -59 DISTINCT PROCEDURAL SERVICE TUBE CHOLANGIOGRAM *\n * -59 DISTINCT PROCEDURAL SERVICE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant postop tube study x 3GRAVITY ONLY\n\n REASON FOR THIS EXAMINATION:\n Gravity cholangiogram only. Please for the exam\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Liver transplant postop tube study times 3. Gravity only. Known\n to have a perihepatic collection with pigtail catheter.\n\n PROCEDURE: The procedure was performed by Drs. and with Dr.\n supervising and present throughout. The three small caliber surgical\n biliary tubes were injected sequentially from right to left. The right tube\n injection under gravity demonstrated prompt filling of jejunal loop with\n opacification of the a central bile duct adjacent to this. Injection of the\n second tube demonstrated opacification of a small contained space just lateral\n to the jejunal loop. Injection of the third, medial most position tube\n demonstrates opacification of a nondilated intrahepatic biliary tree.\n\n IMPRESSION: Gravity cholangiograms through three tubes as above. The biliary\n system is decompressed.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-12 00:00:00.000", "description": "DUPLEX DOP ABD/PEL LIMITED", "row_id": 812423, "text": " 11:56 AM\n DUPLEX DOP ABD/PEL LIMITED Clip # \n Reason: FOLLOW UP HEPATIC ART\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: Follow up hepatic artery stenosis.\n\n This study was performed as a follow up to yesterday's Doppler study, which\n was unsuccessful in complete assessment of the arterial supply. The portal\n veins and Doppler veins were all normal on the prior study.\n\n Today's study was focused exclusively on the arterial supply. At three\n separate sites within the transplanted right lobe of the liver, arterial\n signals could be obtained. The sites were along the left anterior margin, in\n the mid portion, and more posteriorly in the right lobe. All of the signals\n showed a parvus-tardis waveform with peak velocities ranging from 30-45 cm per\n second. This compares with a more vigorous and higher amplitude waveform in\n the porta hepatis, where peak velocities of 80-90 were obtained.\n\n CONCLUSION: Three separate arterial tracings were obtained within the graft,\n but the waveforms were all parvus-tardis and considerably diminished compared\n to the extrahepatic waveform proximal to the area of stenosis demonstrated on\n angiography.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-12 00:00:00.000", "description": "CT ABD W&W/O C", "row_id": 812440, "text": " 3:24 PM\n CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate portal and hepatic blood flow\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant with elevated AP\n REASON FOR THIS EXAMINATION:\n evaluate portal and hepatic blood flow\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post right lobe liver transplant with abnormal LFT's.\n\n TECHNIQUE: Axial pre and post contrast CT images of the abdomen with post\n contrast CT of the pelvis.\n\n COMPARISON: Ultrasound dated ; CTA abdomen and pelvis dated\n , Hepatic arteriogram dated .\n\n FINDINGS:\n\n PRE AND POST CONTRAST CT ABDOMEN: The transplanted liver enhances in a normal\n fashion. The portal and hepatic veins are patent. The hepatic artery is\n visualized. The native hepatic artery can be seen coursing anteriorly and\n subsequently to the right. Subsequently the artery narrows significantly and\n can then only be followed for a short course where it is seen to progressively\n narrow. This corresponds to the area of stenosis which was previously\n demonstrated on arteriorgram at the level of the patient's arterial\n anastomosis.\n\n The apparent fluid collection previously seen on other studies has decreased\n in size and now measuring 2.7 x 9.0 cm.\n\n The spleen is enlarged as has been seen on prior studies.\n\n The pancreas, kidneys, and adrenals have a normal appearance.\n\n There is extensive intraabdominal ascites. No abnormally thickened or dilated\n abdominal bowel loops.\n\n POST CONTRAST CT PELVIS: There is extensive pelvic ascites. No abnormally\n thickened or dilated pelvic bowel loops. The bladder fills normally with\n contrast.\n\n No lytic or blastic destructive osseous lesions.\n\n IMPRESSION:\n\n 1) Patent intrahepatic portal veins and hepatic veins; patent extrahepatic\n portal vein.\n (Over)\n\n 3:24 PM\n CT ABD W&W/O C; CT 150CC NONIONIC CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: evaluate portal and hepatic blood flow\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Field of view: 38 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2) Redemonstration of severe narrowing of the hepatic artery distal to the\n arterial anastomosis.\n\n 3) Interval decrease in size of the previously seen perihepatic air and fluid\n collection.\n\n 4) Extensive intraabdominal and pelvic ascites.\n\n" }, { "category": "Radiology", "chartdate": "2160-02-19 00:00:00.000", "description": "CTA ABD W&W/O C & RECONS", "row_id": 813210, "text": " 2:02 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Assess transplant liver. CTA\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 48 year old woman s/p liver transplant with elevated AP\n\n REASON FOR THIS EXAMINATION:\n Assess transplant liver. CTA\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n\n HISTORY: Elevated alk. phosphatase in patient s/p liver transplant.\n\n TECHNIQUE: Pre and post-contrast CT abdomen with post-contrast CT of the\n pelvis and multiplanar reformats using the liver CTA protocol.\n\n COMPARISON: .\n\n CT ABDOMEN W&W/0 CONTRAST: The lung bases are clear.\n The transplanted right hepatic lobe perfuses in a relatively normal fashion.\n The arterial phase images again demonstrate occlusion of two of the three\n arterial anastomoses. The remaining arterial anastomosis is again noted to be\n small in caliber distal to the anastomotic site. The portal vein and hepatic\n veins remain patent.\n\n Again seen anterior and medial to the transplanted liver, is a focal fluid and\n air collection. This has decreased in size since the prior study and now\n measures 8.6 x 1.5 cm having previously measured 11.4 x 1.4 cm.\n\n The spleen remains enlarged but perfuses normally. There are perisplenic\n varices. The pancreas has a normal appearance. The kidneys enhance in a\n symmetric and normal fashion and are without hydronephrosis. The adrenals\n have a normal appearannce0. There remains intra-abdominal ascites with\n interval development of dilated small bowel loops with air fluid levels. This\n is seen, however, in conjunction with free passage of contrast into the colon,\n therefore, suggesting that this does not represenrt a bowel obstruction and\n may represent a small bowel ileus. No free intra-abdominal air is present.\n\n CT PELVIS W/CONTRAST: Small bowel loops with air fluid levels are also\n demonstrated in the pelvis, as described above. There is free fluid within\n the pelvis as well. The bladder has a normal appearance. Stool and contrast\n is seen within the rectum.\n\n MULTIPLANAR REFORMATS aid and confirm the evaluation of the above findings.\n\n IMPRESSION:\n 1) Redemonstration of occlusion of two of the patient's three arterial\n anastomoses in the liver.\n (Over)\n\n 2:02 PM\n CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: Assess transplant liver. CTA\n Admitting Diagnosis: S/P LIVER TX,NAUSEA,VOMITING\n Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n 2) The portal vein and hepatic veins are patent.\n\n 3) Decrease in size of a peritransplant air and fluid collection.\n\n 4) Dilated small bowel loops with air fluid levels which are most likely\n representative of a small bowel ileus given the contrast freely passes into\n the colon.\n\n 5) Findings were discussed with Dr. at 4:30 pm on .\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2160-02-05 00:00:00.000", "description": "Report", "row_id": 1369439, "text": "DATA/ACTION: vss. adm. from angio post hepatic arteriogram. rt fem she\nalth w/ tpa and heparin gtt infusing. ptt low despite inc. hep gtt presently on 500u/hr. tpa rate adjusted per orders. ozzing mod. amt bloody from fem. site-dsg reinforced. bppp. leg splint on to prevent bending leg. 3 t-tubes label and attached to bile bags. c/o abd. pain-med w/ percoette 2tabs q4 w/ good relief. npo after mn except meds-to go back to angio @ 0800.\n" }, { "category": "Nursing/other", "chartdate": "2160-02-05 00:00:00.000", "description": "Report", "row_id": 1369440, "text": "NPN\n PT ALERT AND X 3, MAE. DOZING ON AND OFF THROUGHOUT THE DAY.\nCV- BP STAYING IN 130 RANGE. BECOMING TACHY 115-120 DURING AFTERNOON, DR. UPDATED AND HCT SENT RETURNING NORMAL. NO FURTHER ORDERS AT THIS TIME. DOWN FOR ANGIO THIS AM SHOWING MINIMAL IMPROVEMENT IN VESSEL, AND TPA DC'D. SHEATH REMOVED FROM RIGHT GROIN BY RADIOLOGY, PEDAL PULSES + WITH DOPPLER (DUE TO EDEMA) FREQUENTLY CHECKED AND NO BLEEDING NOTED.\nRESP- LUNGS CLEAR BILAT TO BASES.\nGI/GU- ABD FIRM, TOLERATING LIQUIDS WITH PILLS, NO NAUSEA NOTED. ABDOMINAL INCISION OPEN TO AIR WITHOUT DRAINAGE, STAPLES INTACT, THREE T-TUBE DRAINAGE BAGS INTACT WITH MILD OOZING AROUND SITE. UOP AVERAGING 35-50CC/HR, DARK AMBER URINE, ICU TEAM AS WELL AS TRANSPLANT TEAM AWARE, NO INTERVENTION AT THIS TIME.\nAFEBRILE, TAKING PERCOCET FOR PAIN WITH GOOD EFFECT\n" }, { "category": "Nursing/other", "chartdate": "2160-02-06 00:00:00.000", "description": "Report", "row_id": 1369441, "text": "CONDITION UPDATE\nPLEASE SEE CAREVUE FLOWSHEET FOR SPECIFICS.\nNEURO: PT ALERT THROUGH MOST OF NOC. X3. MAEW. PERRL. C/O CONSTANT RUQ PAIN. DISCUSSED WITH MD' AND . MD , PT GIVEN 2MG IV MSO4 BETWEEN SCHEDULED PERCOCET DOSES, AND PERCOCET AND OXYCODONE ALTERNATED TO AVOID TYLENOL > 4G IN 24HOURS.\nRESP: LSA CTA. SATS >98% ON RA.\nCV: AFEBRILE. SBP STABLE. NSR TO ST 90S TO 100S. EDEMA AT EXTREMTITES. PEDAL PULSES PALPABLE. HEP GTT INCREASED TO 900UNITS/HOUR MD FOR PTT 36.7, REPEAT PENDING. HCT STABLE AT 28, MD INFORMED.\nGI: ABD FIRMLY DISTENDED. FAINT BOWEL SOUNDS. TOL CL WELL. NO N/V. NO BM.\nGU: AMBER U/O VIA FOLEY. 20-30CC/HOUR. MD INFORMED.\nSKIN: ABD INC CLEAN AND DRY WITH STAPLES INTACT. 3 BILIARY DRAINS INTACT WITH SM AMTS BILIOUS DRG. PIGTAIL DRAIN WITH MOD AMTS DEEP CLEAR AMBER DRG, INTERMITTENTLY MIXED WITH CLOUDY MUCOUSY DRG.\nPLAN: CONT TO MONITOR CLOSELY. EMOTIONAL SUPPORT. PAIN CONTROL. CONT PER CURRENT MGMT.\n" } ]

[ { "category": "Echo", "chartdate": "2175-11-14 00:00:00.000", "description": "Report", "row_id": 80478, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction.\nHeight: (in) 72\nWeight (lb): 250\nBSA (m2): 2.34 m2\nBP (mm Hg): 124/74\nHR (bpm): 70\nStatus: Inpatient\nDate/Time: at 10:00\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Mild LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is\nseen in the RA and extending into the RV.\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild-moderate\nregional LV systolic dysfunction. No LV mass/thrombus.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - hypo; anterior apex - akinetic; septal apex-\nakinetic; inferior apex - akinetic; apex - dyskinetic;\n\nRIGHT VENTRICLE: Normal RV chamber size. Focal apical hypokinesis of RV free\nwall.\n\nAORTA: Mildly dilated aortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.\n\nMITRAL VALVE: Normal mitral valve leaflets. No MVP. Mild (1+) MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\nIndeterminate PA systolic pressure.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor parasternal views.\nSuboptimal image quality as the patient was difficult to position. Suboptimal\nimage quality - body habitus. Based on AHA endocarditis prophylaxis\nrecommendations, the echo findings indicate a moderate risk (prophylaxis\nrecommended). Clinical decisions regarding the need for prophylaxis should be\nbased on clinical and echocardiographic data.\n\nConclusions:\nThe left atrium is mildly dilated. Left ventricular wall thicknesses and\ncavity size are normal. There is mild to moderate regional left ventricular\nsystolic dysfunction with severe hypo/akinesis of the distal half of the\nanterior and anteroseptal walls. The distal inferior wall is also severely\nhypokinetic. The apex is mildly dyskinetic, but not aneurysmal.. No masses or\nthrombi are seen in the left ventricle. Right ventricular chamber size is\nnormal with focal hypokinesis of the apical free wall. The aortic root is\nmildly dilated. The aortic valve leaflets (3) appear structurally normal with\ngood leaflet excursion. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are structurally normal. There is no mitral valve prolapse.\nMild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure\ncould not be quantified. There is no pericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction c/w CAD (mid-LAD\nlesion). Mild aortic regurgitation. Mild mitral regurgitation. Dilated\nascending aorta.\n\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a moderate risk (prophylaxis recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2175-11-16 00:00:00.000", "description": "Report", "row_id": 203536, "text": "Sinus rhythm\nAnterior myocardial infarction - ST-T wave configuration consistent with\nacute/recent/in evolution\nInferior myocardial infarction - possible acute\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2175-11-14 00:00:00.000", "description": "Report", "row_id": 203537, "text": "Sinus rhythm\nAnterior myocardial infarction - ST-T wave configuration consistent with\nacute/recent/in evolution process\nInferior myocardial infarction - possible acute\nSince previous tracing of , inferior Q waves more prominent\n\n" }, { "category": "ECG", "chartdate": "2175-11-13 00:00:00.000", "description": "Report", "row_id": 203538, "text": "Sinus rhythm\nLeft atrial abnormality\nAnterior myocardial infarction with ST-T wave configuration consistent with\nacute/recent/in evolution precess\nProminent inferior Q waves - are nondiagnostic\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2175-11-15 00:00:00.000", "description": "Report", "row_id": 1486621, "text": "CCU NPN 1900-0700\nS: I feel better today than I did yesterday...I'm not having any of the pain that brought me in here.\"\n\nO: Please see careview flowsheet for VS and additional data.\n\nCV: Pt HR 68-80 NSR rare PAC's noted, run NSVT x 1, pt asymptomatic, see strip in chart, NBP 88-122/55-88, captopril dose 12.5 mg held d/t SBP<90 HO aware, metoprolol dose 12.5 mg held at midnoc d/t SBP, Ho aware, dose given at 0400. ECHO done during prior shift, results back-EF 35%, severe hypo/akinesis of distal half of anterior and antereoseptal walls noted per report, please see ECHO report for additional info. R groin CDI, area soft, no hematoma, sm area of ecchymosis noted, unchanged throughout shift. Heparin gtt started at 1000 units/hr at 2215, PTT drawn this am, results pending. Bilateral distal pulses palp. Am labs pending.\n\nResp: LS CTA, RR 13-20 O2 sats 94-99% on room air, pt O2 sats briefly dropped to 93% while sleeping but increased without intervention.\n\nNeuro: Pt pleasant, cooperative with care, pt MAE, turning self in bed. Pt with c/o back pain, knees and legs aching, tylenol given and pt repositioned witih some relief, no c/o CP.\n\n\nGI/GU: Pt abd soft, +BS x 4 no stool this shift. Foley cath draining clr yellow u/o 30-45 cc/hr prior to lasix dose 20 mg, after lasix u/o 65-460 cc/hr, -585.9 at midnoc, -2454 LOS.\n\nID: pt afebrile, T max 98.2.\n\nA/P: 60 y/o male s/p anterior STEMI with stent to RCA, captopril dose held , am metoprolol dose tol at 0400, EHCO results EF 35%. Continue to monitor pt hemodyanmics, titrate BB/ace as tol. Cont to monitor PTT, groin site, resp status, u/o, advance activity/diet as tol. Cont to provide post-MI teaching, emotional support to pt.\n\n" }, { "category": "Nursing/other", "chartdate": "2175-11-14 00:00:00.000", "description": "Report", "row_id": 1486620, "text": "CCU NPN: 0700-1900\n\nS: \"So 50-some hours and then I can go home?\"\n\nO: See CareVue flowsheet for complete assessment details\n\nCV: HR 70s, SR w/ rare PAC. BP stable w/ SBP 100-130s, MAP >80s - tolerated Captopril and Metoprolol doses. Prior to PA-line removal, PADs 20s. AM hemodynamics: C.O./C.I. 5.3/2.18. ECHO obtained - results pending. Arterial and venous sheaths discontinued at 1430 - pt. tolerated well but required 4mg Morphine sulfate IVP for comfort. Right groin D/I, no oozing nor hematoma noted, slightly ecchymotic. +3 pedal pulses.\n\nRESP: Lungs CTA bilaterally. O2 sat > 95% on 2L NC - weaned to off.\n\nGI/GU: Abd. soft, non-tender, slightly distended. BS active x4 quadrants. No further sx's of GI discomfort. Remained on liquids only prior to sheath discontinuation - post-sheath pull, tolerated cardiac diet w/o difficulty. Adequate UOP - approx. 50cc/hr.\n\nNEURO/COMFORT/SOCIAL: Alert and oriented x3. Pleasant and cooperative. MAE, +CSM. Follows commands appropriately. Asking questions re: plan of care, medications etc. Received 650mg Tylenol PO for mild discomfort in back (pt. described as arthritic pain) w/ good results. Anxious about his dog as pt. lives alone - able to be in touch w/ neighbors which relieved some anxiety. Post-MI teaching initiated. Plan for social work consult .\n\nA/P: Sustained CP at home prior to admission to OSH - found to have anterior STEMI and transferred to for cardiac cath/ PCI. S/P stent placement to LAD (100% occlusion). Post-MI teaching initiated. Tolerated addition of Metoprolol to current medication regimen (including Captopril). ECHO obtained - results pending. Right femoral arterial and venous sheaths discontinued w/ hemostasis at 1445 - gradual increase in activity if groin remains stable. Monitor UOP - discuss w/ team poss. diuresis this PM (elevated RHC pressures). Emotional support and comfort.\n" }, { "category": "Nursing/other", "chartdate": "2175-11-14 00:00:00.000", "description": "Report", "row_id": 1486618, "text": "CCU NPN 19-0700\nS: \"So 72 hours and I can get out of here...I don't know if its pain, gas, its irritating...sometimes my memory isn't that good...I don't want my girlfriend to worry.\"\n\nO: Pt is 60 y/o male s/p ant STEMI admitted to cath lab after presenting to OSH with radiating CP to arm and neck, pt drove to OSH and rec'd asa, plavix, heparin, integrillin in ED and transferred to cath lab. In cath lab pt with 100% LAD TO, 70% D1-> 1 to LAD placed and cutting balloon angioplasty to D1. Pt had increased filling pressures, CO/CI 4.5/1.9, rec'd 20 mg IV lasix and transferred to CCU for further monitoring. Please see admission note and careview for VS and additional data.\n\nCV: Pt HR 68-83 NSR with rare Pac's noted and several runs of NSVT-pt asymptomatic, Dr. and Dr. aware, see strips in chart. ABP 115-145/65-88, PAP 29-41/15-25, pt started on 6.25 mg captopril, pt tol, 12.5 mg captopril to be given this am. Pt with c/o CP/tightness/irritating on L side of chest 1.5/10, non-radiating, EKG done, Dr. and Dr. aware and in to eval pt,per Dr. EKG elevation improved->0.3 mg SL nitro given with minimal effect, 2 mg IVP morphine sulfate given with some effect, pain/tightness/ache . pt stating to RN that pain is unlike prior CP that brought him into hospital. Pt unable to quantify pain at times or identify as actual pain, maalox given with some relief. ? indigestion/residual ache from manipulation. Please see careview for CO/CI-most recent CO 5.8/CI 2.39 am numbers pending. Hct 38.6, K 3.4->repleted with 60 MEQ KCL, Mg 1.7->repleted with 2 grams mag sulfate, am labs pending. Received pt with R groin stable ooze, area marked, site stable, area soft-dsg changed this am, site remains CDI, area soft. Bilateral distal pulses palp.\n\nResp: pt LS CTA, RR 10-19, O2 sats 98-99 % on 3 L n.c. Pt noted to be snoring intermittently throuhgout night. Pt denies SOB.\n\nNeuro: Pt alert and oriented x 3, pleasant and cooperative with care-pt stating he has some difficulty remembering things, no deficiets noted-pt unable to identify/describe/differentiate pain/discomfort/gas at times. Pt initially asking for antidepressants to be held until later in night before sleep-pt slept intermittently throughout night. Pupils 4mm equal brisk reactive, pt MAE.\n\nGI/GU: pt abd soft distened, +BS x 4, no stool this shift. Pt with foley cath draining adequate amts u/o, please see careview flowsheet. Pt -1868 cc at midnoc and LOS, no post cath fluid ordered- Confirmed with Dr. and Dr. no post cath IVF to be given.\n\nID: Pt afebrile.\n\nSocial: No calls or visitors . pt, pt resides alone with pet dog 6 months of year and lives with girlfriend 6 months of the year. Pt has been previously married and has several teenage children.\n\nA/P: 60 y/o male s/p ant STEMI, with c/o CP/discomfort partially relieved with maalox and morphine, no worsening EKG changes noted MD's, captopril added and pt tol. Continue to monitor pt hemodynamic\n" }, { "category": "Nursing/other", "chartdate": "2175-11-14 00:00:00.000", "description": "Report", "row_id": 1486619, "text": "CCU NPN 19-0700\n(Continued)\ns, cardiac numbers, CP/discomfort HCt, lytes, R groin site, pulses. Cont to monitor pt resp status, u/o, neuro/pain status. Continue to provide emotional support to pt.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "SEL CATH 3RD ORDER THOR", "row_id": 808915, "text": " 9:27 AM\n CAROT/CEREB Clip # \n Reason: TRAUMA\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n Contrast: OPTIRAY Amt: 155\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CEREBRAL BILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * VERT/CAROTID A-GRAM -59 DISTINCT PROCEDURAL SERVICE *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n * C1760 CLOSURE DEVICE VASC IMP/INS C1894 INT/SHTH NOT/GUID EP NON-LASER *\n ****************************************************************************\n ______________________________________________________________________________\n FINAL REPORT\n PREOPERATIVE DIAGNOSIS: Traumatic injury with skull fracture rule out carotid\n or vertebral intimal dissection or occlusion.\n\n POSTOPERATIVE DIAGNOSIS: No evidence of dissection or other anomaly.\n\n INDICATION: is a patient who was involved in a cranial trauma\n resulting in skull base fractures. He is undergoing this cerebral angiogram to\n rule out intracranial and extracranial carotid or vertebral artery dissection\n or injury.\n\n CONSENT: The patient's family were given a full and complete explanation of\n the procedure. Specifically, the indications, risks, benefits, and\n alternatives to the procedure were explained in detail. In addition, the\n possible complications, such as the risk of bleeding, infection, stroke,\n neurological deficit or deterioration, groin hematoma, and other unforeseen\n complications including the risk of coma and even death, were outlined. The\n patient's family understood and wished to proceed with the operation.\n\n PROCEDURE IN DETAIL: The patient was brought into the Endovascular Suite and\n placed on the table in supine position. The right groin area was/were prepped\n and draped in the usual sterile fashion. A 19-gauge single- wall needle was\n then used to puncture the right common femoral artery, and upon the return of\n brisk arterial blood, a 4Fr vascular sheath was inserted over a guidewire and\n kept on a heparinized saline drip. Next, a diagnostic catheter was used to\n selectively catheterize the following vessels: right common carotid artery,\n right internal carotid artery, right external carotid artery, left common\n carotid artery, left internal carotid artery, left external carotid artery,\n left subclavian artery, left vertebral artery, right subclavian artery, right\n vertebral artery.\n\n RESULTS: Injection of both common carotid arteries in the cervical region\n reveals no evidence of abnormal finding. No evidence of dissection or injury.\n Injection of both external carotid arteries reveals no evidence of abnormal\n arteriovenous shunting and intracranially the internal carotid artery showed\n no evidence of dilatation or pseudoaneurysm or arteriovenous malformation.\n (Over)\n\n 9:27 AM\n CAROT/CEREB Clip # \n Reason: TRAUMA\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n Contrast: OPTIRAY Amt: 155\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n Similarly the posterior circulation involving both vertebral arteries in the\n cervical region and intracranially were within normal limits with no abnormal\n findings. The subclavian arteries were normal with unremarkable origins of the\n vertebral arteries.\n\n IMPRESSION: Negative cerebral angiogram for carotid artery dissection.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 809130, "text": " 10:57 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed and or infarction. use contast if indicat\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC, change in mental status please eval for\n bleed\n REASON FOR THIS EXAMINATION:\n eval for bleed and or infarction. use contast if indicated.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Loss of consciousness and change in mental status, status post\n fall. Please evaluate for bleed and/or infarction.\n\n TECHNIQUE: Noncontrast CT of head.\n\n FINDINGS: Comparison is made with prior noncontrast head CT dated . Again seen is a moderate amount of subarachnoid hemorrhage bilaterally,\n extending into the frontal sulci. Bilateral frontal hemorrhagic contusions\n are again noted. The amount of intraparenchymal hemorrhage is approximately\n stable since the examination of two days prior; however, there is marked\n progression of hypodensity surrounding the frontal parenchymal hemorrhages,\n more pronounced on the left. This is consistent with interval progression of\n hemorrhagic contusions. There is associated mass effect, with compression of\n the frontal horns of the lateral ventricles bilaterally, left greater than\n right. An additional focus of hypodensity is seen in the right cerebellar\n hemisphere near the tonsil. This was not apparent on the prior examination.\n Unchanged appearance of multiple previously described fractures is noted.\n There is interval progression of opacification of the mastoid air cells,\n right greater than left, and of the maxillary sinuses, ethmoid sinuses, and\n sphenoid sinuses. The patient is intubated.\n\n IMPRESSION:\n 1. Marked interval progression of bilateral frontal hemorrhagic contusions,\n with worsening edema and mass effect.\n 2. Hypodensity within the right cerebellum cosistent with evolving contusion.\n 3. Unchanged appearance of multiple skull fractures.\n 4. Worsening fluid collections within the paranasal sinuses and mastoid air\n cells.\n\n These findings were communicated to the clinical team at the time of\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809044, "text": " 3:41 PM\n CHEST (PORTABLE AP) Clip # \n Reason: verify placement of feeding tube\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n\n REASON FOR THIS EXAMINATION:\n verify placement of feeding tube\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Verify placement of feeding tube.\n\n COMPARISON: \n\n CHEST AP: The tip of the Dobbhoff tube is visualized in the body of the\n stomach. The heart size, mediastinal and hilar contours are unremarkable.\n The lung fields are clear. No pleural effusions are seen. The pulmonary\n vasculature is normal.\n\n IMPRESSION: Satisfactory position of the feeding tube.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809708, "text": " 2:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for signs of pneumonia\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p intubation now with increased secretions and\n febrile\n REASON FOR THIS EXAMINATION:\n assess for signs of pneumonia\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM:\n\n History of intubation with fever and increased secretions.\n\n Subclavian CV line overlies proximal SVC. No pneumothorax.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809298, "text": " 8:04 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p intubation and now with fever\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Fever, evaluate for pneumonia.\n\n PORTABLE AP CHEST: Comparison is made to previous films from .\n\n FINDINGS: The tips of the endotracheal tube, right subclavian line and the\n Dobhoff tubes are in satisfactory positions. Slight left ventricular\n enlargement is again noted. There is unfolding of the aorta. The pulmonary\n vasculature is within normal limits. The lung fields are clear. There are no\n pleural effusions.\n\n IMPRESSION: No evidence of pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809563, "text": " 3:03 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p intubation now with desat and secretions.\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Desaturation status post intubation.\n\n COMPARISON: at 15:10.\n\n FINDINGS: Lines and tubes remain in place. No pneumothorax. Subsegmental\n atelectasis at the right lower lung zone is again noted. There are no new\n infiltrates and the pulmonary vascular markings are within normal limits. The\n left lateral costophrenic sulcus is cut off from view. No change in the\n mediastinal or cardiac contours.\n\n IMPRESSION:\n\n No significant interval change vs. prior.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809389, "text": " 3:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: central line change over wire; eval placement\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p intubation and now with fever\n\n REASON FOR THIS EXAMINATION:\n central line change over wire; eval placement\n ______________________________________________________________________________\n FINAL REPORT\n History of fever in patient with intubation and CV line.\n\n Endotracheal tube is ___ cm above carina. Tip of left subclavian CV line\n overlies proximal SVC. No pneumothorax. Heart size is normal for technique. No\n definite pulmonary consolidation or pleural effusions in this single view.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST", "row_id": 808894, "text": " 3:13 AM\n CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: thin cuts of face. evaluate for fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with fall down steps. Blood in right ear, nose and mouth\n REASON FOR THIS EXAMINATION:\n thin cuts of face. evaluate for fx\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa SUN 4:34 AM\n spenoid fracture extending into right carotid canal\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n\n INDICATION: Blood in right ear, nose and mouth. Evaluate for fx, fell down\n steps.\n\n TECHNIQUE: Non-contrast axial images were obtained from the superior portion\n of the frontal sinuses to the mandible. Coronal reformatted images were\n obtained.\n\n CT FACIAL BONES W/O CONTRAST: Again demonstrated, is the occipital bone\n fracture. Again demonstrated is pneumocephalus anteriorly. There is a\n fracture through the sphenoid bone extending into the carotid canal. There\n is a fracture of the anterior portion of the sphenoid bone extending into an\n ethmoid air cell. There is blood within the ethmoid air cells. There is\n fluid within several of the right sphenoid sinuses. There is a trace amount\n of fluid within the right maxillary sinus. The left maxillary sinus and\n frontal sinuses are clear. There is anterior subluxation of the right\n mandibular condyle within the temporo-mandibular joint. There is a fracture\n of the sphenoid bone extending through the right external auditory canal.\n Fluid is present within the right mastoid air cells. The left mastoid air\n cells are clear.\n\n IMPRESSION: Skull base fractures, as described above. There is no nasal\n bone, orbital or maxillary fractures. There is pneumocephalus.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "T-SPINE", "row_id": 808896, "text": " 3:49 AM\n T-SPINE; LUMBO-SACRAL SPINE (AP & LAT) Clip # \n Reason: r/o fx\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with fall down steps\n REASON FOR THIS EXAMINATION:\n r/o fx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fell down steps.\n\n AP AND LATERAL VIEWS OF THE LUMBAR AND THORACIC SPINES:\n\n The thoracic and lumbar vertebral bodies are normal in height and alignment.\n No fractures are identified. The ET tube is in satisfactory position within\n the mid-trachea. The NG tube has been advanced and is coiling within the\n stomach. Surgical clips overlie the right hemipelvis. Contrast excretion is\n noted in the collecting systems bilaterally.\n\n IMPRESSION: No fractures.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 809111, "text": " 8:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: CHECK ETT AND LEFT SUBCALAVIAN LINE\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p intubation\n\n REASON FOR THIS EXAMINATION:\n 56 year old man with s/p intubation\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Status post intubation. Check position of endotracheal tube and\n left subclavian line.\n\n PORTABLE AP CHEST: Two AP semiupright views. Comparison is made to previous\n films from . A new endotracheal tube has been inserted and its tip is\n well positioned approximately 7 cm above the carina. The left subclavian line\n tip is in the upper SVC, also in good position. The prior Dobhoff NG line is\n in the fundus of the stomach. The heart shows slight left ventricular\n enlargement. The aorta is slightly unfolded. The pulmonary vessels are within\n normal limits. No pulmonary abnormalities can be identified. There is no\n evidence of any pleural effusion.\n\n IMPRESSION: Satisfactory placement of ET tube and left subclavian line. No\n significant cardiopulmonary abnormality is demonstrated. Some LV enlargement\n is noted.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-11 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 809826, "text": " 11:34 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please assess swelling\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC, change in mental status please eval\n for bleed\n REASON FOR THIS EXAMINATION:\n please assess swelling\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INFORMATION: Change in mental status follow up study.\n\n Exam compared to prior study of .\n\n FINDINGS: The bifrontal contusions with some deformity of the frontal horns\n and edema extending into the corpus callosum. There are no definite new\n findings. The ventricles are unchanged in conformation.\n\n IMPRESSION: Stable appearance compared to prior study with bifrontal\n contusions.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "TRAUMA #2 (AP CXR & PELVIS PORT)", "row_id": 808888, "text": " 2:20 AM\n TRAUMA #2 (AP CXR & PELVIS PORT) Clip # \n Reason: TRAUMA\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Trauma, post fall.\n\n AP CHEST:AP PELVIS: The cardiomediastinal contours are normal. The lungs are\n clear. There are no pleural effusions or pneumothoraces. No thoracic or\n pelvic fractures are identified. Note the right CP angles are not included in\n this radiograph. Fine osseous detail is limited by overlying trauma board.\n\n IMPRESSION: No evidence of acute cardiopulmonary disease. No pelvic\n fracture is identified.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 808889, "text": " 2:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa SUN 4:04 AM\n bitemoporal hemorrhagic contusions, skull base and occipital bone fractures\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n\n INDICATION: Trauma, loss of consciousness.\n\n TECHNIQUE: Non-contrast head CT.\n\n CT HEAD W/O CONTRAST: There are bitemporal hemorrhagic contusions, left\n greater than right. There is a small amount of subarachnoid hemorrhage\n extending into the frontal sulci. There is a small subdural hemorrhage\n extending along the anterior inferior falx. There is diffuse brain edema,\n left greater than right with loss of the normal sulcation pattern. There is\n no shift of the normally midline structures. There is a small focus of\n hyperdensity within the anterior portion of the mid-brain. The ventricles are\n symmetric. The basilar cisterns are patent. There is pneumocephalus\n anteriorly and several small foci of air posteriorly. There is a non-\n displaced occipital bone fracture extending from the skull base to the mid-\n portion of the skull. There is a fracture through the posterior right ethmoid\n air cell extending into the sphenoid sinus. There is a fracture of the right\n temporal bone which forms the anterior portion of the external ear canal.\n There is hemorrhage within the right temporo-mandibular joint displacing the\n mandible anteriorly. Fluid is present within the right mastoid air cell. The\n left mastoid air cells are well pneumatized. There is hemorrhage within the\n ethmoid air cells and sphenoid sinus. There is a trace amount of fluid within\n the right maxillary sinus. The frontal sinuses are clear. Note is made of\n calcification of the right internal carotid. There is a minimally displaced\n fracture of the posterior right portion of the sphenoid bone which extends\n through the right internal carotid canal.\n\n IMPRESSION:\n 1) There are bitemporal hemorrhagic contusions left greater than right. There\n is brain edema causing loss of tbe normal left hemispheric sulcation pattern.\n\n 2) There is a fracture through the posterior portion of the sphenoid bone\n extending into the right carotid canal. There is a fracture of the occipital\n bone which is non-displaced. There is a fracture of the anterior portion of\n the sphenoid bone extending into the ethmoid air cells. There is a fracture\n of the right temporal bone extending through the anterior portion of the right\n external ear canal. There is subluxation of the right temporo- mandibular\n joint anteriorly. There is pneumocephalus.\n\n (Over)\n\n 2:37 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: trauma\n ______________________________________________________________________________\n FINAL REPORT (REVISED) *ABNORMAL!\n (Cont)\n These findings were directly discussed with the Neurosurgical and Trauma\n surgeons.\n\n 3) Suggestion of punctate hemorrhage in the brainstem, may be related to the\n shear injury.\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 808890, "text": " 2:38 AM\n CT C-SPINE W/O CONTRAST; CT RECONSTRUCTION Clip # \n Reason: trauma\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa SUN 4:21 AM\n no c-spine fx. non displaced Occipital bone fx\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Post fall.\n\n TECHNIQUE: Noncontrast axial images were obtained through the cervical spine.\n Coronal and sagittal reformatted images were obtained.\n\n CT C SPINE WITHOUT IV CONTRAST: There is no prevertebral soft tissue swelling.\n The cervical vertebral bodies are normal in height and alignment. There is a\n trace amount of air posterior to the odontoid at the occipital bone/C1\n junction, which is likely due to vacuum phenomenon. There is a nondisplaced\n fracture through the anterior portion of the occipital bone at this level.\n There is a nondisplaced fracture of the posterior portion of the occipital\n bone. The ring of C1 is intact. No fractures are identified involving the\n cervical spine. There is degenerative change of the lower cervical spine with\n loss of the normal disc space height at the C5-6, C6-7 and C7-T1 levels. There\n is mild osteophyte formation at these levels extending both anteriorly and\n posteriorly. There is narrowing of the left neural foramen at the C5-C6 level\n due to uncovertebral degenerative change.\n\n IMPRESSION: No cervical spine fractures or malalignment. There is a\n nondisplaced fracture through the posterior and anterior portion of the\n occipital bone.\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "CT PELVIS W/CONTRAST", "row_id": 808891, "text": " 2:39 AM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 43 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC\n REASON FOR THIS EXAMINATION:\n trauma\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PSLa SUN 4:40 AM\n probable aspiration, diverticulosis without diverticulitis, no acute traumatic\n process\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n INDICATION: Trauma, post fall.\n\n TECHNIQUE: Contiguous axial images were obtained from the lung bases to the\n pubic symphysis after the administration of IV contrast.\n\n CONTRAST: 150 cc Optiray was administered.\n\n CT ABDOMEN WITH INTRAVENOUS CONTRAST: There is focal density within the medial\n aspect of the right lower lobe consistent with probable aspiration. There is\n bibasilar atelectasis. There are no pleural effusions. The liver,\n gallbladder, spleen, pancreas, adrenal glands and intraabdominal bowel loops\n are unremarkable. The kidneys enhance symmetrically and enhance normally.\n There is no free fluid or free air within the abdomen. There is no significant\n abdominal adenopathy.\n\n CT PELVIS WITH IV CONTRAST: A Foley catheter is present within the urinary\n bladder. The distal ureters and intrapelvic small bowel loops are\n unremarkable. There is sigmoid and descending colon diverticulosis without\n evidence of diverticulitis. The remainder of the colon is collapsed. There\n has been probable resection of the cecum and terminal ileum. Surgical clips\n overlie the right hemipelvis posteriorly. There is no free fluid within the\n pelvis.\n\n The osseous structures are unremarkable. Note is made of a tiny focus of\n sclerosis within the right iliac bone adjacent to the SI joint, most likely a\n benign bone island. If this patient has a history of malignancy, followup of\n this osseous lesion is recommended.\n\n IMPRESSION:\n 1) There is no evidence of an acute traumatic process involving the abdomen\n and pelvis.\n 2) This is probable aspiration in the posterior portion of the right lower\n lobe.\n 3) There are surgical clips within the right hemipelvis likely due to prior\n bowel resection. Recommend correlation with clinical history.\n\n (Over)\n\n 2:39 AM\n CT PELVIS W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT 150CC NONIONIC CONTRAST\n Reason: trauma\n Field of view: 43 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT *ABNORMAL!\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2183-11-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 809276, "text": " 3:03 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for further edema\n Admitting Diagnosis: S/P FALL-HEAD INJURY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with s/p fall ? LOC, change in mental status please eval for\n bleed\n REASON FOR THIS EXAMINATION:\n eval for further edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post fall. ? loss of consciousness. Please evaluate for\n further edema.\n\n TECHNIQUE: Non-contrast CT of the head.\n\n FINDINGS: Comparison is made with most recent prior CT of the head dated\n . The exam is severely limited by extensive patient movement,\n despite multiple attempts to rescan. The bilateral frontal hemorrhagic\n contusions can again be appreciated and appear grossly unchanged in size. No\n evidence of new intracranial hemorrhage can be detected. There is again seen\n mass effect with compression of the left lateral ventricle to a greater extent\n than compression of the right, and this appears grossly unchanged. Images of\n the posterior fossa are nondiagnostic due to patient motion.\n\n IMPRESSION: Technically limited exam with extensive patient motion artifact.\n No gross interval changes in the appearance of bilateral hemorrhagic\n contusions of the frontal lobe with edema and mass effect can be detected.\n These results communicated to the clinical team at the time of interpretation.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2183-11-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 808893, "text": " 2:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p intubation, ng tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 56 year old man with\n REASON FOR THIS EXAMINATION:\n s/p intubation, ng tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION; Post-intubation and NG tube placement.\n\n AP CHEST: The ET tube is in the mid-trachea. The NG tube terminates in the\n mid-esophagus. The cardiac and mediastinal contours are stable. The lungs are\n clear. There are no pleural effusions or pneumothoraces. The osseous\n structures are unremarkable.\n\n IMPRESSION: The NG tube is within the distal esophagus. The ET tube is in\n satisfactory position.\n\n\n\n" }, { "category": "ECG", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 196100, "text": "Baseline artifact\nSinus rhythm\nPremature atrial contractions\nModest nonspecific low amplitude T waves changes\nNo previous tracing for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1483859, "text": "NPN 7a-7p:\n S/O: please see transfer note for full assessment. Pt oob to chair via lift x several hours. tolerated well. requiring sx q 3 hrs of tenacious tan/blood tinged secretions. Pt opens eyes and looks to voice, not follwing commands. Family meeting held with pt's son , Dr. , Dr. , and this RN. Dr. expressed concern r/e son's desire to withdraw all care at this point and to make pt at this point. Son is adamant that any recovery other than a full recovery would not be acceptable to patient, and therefore son does not want to \"gamble with his father's life\" and risk having pt be bedbound or dependent on others for self care. Son therefore wants to make Pt . Ethics committee to be first thing in am to review this case per Dr. . Dr. explained to pt's son that although the caregivers want to honor pt's wishes, he would like first to consult ethics team to be sure we are doing what is ethical in this situation. Son is agreeable to meeting with , but sates he will not change his position. Dr. stated understanding of son's position, and discussion to be resumed tomorrow with . Please page first thing in the morning. Pt to remain DNR/DNI but full treat at this time. We will not, however replace pt's feeding tube which he pulled our o/n. pt will remain without feeding tube at son's request. Social worker also spoke with family, and Priest was called at request of family to administer Sacrament of the sick.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1483860, "text": "left subclavian line d'cd - tip sent for culture. pt remains on 50% face tent, rr~20's, pt w/ strong cough, coarse rhonchi breath sounds, suctioned for thick yellow secretions, IVF D5W @ 40 cc/hr uo~ 30 cc/hr bp~156-70 HR 90's Sr no vea t 100 ax.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1483861, "text": "pmicu nursing progress 7p-7a\nreview of systems\nCV-vs have been stable, hr in 70's-80's, dipped briefly to 58 after lopressor dose.BP has been 160's-170's/.\nRESP-on 50% face tent with sats >95%. RR 15-24, occasionally labored.lungs are coarse throughout.was sx x 1 nasally for thick brown sputum.pt with a poor gag, has a strong productive cough.\nGI-abd is soft with positive bowel sounds. has been passing brown liquid stool via rectal bag.pt is NPO.on famotidine.\nID-afebrile.on unasyn. wbc pnd.\nF/E-ivf of D5 infusing at 40/hr. has been voiding sufficient quantities urine. no peripheral edema noted. am labs just ordered- to be drawn.\nNEURO-eyes open spontaneously- do not follow you. pt does not follow commands.limbs move nonpurposefully.hands are lightly restrained.on dilantin.no sedatives given overnight.neck collar in place.\nIV access- has 2 small bore heplocks in place.\nSOCIAL- no phone calls for him overnight.\na-uneventful night\nP-need to decide plan of care with family\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1483857, "text": "npn 7-7pm\nPt son , was in this afternoon to visit.Spoke at length with RN and then with Dr. . Pt son is confident of his father's wishes that he would not want to exist like this. Dr spoke with his attending, Dr and all teams involved-neuro and TSICU. They all conferred and pt was extubated at 1700. Son is with patient and plans to spend the night.\n\nCODE STATUS: Pt is a DNR/DNI but he has not been made comfort measures at this time. This will be addressed as needed.\n\nneuro: No changes. Now that propofol is off pt does open his eyes, he is not tracking or following commands. Responds to tactile stimuli.\nAt this time he is not being medicated for pain/agitation as he seems quite comfortable. J collar is on.\n\nresp: Open face mask. Sats have decreased from 97 to 94% since extubation. Copious amounts of oral secretions. Pt does not appear to be in any distress.\n\ncv: SR, no ectopy. BP goal is < 160 and has been maintained.\n\naccess: tlc on R sc.\n\ngi/gu: Belly is soft disteded. Several BM today. Please hold colace tonite. Patent foley with good u/o. Received 20mg iv lasix with 1300 out. TF at goal of 90 via pedi- ngt.\n\nskin: L arm with \"trash arm\" per Dr . (Shooting emboli to hand).\nOtherwise intact.\n\nSocial: Very supportive son. advocated for his father and is very comfortable with his decisions. He understands the risk/benefits of extubation. His wife is a nurse practitioner and will be in soon to provide him with emotional support. Plans to stay over tonite in waiting room and check in occasionally with his dad.\n\nPlan: Continue care as discussed above. If needs sedation or pain meds pls call SICU resident.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-10 00:00:00.000", "description": "Report", "row_id": 1483858, "text": "NURSING PROGRESS NOTE:\nPT RECEIVED AT BEGINING OF SHIFT INCONTINENT OF HUGE AMT OF LIQ BROWN STOOL. FECAL INCONTINECE BAG APPLIED.\nNEURO: PT AWAKE WITH EYES OPEN BUT DOES NOT TRACK WITH EYES AND DOES NOT RESPOND TO COMMANDS. MAE, LIMBS ARE VERY STIFF. PERLA 4MM AND REACTING BRISKLY. PT IS NOT VERBAL.\nCV: PT IN WITHOUT ECTOPY, SBP GREATER THAN 150 ON , PT RECEIVED ONE DOSE OF HYDRALAZINE 10MG IV WHICH BROUGHT BP WITHIN ACCEPTABLE RANGE. RR IN MID TO HIGH 20'S. TEMP ELEV TO 101 AX.\nPT GIVEN TYLENOL X 1.\nRESP: PT COUGHING AND ATTEMPTING TO RAISE SECRETIONS BUT UNABLE AND REQUIRES NTSX. PT SX FOR COPIUOS AMT'S OF BLOOD TINGED SPUTUM. O2 SAT'S 98-100%. LUNG SOUNDS COARSE BUT CLEAR WITH SX'ING.\nGI: PT RECEIVING TUBE FEEDS VIA NGT. UNABLE TO CHECK ASPIRANTS. PT HAS GOOD BOWEL SOUNDS AND IS PASSING MOD AMT'S OF LIQ BROWN STOOL THOUGH A FECAL BAG.\nGU: PT HAS FOLEY CATH WHICH IS DRAINING VERY GOOD AMT'S OF AMBER URINE.\nPT CONT TO WEAR J COLLAR. PT IS VERY RESTLESS IN THE BED BUT SETTLES DOWN AFTER A WHILE.\nENDO: FINGERSTICKS TREATED WITH SLIDING SCALE INSULIN.\nFAMILY STAYED WITH PT FOR A WHILE, ASKING AGAIN IF THE PRIEST WAS COMING. OPERATOR NOTIFIED AGAIN TO PAGE PRIEST, UNABLE TO REACH.\nPT IS DNR/DNI.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-02 00:00:00.000", "description": "Report", "row_id": 1483826, "text": "Respiratory Care:\nPt. arrived from E.D., S/P fall down stairs, with injuries including SAH, Lt. Temporal contusion, multiple facial and skull FX's. CXR showed OET ~ 9cm ^ carina>>advanced OET from 23 to 26 @ lip. B/S Bilateral and course. Suctioning large amounts of thick, red secretions, and patient has same from oral and nasal pharynx. Hard collar in place. Placed on settings per E.D. Awaiting ABG. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1483862, "text": "npn; 0700-1700\n\nneuro;. opens eyes spontaneously does not focus or track. mae spontaneously lt arm moves less than rt nothing to command has not spoken entire shift has weak productive cough weak gag.perla 4-5mm. in state of constnt motion in bed. travelled for head ct today. results pending.\n\ncvs; tmax 99.8 po nsr with mod amounts pac.sbp in high 180 initially given lopressor and hydralazine with little effect. sstarted on ngt paste 2\" q6 with better control/ also given haldol 2.5 mgs i.v for ct scan with good effect.\n\ngu; good amounts of clear yelow urine via foley.\n\ngi ; npo receiving 100 mls/hr%5,45ns with 20 meq kcl.\nskin ?rash over arms and shoulder area.\n\nsoc; at family meeting both sons and sister and brother in law.today with md ethics. lisw dr neurosurgery and t sicu it was decided to slook for placement for bridge to hospice and hopefully transfer him to a facility in the . when there is a bed available . all members of the family were in agreement with this plan.\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-11 00:00:00.000", "description": "Report", "row_id": 1483863, "text": "FOCUS; ADDENUM TO AM NOTE\nNEURO- DILANTIN LEVEL 3.8 TODAY. 1000MG BOLUS ORDERED AND GIVEN. TO BE TRANSFERRED TO FLOOR PER TSICU. WILL NEED SITTER. NURSING SUPERVISOR GOT A SITTER FOR 11PM. TRANSFER NOTE UPDATED.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-03 00:00:00.000", "description": "Report", "row_id": 1483831, "text": "NSG NOTE\nsee flowsheet for specifics.\n\nNEURO-PT LETHARGIC BUT RESPONDS TO PAIN. PT LOCALIZES TO PAIN. MAE. PERRL. PT MOANING WITH GARBLED/UNCOMPREHENSABLE SPEECH. PT DID CLEARLY STATE \"HELP ME\" TO PAINFUL STIMULI ON OCC. PT VERY AGITATED, MOVING ALL OVER BED, KICKING, PULLING AT LINES, ATTEMPTING TO SIT UP AND GET OOB. CIWA SCALE ORDERED. ATIVAN Q 1HR. HALDOL GIVEN X MANY, SEE . PRECEDEX STARTED. PT SL MORE LETHARGIC, BUT ESSENTIALLY UNCHANGED. UNABLE TO DO HEAD CT TODAY D/T AGITATION. SITTER AT BEDSIDE.\n\nCV-HR 90-100'S, SINUS, SBP STABLE. ALINE DAMPENED. USING CUFF FOR BP .\n\nRESP-O2 SAT 96% 4LNC. LS WITH WHEEZES. NEB TX GIVEN BY RESP THERAPY. NARD NOTED.\n\nGI-ABD SOFTLY DISTENDED. +BS. FEEDING TUBE PLACED. TF STARTED.\n\nGU-VOIDING VIA FOLEY ADEQ AMTS.\n\nENDO-SSRI.\n\nID-ABX D/C'D. TMAX 100.8 AX. WILL FOLLOW.\n\nPLAN-CON'T WITH CURRENT PLAN. CON'T SEDATION. NEURO CHECKS. HEAD CT WHEN ABLE. SITTER FOR SAFETY.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483849, "text": "See CareVue for objective data.\n\nEvents of the day:\n\nPt did well on weaning trial of 0/5 with adequate ABG. But team decided pt's mechanics of breathing(heavy abdominal breathing) and his status of DNR/DNI did not facilitate pt's chanches for extubation today. Returned to CPAP and tolerated well for remainder of the day.\n\nRequiring much less proprofol and goal is for pt to be managed on prn doses of haldol and proprofol to be dc'd. Neuro staus essentially unchanged except much less restless and opens eyes spontaneously and movements appear more purposeful than Wednesday.\n\nSerum osmo 348 at 1500. Redrawn to ensure accuracy but free water to be given overnight via TF at 100cc's an hour. Mannitol has been dc's X 2 days. NA 147. Serum lytes sent as well. FSBS 175 and covered per SS.\n\nFamily in and updated. Social worker in to speak with them as well. Son would like to be called if pt does get extubated.\n\nPlan: Monitor serum osmo and NA,SSRI per FSBS,free water at 100cc's/hr\novernight,continue with neuro checks,dc proprofol and haldol prn for sedtaion,lopressor po for bp control and continue to support pt and family.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-02 00:00:00.000", "description": "Report", "row_id": 1483827, "text": "Nursing Admit Note:\n\nPt is a 56 yo man found by neighbor at the bottom of stairs ?LOC, taken to Hospital. Agitated and confused +ETOH=211 at OSH. Taken to where he became increasingly agitated and confused, pt sedated and intubated. Injuries found to be non-displaced occipital bone fx c pneumocephalus, SAH, L temporal contusion, R temporal bone fx, sephnoid sinus fx.\n\nPmh: Unknown\nAllergies: NKA\nMeds at home: Unknown\n\nReview of Systems:\n\nNeuro: Pt sedated on IV propofol, when propofol lightened pt becomes very agitated with coughing/gaging spell until propofol restarted. Pt withdraws all extremities to nail bed pressures. MAE stronhly on bed. Does not open eyes or follow commands at this time. +strong gag and cough. Logroll and c spine precuations maintained.\n\nCv: NSR/ST with hr=80-100s, no ectopy. SBP=100-140s, up to 170s with stimulation and when off propofol. Venodynes in place. Palpable peripheral pulses.\n\nResp: LS dm bases. IMV with adequate ABG. SaO2=99-100% on 50% fio2. +strong cough. Suctioned for thick bloody secretions.\n\nGI: Abd soft, hypoactive BS. NPO. OGT to LWS. No BM. IV pepcid started.\n\nGU: Indwelling foley intact and draining clear yellow urine, sufficient UO.\n\nHeme: Am labs pending.\n\nID: Afebrile.\n\nEndo: RISS started, no coverage required.\n\nSkin: Intact, warm and dry. R ear with lg amt of blood, clearned and unable to find laceration.\n\nSOC: Unknown. No contact from family or friends.\n\nPlan: Continue neuro checks q 1hr. plan for 4 vessel angiogram today.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-02 00:00:00.000", "description": "Report", "row_id": 1483828, "text": "TRAUMA SICU NPN\nO:\nNEURO: INITIALLY SEDATED ON PROPOFOL AND BECAME INCREASINGLY AGITATED REQUIRING MS04 AND ATIVAN. AROUSABLE BUT UNABLE TO FOCUS OR OPEN EYES. PEARL 3MM BILAT. +CORNEALS, +GAG, +COUGH. MAE, LOCALIZING BUT DOES NOT FOLLOW COMMANDS. PT STARTED HALDOL AND INCREASED HALDOL AND PROPOFOL WEANED OFF. INITIALLY TALKING IN INCOMPREHENSIBLE SOUNDS. NOW W/ GARBLED SPEECH, ORIENTED X1 AND VERY RESTLESS. PT IS S/P 4 VESSEL ANGIO, WNL. C-COLLAR REMAINS IN PLACE TLS CLEARED.\n\nCV: HTN AND TACHY WHEN LIGHT, 170/100, 120'S NST. HEMODYNAMICS WNL WHEN CALM. +PEDAL PULSES.\n\nRESP: STABLE FULLY VENTED ALL DAY W/ 02SATS 96-98%. SXN FOR THICK, BLOODY SECRETIONS. CHANGED TO PSV AND PASSED SPONTANEOUS BREATHING TRIAL W/ SRR 18 AND TV 700'S. ACUTELY AGITATED AND GAGGING AROUND ETT.\n+LEAK. EXTUBATED AND PLACED ON 50%FACE TENT. DESATURATED INITIALLY TO 88%. INCREASED TO 100% AND 4LNP ADDED. PT GRADUALLY IMPROVED AND NOW HAS STABLE ABG ON 100%FACE TENT: 7.35/43/96/-. 02SAT 97%. SRR 24.\n\nRENAL: BRISK U/O. EVEN BODY BALANCE. IVF CONT AT 80CC/HR. LYTES WNL.\n\nGI: OGT-LCS W/ LGE AMT THICK BROWN DNGE. OGT D/CED W/ EXTUBATION. ABD SOFT, OBESE, +BS.\n\nHEME: STABLE\n\nID: TMAX 100.7. STARTED CEFAZOLIN.\n\nSKIN: INTACT. SM AMT OLD BLOODY DNGE FROM R EAR. BACKSIDE INTACT.\n\nSH: ATTEMPTED TO CALL CONTACT NUMBER, PHONE IS DISCONNECTED.\n\nA: AGITATED AND RESTLESS, DISORIENTED, ?ETOH WITHDRAWAL VS CONTUSION.\nTOLERATED EXTUBATION.\n\nP: CONT TO MONITOR NVS. HALDOL AND ATIVAN PRN. MONITOR VS. PULM TOILET. NEED SITTER FOR SAFETY. CONT ATTEMPTS TO LOCATE FAMILY.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483850, "text": "Pt to transfer to MICU:\n\nPt S/P fall, hit head, Q2H neuro checks, Pt intubated, hemodynamically stable, DNR/DNI, pt currently intubated.\n\nROS:\n\nNeuro: Pt remains lightly sedated on propofol gtt, goal is to achieve sedation with Ativan/haldol Prn. Pt spontaneously MAE X 4 with purposeful movements, opens eyes to noxious stimuli, DOes not follow commands. PERRL 4mm/bsk. Cspine precautions, pt able to sit up-log roll has been Dcd/cleared.\n\nCV: NSR 70s-80s, no ectopy noted. Prn Hydralazine for systolic Bp > 160. DP/PT pulses present and easily palpable. Left radial aline positional. Bp running 130s-150s systolic. Left subclavian triple lumen transducing CVP, dampened wave form.\n\nPulm: Intubated CPAP: %0%, 5 peep, 10 PS, ABGs reflect adequate oxygenation/ventilation, and acid/base balance, see care view for details. Suctioning returns small to moderate clear to white thin secretions. Lung sounds are diminiished throughout.\n\nGI: Criticare infusing at 40cc/hour through right nare pedi tube. Goal is to 90cc hour. To check residuals Q4H. -Stool, +BS, H2B prophylaxis.\n\nGU: Foley patent to gravity, green/yellow. Adequate UOP, see care view for lytes, no replenishment required thus far this shift.\n\nID: low grade temps, if pt spikes needs to be recultured. Clindamycin.\n\nSkin: Right heel blister. Otherwise intact.\n\nHeme: stable, see care view for details.\n\nSocial: no contact.\n\nPlan: transfer to MICU, cont with Q2H neuro checks, monitor serum sodium/osm. Skin care, follow replenish lytes, titrate up TF as ordered, PRn haldol, update family and provide support.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483845, "text": "ROS:\n\nNEURO: Pt continues on propofol gtt, light sedation. MAE X 4 when lightened, Does not follow commands, movements are purposeful, withdraw/localizes all extremities to nail bed stimuli. PERRl /bsk. J collar in/intact.\n\nCV: NSR in 70s-80s, no ectopy noted. ABP in left radial, good wave form, Bp trending 130s-140s systolic. DP/PT pulses present ans easily palpable. Receives lopressor.\n\nPulm: See care view for ABG trends. Lung sounds clear to diminished throughout, chest rises equally bilaterqally. O2 sats 98-100%, RR 16-22. Suctioning returns smal amt white/ thin secretions.\n\nGI: Criticare infusing at 40 cc in pedi tube in right nare. Highest residual 60cc. Belly soft, distended, +BS, - stool. NPO. H2B prophylaxis.\n\nGU: Foley patent to gravity. Received 1 time dose of lasix 20 mg with good effect. replenished lytes, Ca & K+. UOP adequate clear/green.\n\nID: low grade temp, Tmax 100.4. Receiving clindamycin.\n\nENDO: RISS\n\nSkin: Right heal blister, duoderm applied. Compression sleeves on/intact. Skin care done.\n\nSocial: no contact this shift.\n\nPlan: extubate this AM?, Continuw Q2H neuro checks, monitor for change in neuro status. Update family/ provide support. Replenish lytes as needed, monitor temps, pan Cx if spikes. Continue to check TF residuals/ increase TF to goal as ordered.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483846, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN SIMV/PS MODE. PT WELL SEDATED, IN SYNCH W/VENT. BS DECR BILAT, MDI ALBUTEROL GIVEN X2. SXN FOR SM-MOD AMTS THICK PALE YEL-CLEAR SEC. AM ABG REFLECTS NORMAL ACID-BASE W/NORMOXIA. RSBI 62. SBT STARTED @ 0545. PLAN TO ASSESS FOR POSS EXTUBATION PENDING SUCCESSFUL COMPLETION OF SBT.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483847, "text": "SOCIAL WORK\nSw met with family at bedside for ongoing support. Present also was RN case manager . Case Mgr answered all questions re rehab and insurance.\n\nFamily appears to be more comfortable with the uncertainty of long term prognosis and appears to have accepted the need to \"wait and see\". SW will conntinue to follow closely. Pls pg prn.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-07 00:00:00.000", "description": "Report", "row_id": 1483848, "text": "Resp. Care Note\nReceived intubated and vented on SBT of PSV 5 peep 0 and 50%. Good ABG on these settings but decision made not to extubate today. Pt placed on PSV 10 and peep 5 to rest. Plan to cont present settings and re-evaluate in AM for extubation.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-05 00:00:00.000", "description": "Report", "row_id": 1483840, "text": "Resp. Care\nPatient remains intubated,on vent , no changes, abg's normal. BS , coarse, Sx moderate thick white secretions. Repeat head ct scan done today. Patient rr increased with increased minute volumes periodically today. Patient on profofol for procedure and given ativan, but patient still agitated. End of shift patient quieted down and in sync with vent.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1483841, "text": "TSICU NPN (1900-0700)\nReview of Systems:\n\nNeuro---Remains sedated on propofol 50-70mcg/kg/min. When lightened, pt localizes to painful stimuli with BUE and briskly withdraws BLE, does not open eyes. Pupils 2-4mm bilaterally and briskly reactive. At times, becomes hyperreflexive to even the most minimal stimuli while on propofol. BP becomes elevated. PRN ativan given along with propofol providing adequate sedation.\n\nCV--NSR with occasional PAC's noted. HR 70-90's. Goal SBP <150. Lopressor 10mg Q4hrs. Held x1 dose last night due to low BP. When adequately sedated, SBP <150. When lightened or worked up, SBP up to 180's. Returns to baseline 15-20min after propofol restarted. CVP trending up 15-19. ICU H.O. aware. No lasix as of now. Extremities warm to touch with palpable pulses.\n\nResp--Remains fully ventillated on IMV 700x14 5/5/50% with adequate am ABG--see care view for specifics. O2 sats >97%. Bilateral upper lobes coarse to expiratory wheezes, bases diminished. Suctioning small amts of thick yellow secretions. Moderate amts of nasal and oral secretions.\n\nGI---Residuals at 240cc. Pt also noted to have what looked like emesis in oral cavity. TF's held. Notified ICU H.O. Repeat residuals only 25cc--TF's restarted. Continue to increase to goal of 90cc/hr. Abd softly distended with active BS. + flatus, no BM.\n\nGU---Urine output trending down 30-50cc/hr. K+ repleted.\n\nID---Tmax 101.6. Pan cx sent. CXR done. WBC 10.3. Clina abx coverage.\n\nHEME---HCT stable at 36. Heparin sub q and pneumatic boots for DVT prevention.\n\nENDO---BS 130 and 129. Coverage per RISS.\n\nSKIN---Small blister noted to R achilles--probable due to shearing from pt's movement. Duoderm applied. Backside intact.\n\nSOCIAL---Pt's family aware and up to date on his condition. No contact overnight. to visit today.\n\nPLAN---Pt is DNR. Continue neruo checksQ2hrs. Repeat head CT today. Maintain SBP <150. Pulmonary toilet. Advance TF's as tolerated. Support pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1483842, "text": "SOCIAL WORK\nFamily meeting held with pts sons, -in-law, aunt, and two brothers, MD , RN and SW. Pts son expressed concerns to team about pts prognosis and states that a significantly impaired quality of life for the pt is not an outcome that they support. MD answered all questions, and family agreed to plan to wait one more week for understanding of pts condition.\n\nFamily appeared to have concerns that their wishes were not being hear by time. Discussed decisionmaking and came to an understanding that there is not a decision to be made re direction of care at this time. Family appeared to be more comfortable with direction of care by end of mtg. Ongoing support offered by SW for family as needed. Pls pg prn.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1483843, "text": "NPN\n\nN: PT WITH UNCHANGED NEURO STATUS. WHEN LIGHT, PT LOCALIZES TO PAIN WITH BOTH ARMS L>R AND WITHDRAWS BLE. PERRL ~3MM/BRISK. THRASHES IN BED AND COUGHS INCESSANTLY. CURRENTLY SEDATED ON PROPOFUL.\n\nCV: NSR 70-90'S. NO ECTOPY. LOPRESSOR 10MG/Q6. BP MAINTAINED <150. K REPLETED. PALP PP.\n\nR: LUNGS COURSE WITH OCC INSP WHEEZE/DIM AT BASES. CONT ON SAME VENT SETTINGS. SXN'D FREQ FOR MOD AMT THICK WHITE SEC. HAS STRONG PROD COUGH. STABLE ABG.\n\nGI: ABD SOFT/DISTENDED +BS. HIGH GASTRIC RESIDUALS->D/C'D TF. ADDED REGLAN. TF CHANGED TO CRITICARE AND CURRENTLY AT 20CC/HR. NO STOOL.\n\nGU: ADEQ U/O\n\nID: LOW GRADE TEMPS. CONT WITH CLINDA. CL CHANGED OVER WIRE AND TIP SENT FOR CX.\n\nENDO: GLUC PER RISS.\n\nSOC: HAD MEETING WITH FAMILY, THIS RN, SW, AND DR TO DISCUSS CURRENT PLAN WITH PT. PLEASE SEE SW NOTE FOR TODAY FOR DETAILS. SUPPORT GIVEN TO FAMILY.\n\nA/P: CONT NEURO CHECKS. CONTTO SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-06 00:00:00.000", "description": "Report", "row_id": 1483844, "text": "Resp Care\nPatient remains intubated, on vent, no changes. BS mild exp wheezes. Mdi given as ordered. Sx'g white thick secretions.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-05 00:00:00.000", "description": "Report", "row_id": 1483838, "text": "TSICU NPN (1900-0700)\nReview of Systems:\n\nNeuro---Pt remains sedated on propofol 80mcg/kg/min. When lightened, localizes and withdrawls to painful stimulus with all extremities. Pupils 2-3mm bilaterally and briskly reactive. Extremely sensitive to stimuli, with hyperreflexive movements at times. No eye opening with any stimuli. J remains on. Ativan 1mg given x 2 doses. Mannitol 50gm increased to Q4hrs. Serum osmo's have been 306 with Na 143. Attempting to minimize fluid intake, IVF TKO and changed to NS.\n\nCV---NSR with occasional PAC's noted. Goal SBP <150. When lightened BP 180's, but when down with propofol SBP 130-160's. Scheduled lopressor increased to 10mg Q4hr. HR with added lopressor 70-80's. Extremities warm to touch with palpable pulses.\n\nRESP--Remains fully ventillated on IMV 700x14 5/5/50%. No changes in vent settings. AM ABG adequate oxyg/vent--see care view. O2 sats >97%. Lungs coarse bilateral upper lobes to exp/insp wheezing occasionally. Suctioning small to moderate tan/yellow thick secretions. Copious thick tan oral secretions.\n\nGI----Impact with fiber TF's via DHT. Residuals up to 110 cc around MN. TF's placed on hold. Restarted at 20cc/hr. Increasing to goal of 90cc/hr. Abd softly distended with hypoactive BS. + flatus. No BM\n\nGU---Adequate clear yellow urine via foley. Increased with mannitol doses. K+ repleted this am.\n\nHEME---HCT stable at 35.6. Heparin subq and pneumatic boots for DVT prevention.\n\nID--Tmax 101.6. Reported to ICU H.O. Tylenol ordered and given. No cx as previous ones not resulted yet. Fan on. Down to 98.8. WBC 10.8. Clindamycin abx coverage.\n\nSKIN---Skin grossly intact. No breakdown. New L radial art line placed.\n\nSocial---No family contact.\n\nPLAN---Continue Q1hr neuro checks, mannitol Q4hr with serum osmo and NA prior. Attempt to minimize fluid intake. Goal SBP <150. Aggressive pulmonary toilet.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-05 00:00:00.000", "description": "Report", "row_id": 1483839, "text": "See CareVue for objective data.\n\nEvents of the day:\n\nNo vent changes and ABG adequate on current settings. Despite RSBI <40\nwill remain intubated related to neuro status. Copious amts of nasal and oral secretions. Suctioned Q2H for tan thick secretions. BP and HR increase when sedation lightened and require 10-15 minutes to return to goal of < 150 after proprofol returned to previous rate.\nNeuro assessment remains unchanged. See flowsheet for complete details. Head CT completed. Verbal report from team: same from yesterday. Issue of ICP/drain discussed in rounds and it decided pt did not require ICP monitoring since team can monitor his mental status when proprofol off.\nMannitol dc'd and if CVP rise lasix will be added to therapy.\n+ flatus but no BM. Abd soft but distended. TF at 60 cc's an hour and tolerating well.\nFamily in and met with MD. After discussion, it was agreed upon by the family that pt would want to be DNR. DNR order written. Family updated on POC and aware of CT Scan results and prognosis.\n\nPlan:Maintain airway and acid/base,keep BP <150,sedate with proprofol and lighten for neuro checks Q2,advance TF to goal,bowel regime in AM,\nmaintain safe environment and support pt and family through this difficult period.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-04 00:00:00.000", "description": "Report", "row_id": 1483835, "text": "ROS 0800-1400:\n\n0800~ EVENT: PT INTUBATED AT START OF SHIFT/SEDATED, LEFT SUBCLAVIAN TRIPLE LUMEN CATH WITH CVP MONITORING PLACED, PLAN FOR CT.\n1000~ TO CT, NO EVENT DURING TRIP.\n\nNEURO: PT SEDATED ON PROPOFOL GTT, ~50-75 MCG/KG/MIN HAD GOOD EFFECT. PT SPONTANEOUSLY MAE X4 WITH CONSISTENT PURPOSEFUL MOVEMENTS. PT DID NOT OPEN EYES TO NOXIOUS STIMULI, PT DID WITH DRAW TO NAILBED ALL 4 EXTREMITIES/ NOT FOLLOWING COMMANDS. PERRL 2MM/BSK.\n\nCV: SINUS ARRYTHMIA WITH OCCASIONAL PACS, 70S-80S. CVP 17-22. DP/PT PULSES PRESENT AND EASILY PALPABLE. BP RANGED FROM LOW 100S TO 150S/80S.\n\nPULM: INTUBATED/ SEE CARE VIEW FOR SETTINGS. ABGS REFLECTED ADEQUATE OXYGENATION/VENTILATION/ ACID-BASE BALANCE. LUNG SOUNDS ARE DIMINISHED THROUGHOUT. SUCTIONING RETURNS SCANT THIN SECRETIONS.\n\nGI: IMPACT WITH FIBER FS AT 20/HOUR THROUGH PEDI TUBE. GOAL TO 90/HOUR TO INCREASE Q6H. +BS, +FLATUS, -STOOL.\n\nGU: FOLEY PATENT TO GRAVITY, MIVF AT 80, REPLENISHED LYTES.\n\nSKIN: COMPRESSION SLEEVES ON/INTACT. SKIN/BACK CARE DONE, NO BREAK DOWN NOTED.\n\nSOCIAL: SON IN TO VISIT, SW MET WITH SON. QUESTIONS ANSWERED BY THIS RN AND SUPPORT PROVIDED.\n\nENDO: RISS, NO COVERAGE.\n\nID: AFEBRILE, STARTED ON CLINDAMYCIN.\n\nPLAN: QH NEURO CHECKS. FOLLOW AND REPLENISH LYTES, MONITOR FOR CHANGE IN VSS, UPDATE FAMILY AND PROVIDE SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-04 00:00:00.000", "description": "Report", "row_id": 1483836, "text": "npn 1400-1900\n\nneuro:arouses w/ stimulation(noise,pain).mae's.does not follow commands.withdraws to nail bed pressure,localizes to sternal rub. perrl,brisk,2-3mm.+ gag,cough,corenal reflexes.given mannitol.propofol increased to reduce agitation and for b/p control.\n\ncv:maintained sbp <150 w/ propofol.haldol x 1 w/o effect.st w/ occ pac's.a-line dampened-to be rewired.unable to get waveform on cvp.\n\nresp:no change of vent settings.sao2 wnl.strong cough-freq sx of thick tan, blood-tinged sputum.\n\ngi:tf increased to 40ml/hr to dht.no residuals.no change in exam.\n\ngu:u/o adequate.\n\nskin:no lacs or breakdown noted.\n\nheme:no issues.\n\nendo:covered x 1 per ssi.\n\nsocial:son,daughter, and grandson visited and updated.brother called and updated.advised to contact son for further updates.\n\nplan:continue neuro checks q1h.maintain sbp<150.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-05 00:00:00.000", "description": "Report", "row_id": 1483837, "text": "RESP CARE NOTE\nPT REMAINS INTUBATED, SUPPORTED OVERNOC IN SIMV/PS MODE. NO CHANGES MADE THIS SHIFT. PT STABLE, IN SYNCH W/VENT, OCCAS OVERBREATHING 2-4BPM. SPONT VT 300-400CC. BS SL COARSE, SXN FOR SM-MOD AMT OLD BLOODY SEC. AM ABG REFLECTS NORMAL ACID BASE W/NORMOXIA. RSBI 39. NO SBT PER TEAM, PENDING DISCUSSION IN ROUNDS. PLAN TO CONTINUE CURRENT SUPPORT.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-04 00:00:00.000", "description": "Report", "row_id": 1483832, "text": "TSICU NPN 7p-7a\nS/\n Pt arousable to voice and stimulation yet does not open eyes. Moves all extremities w/ full stregnth and very purposeful at times trying to pull hand away when getting mouth care. Pt not verbalizing yet moaning and grunting when light. Initially getting haldol 5mg q 2hr and Ativan 1mg q 2hr in addition to precidex gtt at .7mcg/kg/min. Precidex IV had infiltrated however so new line placed, pt more calm w/ precidex going via new IV. Less haldol and ativan given over the rest of the course of the evening secondary to pt adequately calm although pt noted to have generally slower HR w/ periods of Sinus arrythmia and APC's, HR from 54-98, lopresser held this AM and precidex gtt decreased to .5mcgs/kg/min. PERRL at 3-4mm. strong cough, old dried blood in right ear.\n\nCV- HR as noted above, BP 135-180/75-85, Hct stable, potassium repleted, Pt w/ strong pulses peripheraly. IVF of NS at 80cc's hr changed to LR at 6:30 this AM secondary to Na of 145 and chloride of 111.\n\n pt on 4liters NP overnight w/ O 2 sats 96-98%, RR 24-32, increased w/ increased stimulation, labored at times, inspiratory/expiratory wheezes throughout bilaterally, nebs q 4hrs. Strong cough very reactive/ bronchspastic.\n\n pt getting TF's of Promote w/ fiber at 10cc's hr, abd soft nondistended, belly soft nondistended. No BM.\n\nGU- voiding via foley w/o diff. Bun/creat stable.\n\nSkin- skin slightly rashy on upper chest and arms, also irritated around areas of tape. Backside intact.\n\nA/P- altered MS ? secondary to neuro injury and ? w/ drawls. Pt slightly improved on precidex , plan for repeat head CT today even if needs to get reintubated for it.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-04 00:00:00.000", "description": "Report", "row_id": 1483833, "text": "SOCIAL WORK\nSW met with pts son and sons wife for support. All questions answered. Pts other son is en route to . Family had many questions about what happened re fall. SW directed them to police who responded to call.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-04 00:00:00.000", "description": "Report", "row_id": 1483834, "text": "SOCIAL WORK\nSW obtained contact info on pt from Hospital, friend . pts family. Pts sister, , unit and spoke to SW. Sister reports that pt has a brother and a son, , who is an FBI and recently moved. Sister to contact son. Sister updated on medical condition by MD .\n\nSister: : .\n\nSW to follow pt and family. Pls pg prn.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1483851, "text": "RESP CARE:PT RECIEVED FROM TSICU ON CPAP 5, 10 PSV, 50%. NO CHANGES TO VENT DURING THE NOC. PT GIVEN AS ORDERED. LUNGS -COARSE R LUNG. RSBI-52. PLAN- WEAN TO SBT AS TOL\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1483852, "text": "MICU NURSING ADMIT NOTE FROM TSICU:\n Pt is a 56 yr old male admit to TSICU after folling down a flight of stairs. Pt was initially brought to Hospital, where he was aggitated and confused and had ETOH in his system. His family has since denied pt havaing an ETOH dependency. Pt was transferred to where he was intubated d/t aggitation in order to perform diagnostic scans. Injuries include non-displaced occipital bone fx with pneumocephalus, SAH, L temporal contusion, R temporal fx, and Sephoid sinus fx. Pt was Made DNR and do not Reintubate by his family. His RSBI's have been 50-60, he has done well on SBT, however, his MS has not improved. He withdraws to pain, and occasionally opens eyes to pain, but otherwise remains aggitated and does not respond. The plan is to leave pt intubated for the time being in hopes of maximizing his mental status and giving him the best chance to succeed if extuated. TSICU considered trialing Mannitol, but NA has been 145-146 past 24 hrs, and osmolality has been 305. Pt transferred to MICU o/n for further care.\nREview of Systems:\nNeuro: withdraws to pain. PERRLA. opened eyes x 1 with turning. MAE with good strength. c-collar intact. collar care done. pt able to be oob with collar.. collar on at all times.. c-spine cleared by scans but not by exam.\nRESP: vented o/n on PSV 10/5/.40. TV's 500 x 20's. sats 99-100%. sx for thick white secretions, and foul smelling oral secretions. pt has a known sinusitis per team. RSBI 40's today. aline dc'd as was infiltrated. TEam considering SBT and rechecking abg to potentially extubate today. No orders as of yet.\nCV: pt in NsR 80's, no ectopy until 6:40 this am, pt had brief run of SVT to 160's, resolved withing 10 seconds without intervention. sbp 140 at that time. sbp 140's-150's o/n. aline dc'd as was infiltrated.\nFE: NA 145-146, Osmo 305. Per dr. , call HO for Na >150, or serum Osmo >320. fsbs requiring ssi.\nID: tmax 101.6 on admit to micu. team aware. no need for cx per team. tylenol given with temp to 100 oral. cont on ceftaz. am labs pending.\nGU: urine green (? if had dye in tf at one time). UO 60-90cc's/hr.\nGI: ab soft, bs +. tf's advanced to 60cc's/hr.\nSocial: pt has family who are involved.\nA/P: pt s/p fall/SAH and multiple head injury cont vented at this time. await team to make plan for the day. will call to noitfy r/e svt.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1483853, "text": "Resp. Care Note\nPt remains intubated and vented on current settings of SIMV 700x 14x 50% peep 5psv 5. Pt given SBT again today but decision made not to extubate. Pt was placed back on resting settings of PSV 10 peep 5 but required change to SIMV after acute event of ^^BP, ^^frothy secretions and diaphoresis. Improved with SIMV settings. Cont present support.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-08 00:00:00.000", "description": "Report", "row_id": 1483854, "text": "npn 7-7pm\n\nNeuro: No changes today.Not following commands. Responds to pain. Opens L eye when propofol is weaned. Was able to wean to 15mcg/kg/min but pt became restless, was then increased to 50mcg.\nPt was loaded with dilantin today and will then receive tid.\nMonitor osmolaity (04 and 16).\n\nResp: Did not tolerate 0/5, became tachypneic, diaphoretic and was using accessory muscles. Was placed back on IMV.\n\nCV: SR-ST, no ectopy. Goal BP is <160, and has been in the 130-140 range. Is written for hydral prn.\n\ngi/gu: No BM this shift. Belly is soft with + BS. TF at 80cc, to be increased to 90cc at . TF was off today for possible extubation and then resumed. Patent foley with green urine (team aware).\n\nSkin: Intact. L hand is very edemetous and mottled from the site where aline was removed this am.\n\nSocial: Updated a cousin as to the pt condition this afternnon.\n\nDispo: DNR/DNI.\n\nPlan: Attempt to wean tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1483855, "text": "RESP CARE: Pt remains intubated/ on vent. Remained on SIMV all shift. SEE CAREVUE. Lungs slightly coarse bilat. Suctioned for mod amounts thick white secretions. RSBI-54.3.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-03 00:00:00.000", "description": "Report", "row_id": 1483829, "text": "T/SICU Nursing progress Note\nS: \"I'm hot\"\nO: Neuro: very agitated most of shift, pulling at wrist restraints, attempting to get out of bed, turning from side to side. Opens eyes to name. Speech is garbled at best and other times incomprehensible. Moves all extremities equally, purposely, and strongly. States name at times, withdraws to pain in all extremities. Sitter obtained at 11pm and has been in constant attendance for safety. Pt. receiving ativan q 2 hours and haldol q 2 hours with continued agitation. Sleeps very briefly in intervals then returns to perpetual motion. PERRLA, +cough, + gag. At times pt turns deep beefy red with exertion from pulling at restraints. Does not respond to repeated orientation and calming methods. Bed exit alarm on.\nCVS: tachycardic especially when agitation is at it's peak. Also hypertensive. Lopressor given q 6 per order and clonidine patch applied. K+ being repleted. No ectopy Art line dampens despite multiple attempts to secure it so it won't/\nRESP: on 4l np with adequate gas exchange. Snores when asleep but no change in sats. Junky cough. With exertion has inspiratory and expiratory wheezing.\n\nRENAL: receiving ns @ 80/hr, urine output adequate, lytes being repleted per orders\nGI: belly firm, no stool, on famotidine\nENDO: ssri\nID: on kefzol. SKin very warm and flushed, t max 100.4 ax, wbc 15.\nSKIN: blood from R ear, L eye ecchymotic. Developing rash from constantly moving in bed\nSOCIAL: no family has been notified yet as contact number was disconnected (please see nursing note from yesterday)\nLines: art line very tenuous, dampened much of the time, difficult to draw from. Two iv's infiltrated, new IV place L forearm\nA: agitation secondary to ??etoh withdrawal vs head injury\nP: consider increasing haldol and or ativan. Continue sitter for pt safety. ?? contacting substance abuse team for treatment obtions\n\n" }, { "category": "Nursing/other", "chartdate": "2183-11-03 00:00:00.000", "description": "Report", "row_id": 1483830, "text": "SOCIAL WORK\nSW attempting to contact pts family: number left for unit for family to contact. Pls pg prn.\n" }, { "category": "Nursing/other", "chartdate": "2183-11-09 00:00:00.000", "description": "Report", "row_id": 1483856, "text": "NURSING NOTE: 7P-7A\n PT RECEIVED SEDATED ON 50MCG/KG/MIN OF PROPOFOL. PT ONLY WITHDREW TO NAILBED PRESSURE ON THIS DOSE AND HAD NO EYE OPENING RESPONSE EITHER. OVERNIGHT PROPOFOL WAS WEANED IN SMALL INCREMENTS UNTIL PT EVENTUALLY AROUSED TO STIMULI AND OPENED EYES, THIS WAS AT 20MCG/KG/MIN. PT ALSO BEGAN MOVING AROUND IN THE BED A BIT MORE AT THIS DOSE. HE WAS NOT ABLE TO FOLLOW ANY COMMANDS OR MAKE ANY EYE CONTACT. PROPOFOL WAS THEN INCREASED BACK TO 25MCG/KG/MIN, NOW APPEARS SEDATED AND LESS RESTLESS, REALLY ONLY AROUSES TO PAINFUL STIMULI.\nC-COLLAR MAINTAINED.\n\nRESP- REMAINS INTUBATED FOR AIRWAY PROTECTION. NO VENT CHANGES OVERNIGHT. RR 16-24 SATS >95%. SUCTIONED FOR MODERATE AMOUNTS OF THICK WHITE SPUTUM.\n\nCV- HR 70-90'S SR, SBP 120-150'S. RECEIVED 25MG PGT LOPRESSOR TID WITH VERY LITTLE EFFECT NOTED. ? INCREASING DOSE.\n\nGI- ABD SOFTLY DISTENDED +BS NO . TOLERATING CRITICARE TUBEFEEDS AT 90CC/H VIA NGT.\n\nGU- FOLEY PATENT FOR 60-140CC/H OF CLEAR AMBER URINE, CONTINUES WITH SLIGHT GREEN TINT.\n\nID- LOW GRADE FEVER ALL NIGHT, AND CONSTANTLY DIAPHORETIC ACROSS FOREHEAD. RECEIVING UNASYN 3GM IV Q8H.\n\nACCESS- LSC TLCL INTACT, + BLOOD RETURN, SITE WNL.\n\nSKIN- L HAND SWOLLEN WITH PITTING EDEMA, PINK/PURPLE MOTTLED AREAS ACROSS POSTERIOR SIDE. + RADIAL/ULNAR PULSES AND SKIN WARM TO TOUCH. L ARM ELEVATED ON PILLOW.\n\nSOCIAL- NO FAMILY CONTACT OVERNIGHT.\n\nDISPO- REMAINS IN MICU, ON SICU SERVICE. DNR/DNI. CONTINUE TO FOLLOW NEURO EXAMS. WEAN VENT AS TOLERATED.\nACCESS\n" } ]

[ { "category": "Echo", "chartdate": "2148-03-11 00:00:00.000", "description": "Report", "row_id": 75100, "text": "PATIENT/TEST INFORMATION:\nIndication: Diastolic and systolic function. Congestive heart failure. Left ventricular function.\nHeight: (in) 69\nWeight (lb): 237\nBSA (m2): 2.22 m2\nBP (mm Hg): 132/62\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 11:40\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 >55% decrease during respiration (estimated RA pressure\n(0-5mmHg).\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global\nsystolic function (LVEF>55%). TDI E/e' >15, suggesting PCWP>18mmHg. No resting\nLVOT gradient.\n\nRIGHT VENTRICLE: RV hypertrophy. Mildly dilated RV cavity. Mild global RV free\nwall hypokinesis.\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 tricuspid valve leaflets. Mild [1+] TR. Moderate PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nGENERAL COMMENTS: Right pleural effusion. Ascites.\n\nConclusions:\nThe left atrium is mildly dilated. The estimated right atrial pressure is 0-5\nmmHg. There is mild symmetric left ventricular hypertrophy with normal cavity\nsize and regional/global systolic function (LVEF>55%). Tissue Doppler imaging\nsuggests an increased left ventricular filling pressure (PCWP>18mmHg). The\nright ventricular free wall is hypertrophied. The right ventricular cavity is\nmildly dilated with mild 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. There is no mitral valve prolapse.\nThere is moderate pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Right ventricular hypertrophy with mild cavity enlargement with\nfree wall hypokinesis. Moderate pulmonary artery systolic hypertension. Mild\nsymmetric left ventricular hypertrophy with preserved global and regional left\nventricular systolic function.\nThis constellation of findings is suggestive of a chronic or acute on chronic\nprimary pulmonary process (e.g., primary pulmonary hypertension, pulmlonary\nembolism, bronchospasm, sleep apnea, etc.).\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": "2148-03-10 00:00:00.000", "description": "Report", "row_id": 195583, "text": "Sinus rhythm. Borderline prolonged/upper limits of normal QTc interval.\nProminent and modestly peaked precordial lead T waves are non-specific but\ncannot exclude hyperkalemia. Clinical correlation is suggested. Since the\nprevious tracing of lateral precordial lead T waves appear slightly more\nprominent but unstable baseline in those leads on the previous tracing makes\ncomparison difficult.\n\n" }, { "category": "ECG", "chartdate": "2148-03-09 00:00:00.000", "description": "Report", "row_id": 195584, "text": "Sinus rhythm. Compared to the previous tracing of there is no change.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2178-03-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951913, "text": " 10:06 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o ptx\n Admitting Diagnosis: RENAL CELL CARCINOMA\\INTERLEUKIN-2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic renal cell cancer, admitted for IL-2\n therapy s/p Pericardial Window and ct removal\n REASON FOR THIS EXAMINATION:\n r/o ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic renal cell, status post pericardial window and chest\n tube removal, rule out pneumothorax.\n\n COMPARISON: .\n\n Single semi upright AP chest radiograph: The left chest tube, ET tube and NG\n tubes have been removed. Right subclavian line terminates in the mid SVC. No\n evidence of pneumothorax. Heart is stablely enlarged with continued bibasilar\n atelectasis. Retrocardiac opacification persists. No evidence of CHF.\n\n IMPRESSION: No pneumothorax after removal of chest tube, ET tube, and NG\n tube. Persistent retrocardiac opacity may be effusion, infiltrate or\n consolidation.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 951749, "text": " 6:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p pericardial window w/continued hypoxia-evaluate lung \n Admitting Diagnosis: RENAL CELL CARCINOMA\\INTERLEUKIN-2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic renal cell cancer, admitted for IL-2 therapy\n s/p Pericardial Window\n REASON FOR THIS EXAMINATION:\n s/p pericardial window w/continued hypoxia-evaluate lung fields\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, 6:51 A.M., .\n\n INDICATION: Renal cell CA. Status post pericardial window with continued\n hypoxia.\n\n FINDINGS: Compared with 3/6 at 7:18 p.m., no definite significant interval\n changes.\n\n The perihilar infiltrate on the left and retrocardiac\n atelectasis/consolidation appear essentially unchanged. The remainder of the\n lung fields are grossly clear.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-09 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 951536, "text": " 11:55 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: confirm CL placement and R/O pts - pls call wet read to nurs\n Admitting Diagnosis: RENAL CELL CARCINOMA\\INTERLEUKIN-2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic renal cell cancer, admitted for IL-2 therapy\n\n REASON FOR THIS EXAMINATION:\n confirm CL placement and R/O pts - pls call wet read to nursing at \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic renal cell carcinoma, confirm line placement.\n\n COMPARISON: and CT torso .\n\n SINGLE AP UPRIGHT CHEST RADIOGRAPH: Right subclavian line terminates in the\n mid SVC. No pneumothorax. The heart has increased in size from 17 cm to 21\n cm, which may reflect cardiac decompensation or a pericardial effusion. Small\n left-sided pleural effusion is increased in size. Right costophrenic angle is\n excluded from the field of view, but there is no sizeable right-sided pleural\n effusion. Pulmonary vascular congestion has increased slightly consistent\n with mild CHF. Multiple pulmonary nodules again seen consistent with\n patient's known metastatic disease.\n\n IMPRESSION:\n 1. Right subclavian line terminates in mid SVC with no pneumothorax.\n\n 2. Enlarging cardiac silhouette may reflect cardiac decompensation versus\n pericardial effusion.\n\n 3. Mild CHF as evidenced by pulmonary vascular congestion, increasing\n left-sided pleural effusion, and cardiomegaly.\n\n\n" }, { "category": "Radiology", "chartdate": "2178-03-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 951715, "text": " 6:01 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: ptx\n Admitting Diagnosis: RENAL CELL CARCINOMA\\INTERLEUKIN-2\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 67 year old man with metastatic renal cell cancer, admitted for IL-2 therapy\n s/p Pericardial Window\n REASON FOR THIS EXAMINATION:\n ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Metastatic renal cell carcinoma admitted for IL-2 therapy, status\n post pericardial window.\n\n COMPARISON: .\n\n SINGLE AP SUPINE CHEST RADIOGRAPH: The left lower hemithorax is cut off from\n the field of view. There has been interval placement of ET tube with tip 4 cm\n above the carina at the upper margins of the clavicles. Left-sided chest tube\n has been placed. Right subclavian line terminates in the proximal SVC. The\n lung fields are unchanged with mild CHF and upper zone vascular\n redistribution. Cardiomegaly is unchanged.\n\n\n" }, { "category": "Echo", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 82733, "text": "PATIENT/TEST INFORMATION:\nIndication: Intraop Pericardial Window\nStatus: Inpatient\nDate/Time: at 15:15\nTest: TEE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT VENTRICLE: Overall normal LVEF (>55%).\n\nRIGHT VENTRICLE: Normal RV systolic function.\n\nAORTA: Normal aortic arch diameter. Simple atheroma in aortic arch. Mildly\ndilated descending aorta. Simple atheroma in descending aorta.\n\nAORTIC VALVE: No AS. Trace AR.\n\nMITRAL VALVE: No MS. Trivial MR.\n\nTRICUSPID VALVE: Physiologic TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.\n\nPERICARDIUM: Large pericardial effusion. Effusion circumferential. Sustained\nRA diastolic collapse, c/w low filling pressures or early tamponade.\n\nGENERAL COMMENTS: A TEE was performed in the location listed above. I certify\nI was present in compliance with HCFA regulations. Results were personally\nreviewed with the MD caring for the patient.\n\nConclusions:\nOverall left ventricular systolic function is normal (LVEF>55%). Right\nventricular systolic function is normal. There are simple atheroma in the\naortic arch. The descending thoracic aorta is mildly dilated. There are simple\natheroma in the descending thoracic aorta. There is no aortic valve stenosis.\nTrace aortic regurgitation is seen. Trivial mitral regurgitation is seen.\nThere is a large pericardial effusion which measures between 2.9 and 5.1 cm.\nThe effusion appears circumferential. There is sustained right atrial\ncollapse, consistent with low filling pressures or early tamponade. The free\nwall of the RV invaginates during diastole. Post drainage images reveal only a\ntrivial effusion without RA collapse or RV free wall invagination. All\nfindings discussed with surgeons at the time of the exam.\n\n\n" }, { "category": "Echo", "chartdate": "2178-03-10 00:00:00.000", "description": "Report", "row_id": 82841, "text": "PATIENT/TEST INFORMATION:\nIndication: Pericardial effusion.\nHeight: (in) 69\nWeight (lb): 277\nBSA (m2): 2.37 m2\nBP (mm Hg): 177/70\nHR (bpm): 76\nStatus: Outpatient\nDate/Time: at 11:11\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function\n(LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). Trace AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nPERICARDIUM: Moderate pericardial effusion. Effusion circumferential.\nStranding is visualized within the pericardial space c/w organization. RV\ndiastolic collapse, c/w impaired fillling/tamponade physiology. Sgnificant,\naccentuated respiratory variation in mitral/tricuspid valve inflows, c/w\nimpaired ventricular filling.\n\nGENERAL COMMENTS: Echocardiographic results were reviewed by telephone with\nthe houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thickness, cavity\nsize, and systolic function are normal (LVEF>55%). Regional left ventricular\nwall motion is normal. Right ventricular chamber size and free wall motion are\nnormal. The ascending aorta is mildly dilated. The aortic valve leaflets (3)\nappear structurally normal with good leaflet excursion. Trace aortic\nregurgitation is seen. The mitral valve appears structurally normal with\ntrivial mitral regurgitation. There is a moderate sized circumferential\npericardial effusion with some stranding (c/w organization). There is right\nventricular diastolic collapse, consistent with impaired fillling/tamponade\nphysiology. There is significant, accentuated respiratory variation in\nmitral/tricuspid valve inflows, consistent with impaired ventricular filling.\n\nIMPRESSION: Moderate circumferential pericardial effusion with\nechocardiographic evidence of increased intrapericardial pressure/tamponade\nphysiology.\nCompared with the prior study of (images reviewed from ETT echo), the\npericardial effusion is new.\n\nCLINICAL IMPLICATIONS:\nBased on AHA endocarditis prophylaxis recommendations, the echo findings\nindicate a low risk (prophylaxis not recommended). Clinical decisions\nregarding the need for prophylaxis should be based on clinical and\nechocardiographic data.\n\n\n" }, { "category": "ECG", "chartdate": "2178-03-10 00:00:00.000", "description": "Report", "row_id": 208435, "text": "Sinus rhythm\nDiffuse nonspecific T wave flattening\nNo previous tracing available for comparison\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-12 00:00:00.000", "description": "Report", "row_id": 1465754, "text": "NSG NOTE\nSEE FLOWSHEET FOR SPECIFICS.\n\nNEURO-PLEASANT. A+OX3. NO NEURO DEFICITS NOTED.\n\nCV-HR MOSTLY 80'S, NSR. SBP STABLE. SKIN W+D. +PP. DENIES CARDIAC COMPLAINTS.\n\nRESP-O2 SAT 92% ON 2LNC. LS CLEAR, DECREASED AT BASES. USING INHALERS. C+DB AND IS ENC. NARD NOTED. CHEST TUBE D/C'D. SITE WNL. NO CREPITUS OR DRG.\n\nGI-ABD OBESE, SOFT, NT/ND. TOL PO'S. DENIES N/V.\n\nGU-FOLEY D/C'D. VOIDING SPONT VIA URINAL ADEQ AMTS CL YELLOW URINE.\n\nACT-OOB IN CHAIR ALL DAY. AMB AROUND UNIT WITH PHYSICAL THERAPY.\n\nCOMFORT-DENIES NEED FOR PAIN MED AT THIS TIME.\n\nENDO-SSRI.\n\nP-CON'T WITH CURRENT PLAN. MONITOR FOR CHANGES. ASSESS PAIN. OOB AS TOL. SUPPORT. D/C TO FLOOR WHEN BED AVAIL.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465748, "text": "REPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on PS settings at this time. Attempted to decrease PS to 10 but patient became tachypneic and hypertensive. RSBi completed 0400 was 133. Plan to wean whenb tolerating.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465749, "text": "REPIRATORY CARE NOTE\nADDENDUM: PAtient became increasingly tachypneic, febrile, agitated. BLBS diminished more from earlier in shift.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465750, "text": "Nursing Progress Note\nNeuro: initially awake intubated, eyes open, folowing commands and calm. 0500 awoke aggitated, sitting up in bed, wretching and coughing, at high risk for self extubation. Resedated with propofol. bilateral soft wrist restraints per hospital med policy to protect lines tubes and drains.\n\nCVS: hr 70's sr no ectopy, sbp labile, initially on nitro then neo. Pulses palp x 4 ext. Skin flushed and moist. T max 100.2 ax, but feels much warmer to touch. CVP 7-15, chest tube with straw to serosang output. RSC multi lumen line, patent x 3 ports. Currently on neo at 0.6, off propfol.\n\nResp: LS initially clear in uppers and dim at bases now dim throughout. Sats falling with aggitated episode at 0500. Awaiting cxr. Oral suction for copious thick yellow, ett suction for scant thick white. Sats now 97 on 50 % fio2.\n\nGI: abd obese distended. ogt to lcs yellow bilious output. BS very hypoactive. nause and wretching controlled with metocloperamide.\n\nGU: Foleyc ath with uop > 100 cc hour, cloudy at times.\n\nEndo: FS BS on and off insulin gtt currently at 2 units/hour.\n\nPain: incisional pain controlled with morphine ivp.\n\nSocial: family called for update this am.\n\nActivity: turned side to side, moves well but holds breath.\n\nPlan: reattempt wean to extubate, address code status with family, control pain and blood sugars.\n\nSkin: multiple areas of irritation and rash. pt is sensitive at baseline, allergic to all tapes except paper. Left upper thigh has 3x3 cm reddened lump, noted on previous shift as well.\n\n\nSee carevue flowsheet and mars for further details and values.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465751, "text": "Resp Care\nPt weaned to PSV 5/5 with good abg then extubated today to 100% cool aerosol face tent. pt became slightly aggitated and tachypnic initially on PSV 5/5 due to chest pain from surgery, once pain issue was addressed pt calmed down to rr 18-22. pt currently on 6l nasal cannula satting >90%.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465752, "text": "See and Carevue for detailed documentation\n\nNeuro: Rec'd patient on low dose propofol. Easily arouses, communicates effectively with gestures. c/o pain treated with morphine with good result. Propofol off due to decrease SAT. Patient became agititated with c/o of severe LUQ pain, rec'd morphine IV, morphine sc, dilaudid with improvment. Patient given pg percocet before extubation, covered with morphine sc x1 s/p extubation. Patient now OOB with minimal assist. Denies pain, orieted, appropriate.\n\nResp: Pateint weaned on vent. Decrease SAT noted with PEEP wean. Patient continued to mentate appropriately. ABG stable thru vent wean with PaO2 70-80's. Extubate to face tent, SAT remained unchanged with FiO2 wean. Now on NC O2 with goal SAT >90%.. Patient snoring with sleep. Improved SAT/ aeration OOB to chair. Using I/S well ~500ml. Patient remains diminshed thru out. CT in place with ~20ml/hr drainage now straw colored.\n\nCV: In NSR 70-80's. BP 120-150/50's. Weaned off neo without difficulty. LE pulses weakly palpable. Low grade temp associated with agitation, diaphoretic. Resolved s/p extubation. Potassium and calcium repleted.\n\nGI/Endo: Insulin gtt off. RSSI per protocol. OGT out, small amounts bilious drainage. Tolerating ice chips. Hypoactive bowel sounds.\n\nGU: Foley to gravity with large amounts urine output s/p lasix.\n\nSocial: Wife and daughter into visit. Pleased with progress.\n\nPlan: Continue cardiopulmonary monitoring. Encourage activity, advance po's if tolerated. Monitor CT output. Control pain with morphine/ percocet.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-12 00:00:00.000", "description": "Report", "row_id": 1465753, "text": "ROS:\n\nNeuro: A+O x's 3. MAE's x's 4 strong and =. Percocet tabs 2 for pain mngt w/good effect.\n\nCV: RSR w/o ectopy. HR towards AM slowing to a sinus brady rate low of 56. VSS. Peripheral pulses palpable w/ease. Has left radial ABP line positional and damped wave forms. Has RSC multi lumen central line w/distal port transduced for CVP = . Heparin sq for DVT prophylaxis.\n\nResp: Lungs coarse. ABGs w/low pO2. MDI's ordered along w/much IS + C+DB. expectorates thick white secreations. ABGs w/improving pO2. Has left pleural chest tube draining straw colored fluid in small amt. DRSG .\n\nGI: Abd obese w/active BS. Taking PO meds and liq w/o c/o N/V. Protonix for GI prophylaxis.\n\nGU: Foley patent draining clear yellow urine in QS.\n\nEndo: No coverage required for FSG\n\nLytes: Both K and IC repleted w/good effect\n\nHeme: Stable\n\nSocial: No contact from family this shift.\n\nPlan: Pulmonary toileting. Mobilization. Monitor ABGs. Monitor, tx, support, and comfort.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2178-03-10 00:00:00.000", "description": "Report", "row_id": 1465745, "text": "~1445 PATIENT ADMITTED FROM WITH DIAGNOSIS OF CARDIAC TAMPONADE. ANESTHESIA HERE, LT RADIAL LINE INSERTED AND PATIENT SIGHNED ALL CONSENTS FOR THE OR. TRANSFERRED TO THE OR WITH O TECK, 2 ANESTHESIOLOGISTS.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-10 00:00:00.000", "description": "Report", "row_id": 1465746, "text": "~1806 PATIENT RETURNED FROM OR. PATIENT INTUBATED AND SEDATED WITH IV PROPOFOL. IV NEO INFUSING. REPORT RECEIVED FROM ANESTHESIA.\nPMERL. OG IN PLACE, PLACEMENT CHECKED. CS DIMINISHED IN BASES. CT PATENT FOR SMALL AMT SERO-SANG DRAINAGE. FOLEY IN PLACE, PATENT FOR CLEAR YELLOW URINE. PALPABLE PULSES.\n\nNEURO: PATIENT HAS BEEN REVERSED, AWAKE, MAE, FOLLOWING COMMANDS.\n\nCARDIAC: HEART RATE 70'S SR WITHOUT ECTOPY. SB/P ELEVATED AFTER REVERSALS GIVEN, PAIN MED GIVEN WITH SOME EFFECT. PA NOTIFIED AND 1 MG IV LOPRESSOR GIVEN, REPEAT X 1.\n\nRESP: REMAINS INTUBATED, WEANING TO EXTUBATE. CS DIMINISHED IN BASES. SUCTIONED FOR SMALL AMT CLEAR, ORALLY FOR THICK WHITE.\n\nGI: OG IN PLACE, TUBE ADVANCED AFTER CHEST X-RAY DONE PER PA. PATENT FOR BILIOUS.\n\nGU: FOLEY ION PLACE, PATENT FOR NOW CLOUDY DISCOLORED URINE, WILL SEND C/S.\n\nPAIN: MEDICATED WITH IV MORPHINE WITH PAIN RELIEF PER PATIENT.\n\nENDO: INSULIN GTT INFUSING, FOLLOWING PROTOCOL.\n\nFAMILY IN TO VISIT.\n\nPALN: ATTEMPT TO WEAN TO EXTUBATE. IF NO RESPONSE FROM IV LOPRESSOR(B/P) WILL HANG IV NITRO. MONIOTR LAB VALUES AND REPLEATE AS NEEDED. ? TRANSFER TO F2 IN AM. PLAN IS TO LEAVE CT IN TILL AT LEAST . AFTER CT OUT RETURN TO THE FOR FURTHER CA TX.\n\nFAMILY CALLED AT 2130 TONIGHT AND EXPLAINED THAT WIFE IS THE HEALTH CARE PROXY AND IF PATIENT ARRESTS THEY DO NOT WANT CPR TO BE DONE. I HAVE CALLED PA () AND WILL EXPLAIN MY CONVERSATION WITH HER. PLEASE CALL FAMILY RE ANY ISSUES.\n" }, { "category": "Nursing/other", "chartdate": "2178-03-11 00:00:00.000", "description": "Report", "row_id": 1465747, "text": "attempt to wean\nAttempt to wean vent peep and ps when gas returned at 2330, failed becoming tachypneix with falling sats. Unable to calm even when medicated, rt returned to prior settings. Will attempt to wean further later.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576844, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576846, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1. PADs 17-22 & CVP 11-13.\n Latest CO/CI/SVR @ 0330=7/3.7/700.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support CMV/AS 550X24 60% +8\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576859, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1. PADs 17-22 & CVP 11-13.\n Latest CO/CI/SVR @ 0330=7/3.7/700.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 PM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: No changes\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support CMV/AS 550X24 60% +8\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576613, "text": "Chief Complaint: None\n 24 Hour Events:\n - Maxed Dopamine at 14\n - Changed propafol to fentanyl versed to help improve maps\n - Gave Fluid bolus 500 cc x3 and 1 L x1\n - CI 2.8 > 3.5 > 2.7\n - MAPs less than 40 not responsive to IVF. Started levophed.\n - Vent - FIO2: 80 % > 60 %; PEEP 10 > 8 > 5\n - Ortho requested - Shoulder films\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:25 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Dopamine - 12 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:24 PM\n Fentanyl - 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 84 (82 - 104) bpm\n BP: 76/30(55) {59/24(42) - 118/59(90)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (4 - 20)mmHg\n PAP: (41 mmHg) / (18 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.1 L/min) / (2.7 L/min/m2)\n SVR: 1,083 dynes*sec/cm5\n Mixed Venous O2% Sat: 65 - 72\n SV: 49 mL\n SVI: 27 mL/m2\n Total In:\n 1,796 mL\n 3,404 mL\n PO:\n TF:\n IVF:\n 1,736 mL\n 3,404 mL\n Blood products:\n Total out:\n 1,010 mL\n 470 mL\n Urine:\n 1,010 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 786 mL\n 2,934 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/30/99./16/-6\n Ve: 12.5 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 214 K/uL\n 10.3 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.7 %\n 10.2 K/uL\n [image002.jpg]\n 01:57 PM\n 02:10 PM\n 03:30 PM\n 03:58 PM\n 06:32 PM\n 09:28 PM\n 09:36 PM\n 12:45 AM\n 01:24 AM\n 05:28 AM\n WBC\n 12.9\n 10.2\n Hct\n 40\n 39\n 35.5\n 33.0\n 29.7\n Plt\n \n Cr\n 2.5\n 2.4\n TropT\n 15.22\n 15.28\n TCO2\n 20\n 19\n 20\n 19\n 20\n 19\n 18\n Glucose\n 173\n 150\n Other labs: PT / PTT / INR:15.8/64.6/1.4, CK / CKMB /\n Troponin-T:4078/235/15.28, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, hyperlipidemia here with STEMI.\n .\n # Cardiogenic shock and STEMI: likely from ischemic cause. Patient\n underwent cath with 3 BMS to distal SVG to OM with subsequent\n persistent low BPs so placed on dopamine and IABP.\n - cardiac index 3.3 on arrival to CVICU with dopa 15 and IABP 1:1\n - reassess CI later tonight\n - eval for tamponade now (prelim neg).\n - continue dopa 15 and titrate prn.\n - continue IABP 1:1\n - trend CE - still rising\n - continue ASA 325\n - plavix 600x1 then 75 daily\n - continue heparin gtt without bolus for his IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR\n so will diurese for goal I<O -500 tonight.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - continue dopa for inotrophy\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure: intubated for airway protection but now with\n hypoxic resp failure. Suspect underlying obstructive dz from 120 pack\n yrs tobb hx. Suspect asp pneumonitis and suspect pulm congestion from\n elevated LVEDP\n - continue FiO2 100% and PEEP 10 for O2 sat>92.\n - frequent suctioning\n - monitor Pplateau and Ppeak which have been normal thus far\n - diurese gently\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - vanco/zosyn\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n .\n # metabolic acidosis: AG 14 so some degree of anion gap acidosis likely\n lactate. Delta/delta suggests concomittant nongap likely from\n ARF. Based on winter's formula, pCO2 should be 31-34 so will increase\n minute ventilation to improve pH.\n - recheck gas after increasing rate to 24 and Vt to 550.\n - likely pressor activity will improve with improvement in acidosis.\n .\n # ARF: baseline Cr 1.3 - now 2.5. FeNa 5.7 (although had been given\n lasix) suggestive of ATN. FeUrea 25% suggests prerenal. regardless,\n suspect poor renal perfusion and ATN.\n - diurese as above for goal -500\n - treat hyperkalemia with insulin IV and recheck\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # question of SVC perforation: have occurred during placement of\n cortis. CXR with no significant widening of mediastinum and echo\n prelim without pericardial effusion.\n - monitor hct and xfuse for <28\n - repeat CXR in am\n - if becomes hypotensive with rising CVP, will consider tamponade as\n etiology and d/w cards team\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. if stabilizis o/n start tube feeds\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-05-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578251, "text": "Chief Complaint:\n 24 Hour Events:\n - Extubated, satting 92-97% on 6L NC this AM, but O/N Hypertensive,\n hypoxic to mid 80's--crackles on exam gave 100mg IV lasix and started\n BIPAP--> resp status and vitals improved\n - Gave 2.5 mg IV lopressor for hr in low 100's\n - Started nitro drip titrated for SBP < 150\n - I/O check (20mg lasix in AM, 100mg in PM): -3L\n - had bowel movement\n - Vomited this AM while suctioning himself; denied nausea\n - c/o dizziness, feeling \"vertical\"\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 11:24 AM\n Heparin Sodium (Prophylaxis) - 11:24 AM\n Metoprolol - 04:00 PM\n Furosemide (Lasix) - 05:15 PM\n Morphine Sulfate - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.5\nC (97.7\n HR: 94 (78 - 114) bpm\n BP: 152/64(94) {101/57(75) - 152/70(95)} mmHg\n RR: 34 (14 - 42) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 20 (13 - 26)mmHg\n PAP: (56 mmHg) / (35 mmHg)\n Total In:\n 739 mL\n 183 mL\n PO:\n 100 mL\n TF:\n 252 mL\n IVF:\n 487 mL\n 83 mL\n Blood products:\n Total out:\n 3,985 mL\n 450 mL\n Urine:\n 3,985 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,246 mL\n -267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 661 (560 - 1,383) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 10\n PIP: 14 cmH2O\n SpO2: 93%\n ABG: 7.48/36/143/24/4\n Ve: 5.1 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): (\" ,\" \"Saturday\" but thinks it's\n , \"\"), Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 205 K/uL\n 9.2 g/dL\n 97 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 106 mEq/L\n 145 mEq/L\n 27.7 %\n 9.1 K/uL\n [image002.jpg]\n 04:18 PM\n 04:42 PM\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n WBC\n 6.0\n 7.8\n 9.1\n Hct\n 25.8\n 27.9\n 27.7\n Plt\n 127\n 150\n 205\n Cr\n 1.2\n 1.3\n 1.2\n TCO2\n 25\n 25\n 25\n 22\n 27\n 28\n Glucose\n 104\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n # Cardiogenic Shock/STEMI. Pressures from 101/53 - 157/76. No longer\n requiring hydrocortisone. Pressures have actually been elevated\n requiring nitro gtt which was weaned off over night\n - Marked improvement yesterday, will monitor today.\n - Start captopril and titrate to BP<150\n - Continue ASA 325, Plavix 75, simva 80\n .\n # PUMP: Pulm edema post intubation. Received total of lasix 100 mg,\n 100mg, is -3L and clinically euvolemic.\n - Lasix 20 mg IV x 1 today\n - Goal even\n .\n # RHYTHM: NSR with more volatile HR 85-114, sporadic PVCs. Received\n lopressor x1 2.5mg for tachycardia post-extubation.\n - replete lytes PRN\n .\n # Resp Failure/Aspiration Pneumonitis: Stable post-intubation. SaO2\n 92-97% on 6L NC.\n - ABG 7.48/36/143; respiratory alkalosis. Will monitor for improvement\n as respiratory status improves. Likely related to agitation as sedation\n was weaned.\n - frequent suctioning\n - continue COPD meds, now with standing albuterol and ipratropium q4h\n - Day Abx course (levaquin) for suspected aspiration\n .\n # Vomiting: Likely related to self-suctioning, RN.\n - Ondansetron PRN, monitor\n .\n # Dizziness: Thinks he is vertical. Given normotensive, may be related\n to weaning sedation or inner-ear process.\n - Check orthostatics\n - Use zofran PRN\n .\n # Rash on back: be related to heating pad used for home PT for\n spinal stenosis. Will monitor for change.\n .\n # Anemia: Hct stable since yesterday, now 27.7.\n - Check iron studies\n .\n # Groin Rash: Started miconazole powder \n .\n # Abdominal distension. Resolved with BM overnight. No pain.\n - Continue bowel regimen PRN (senna, colace)\n - Continue to monitor by physical exam\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n - Reconsult ortho\n .\n # UC. per GI. Can restart Asacol.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # FEN: Cont maintenance fluids. will monitor PO intake today. Restart\n H2 blocker (has dx of GERD)\n - D/C foley today.\n # Access: Cortis, 2x forearm IVs, A-line.\n - Can likely D/C Cortis, A-line today.\n # Dispo: CCU for now. Consider floor call out if stable x next 24 hrs.\n FULL CODE\n" }, { "category": "Physician ", "chartdate": "2176-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577809, "text": "24 Hour Events:\n -Hypoxic with O2 sat 88% 11am, CXR with slightly worsened effusion\n otherwise no change. FiO2 70% and PEEP 8\n -ECHO no PFO, did not look specifically for for RV strain, but with the\n images they did get no evidence\n -Dopamine was turned off, but pt with MAP in 40's. Restarted Dopa @ 3\n -A-line placed\n - HIT antibody negative\n - I/O neg 1.1L @2300\n Fick: 1:2 3pm 5.4/2.9/833 --> 1:4 4am 7/3.7/793\n ABG: 7.39/39/85 70% 8 PEEP at 2300 --> changed to 1:4 given improved\n resp\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Dopamine - 3 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Fentanyl - 05:00 AM\n Midazolam (Versed) - 05:00 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 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 68 (58 - 81) bpm\n BP: 127/62(96) {87/32(60) - 155/63(109)} mmHg\n RR: 16 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n PAP: (52 mmHg) / (22 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 59 - 69\n Total In:\n 1,838 mL\n 433 mL\n PO:\n TF:\n 612 mL\n 155 mL\n IVF:\n 1,097 mL\n 278 mL\n Blood products:\n Total out:\n 2,946 mL\n 200 mL\n Urine:\n 2,886 mL\n 200 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,108 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 28 cmH2O\n SpO2: 99%\n ABG: 7.37/42/84./22/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 120\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT/ND, BS+\n Ext: 1+ edema to 6cm above ankle, dopplerable pulses bilaterally\n Labs / Radiology\n 114 K/uL\n 9.6 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n WBC\n 6.4\n 8.0\n Hct\n 31\n 27.8\n 30.6\n 28.4\n Plt\n 111\n 114\n Cr\n 1.3\n 1.5\n 1.3\n TCO2\n 22\n 22\n 24\n 22\n 24\n 24\n 25\n Glucose\n 118\n 114\n 108\n Other labs: PT / PTT / INR:14.8/58.7/1.3, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n # Cardiogenic Shock/STEMI. Latest Co/CI/SVR=7.3/3.9/722. Remains very\n labile O/N but less highs/lows than yesterday. Likely a component of\n autonomic dysregulation.\n - Plan to cont IABP on 1:1\n - Continue dopamine for pressure support\n - Repeat Fick calculations with change in pressors\n - Continue ASA 325, Plavix 75, heparin gtt for IABP, simva 80.\n - Try to wean FiO2 again today.\n .\n # PUMP: Still volume up. Did not receive lasix yesterday.\n - 20 mg this AM. Goal I/O -500 cc if BP allows\n - Continue afterload reduction with IABP, consider ACE if Cre allows.\n .\n # RHYTHM: Mostly NSR with rate 50s-60s, sporadic PVCs. Hold BB.\n .\n # Anemia: PLT stabilized but Hct dropping. Will follow today and\n consider transfusion if continues to drop.\n - Continue to avoid drugs that may cause thrombocytopenia\n .\n # Vomiting: resolved\n .\n # Resp Failure/Aspiration:\n - Try to wean FiO2 again today to 40%\n - frequent suctioning\n - continue COPD meds\n - Continue levaquin instead of Vanc/Zosyn\n .\n # ARF. Cre improved O/N.\n - monitor daily lytes, renally dose meds\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # GERD. conitnue to avoue H2b or PPI for now due to thrombocytopenia.\n # FEN: Tolerating TFs.\n # Code: FULL\n # Dispo: CCU for now\n" }, { "category": "Physician ", "chartdate": "2176-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577814, "text": "24 Hour Events:\n -Hypoxic with O2 sat 88% 11am, CXR with slightly worsened effusion\n otherwise no change. FiO2 70% and PEEP 8\n -ECHO showed no PFO, did not look specifically for for RV strain, but\n with the images they did get no evidence\n -Dopamine was turned off, but pt with MAP in 40's. Restarted Dopa @ 3\n -A-line placed\n - HIT antibody negative\n - I/O neg 1.1L @2300\n Fick: 1:2 3pm 5.4/2.9/833 --> 1:4 4am 7/3.7/793\n ABG: 7.39/39/85 70% 8 PEEP at 2300 --> changed to 1:4 given improved\n resp\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Dopamine - 3 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Fentanyl - 05:00 AM\n Midazolam (Versed) - 05:00 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 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 68 (58 - 81) bpm\n BP: 127/62(96) {87/32(60) - 155/63(109)} mmHg\n RR: 16 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n PAP: (52 mmHg) / (22 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 59 - 69\n Total In:\n 1,838 mL\n 433 mL\n PO:\n TF:\n 612 mL\n 155 mL\n IVF:\n 1,097 mL\n 278 mL\n Blood products:\n Total out:\n 2,946 mL\n 200 mL\n Urine:\n 2,886 mL\n 200 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,108 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 28 cmH2O\n SpO2: 99%\n ABG: 7.37/42/84./22/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 120\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n 114 K/uL\n 9.6 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n WBC\n 6.4\n 8.0\n Hct\n 31\n 27.8\n 30.6\n 28.4\n Plt\n 111\n 114\n Cr\n 1.3\n 1.5\n 1.3\n TCO2\n 22\n 22\n 24\n 22\n 24\n 24\n 25\n Glucose\n 118\n 114\n 108\n Other labs: PT / PTT / INR:14.8/58.7/1.3, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n # Cardiogenic Shock/STEMI: Has required IABP-- Latest\n Co/CI/SVR=7.3/3.9/722. BP labilility improved-- Likely a component of\n autonomic dysregulation.\n - Plan to DC IABP\n - Continue to wean dopamine\n - Continue ASA 325, Plavix 75, DC heparin gtt for IABP, simva 80.\n - Try to wean FiO2 again today.\n .\n # PUMP: Still volume up.Put out well to 40 IV lasix.\n - Goal I/O -1000 cc today\n .\n # RHYTHM: Mostly NSR with rate 50s-60s, sporadic PVCs. Hold BB.\n .\n # Anemia: HCT and PLTslightly improved. Will follow today and consider\n transfusion if continues to drop.\n - Continue to avoid drugs that may cause thrombocytopenia\n - Transfusion for Hct<21 or >3pt Hct drop\n .\n # Abd Distension: Active bowel sounds though nearly no stool output\n past few days. Possible to could represent obstruction versus ileus\n versus reduced gastric motlity secondary to limited feeding.\n - KUB to r/o obstruction\n -Holding TF high residulas\n - Consider reglan to improve motility if no obstruction on KUB\n .\n # Resp Failure/Aspiration:\n - CXR to assess tube placement\n - Cont to wean FiO2\n - frequent suctioning\n - continue nebs\n - Continue levaquin for asp PNA\nDC tomorrow for 10 day course\n .\n # ARF. Cre improved O/N.\n - monitor daily lytes, renally dose meds\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # GERD. conitnue to avoid H2b or PPI for now due to thrombocytopenia.\n - begin sucralfate for stress ulcer PPX\n # FEN: Tolerating TFs.\n # PPX: sucralfate, start Hep SC when Heparin IV stopped, bowel regimen\n # Code: FULL\n # Dispo: CCU for now\n" }, { "category": "Echo", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 61728, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Myocardial infarction. H/O cardiac surgery.\nHeight: (in) 65\nWeight (lb): 148\nBSA (m2): 1.74 m2\nBP (mm Hg): 86/43\nHR (bpm): 87\nStatus: Inpatient\nDate/Time: at 16:55\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. No ASD by 2D or color Doppler.\n\nLEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. No LV\nmass/thrombus. Mildly depressed LVEF.\n\nRIGHT VENTRICLE: RV function depressed.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. No MS. Trivial MR.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild [1+] TR. Mild\nPA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\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. The left\nventricular cavity size is normal. No masses or thrombi are seen in the left\nventricle. Overall left ventricular systolic function is mildly depressed\n(LVEF= 40-45 %) with lateral hypokinesis. with depressed free wall\ncontractility. The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. No aortic regurgitation is seen. The mitral valve\nleaflets are mildly thickened. Trivial mitral regurgitation is seen. The\ntricuspid valve leaflets are mildly thickened. There is mild pulmonary artery\nsystolic hypertension. There is no pericardial effusion.\n\n\n" }, { "category": "Echo", "chartdate": "2176-05-01 00:00:00.000", "description": "Report", "row_id": 61695, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 65\nWeight (lb): 148\nBSA (m2): 1.74 m2\nBP (mm Hg): 90/40\nHR (bpm): 60\nStatus: Inpatient\nDate/Time: at 12:03\nTest: Portable TTE (Focused views)\nDoppler: No Doppler\nContrast: Saline\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nGENERAL COMMENTS: Contrast study was performed with 1 iv injection of 8 ccs of\nagitated normal saline at rest.\n\nConclusions:\nPatient intubated, maneuvers with saline contrast were not performed. No\nevidence of PFO with rest injection. If clinically indicated, a TEE might be\nmore sensitive to identify PFO.\n\n\n" }, { "category": "Echo", "chartdate": "2176-04-29 00:00:00.000", "description": "Report", "row_id": 61696, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Cardiogenic shock.\nHeight: (in) 65\nWeight (lb): 148\nBSA (m2): 1.74 m2\nBP (mm Hg): 108/78\nHR (bpm): 68\nStatus: Inpatient\nDate/Time: at 11:31\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically ventilated.\nCannot assess RA pressure.\n\nLEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild regional LV\nsystolic dysfunction. No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: basal inferior\n- hypo; basal anterolateral - hypo; mid anterolateral - hypo;\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild mitral\nannular calcification. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Physiologic TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Significant\nPR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. Left ventricular\nwall thicknesses and cavity size are normal. There is mild regional left\nventricular systolic dysfunction with hypokinesis of the basal inferior and\nbasal half of the anterolateral wall. The remaining segments contract normally\n(LVEF = 45-50 %). Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. The tricuspid valve\nleaflets are mildly thickened. There is mild pulmonary artery systolic\nhypertension. Significant pulmonic regurgitation is seen. There is no\npericardial effusion.\n\nCompared with the prior study (images reviewed) of , the inferior\nwall motion abnormality was previously present. The lateral dysfunction is\nmildly improved.\n\n\n" }, { "category": "ECG", "chartdate": "2176-05-06 00:00:00.000", "description": "Report", "row_id": 114539, "text": "Sinus rhythm. Non-specific ST-T wave changes. Possible inferior wall\nmyocardial infarction of indeterminate age. Lateral ST-T wave changes which\nare modest but cannot rule out myocardial ischemia. Compared to the previous\ntracing of lateral ST-T wave changes are more prominent. Clinical\ncorrelation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2176-04-27 00:00:00.000", "description": "Report", "row_id": 114540, "text": "Probable sinus rhythm. Diffuse non-specific ST-T wave abnormalities. Compared\nto previous tracing of inferior ST segment elevations have resolved.\nAnteroseptal ST segment depression is less marked. Suggest clinical\ncorrelation and repeat tracing.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2176-04-26 00:00:00.000", "description": "Report", "row_id": 114541, "text": "Irregular rhythm without clear P wave seen, question accelerated junctional\nrhythm. There are ST-T wave abnormalities suggestive of myocardial infarction\nor ischemia. These include less than one millimeter of ST segment elevation\nin the inferior leads with a Q wave in lead III and ST segment depression in\nleads V-V3 which could represent reciprocal changes. Suggest clinical\ncorrelation and repeat tracing.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2176-04-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081321, "text": " 8:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Interval change\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old male s/p STEMI, with balloon pump for cardiogenic shock\n REASON FOR THIS EXAMINATION:\n Interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: STEMI, with balloon pump for cardiogenic shock. Please evaluate\n interval change.\n\n FINDINGS: Comparison made to multiple priors, most recently , 10:05.\n\n Intraaortic balloon pump remains high, at least 3 cm above the top of the left\n main bronchus. Other lines and support tubes remain in appropriate position.\n Lung volumes have improved, and there are signs of improving volume overload.\n Small left pleural effusion and left basilar collapse is not significantly\n changed. There is no new or worsening airspace opacity. There is no\n pneumothorax.\n\n IMPRESSION:\n 1. IABP positioned high, tip at least 3 cm above the top of the left mainstem\n bronchus.\n 2. Improving volume overload and overall lung aeration.\n 3. Unchanged small left pleural effusion and left lower lobe collapse.\n\n" }, { "category": "Radiology", "chartdate": "2176-04-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1080978, "text": ", S. 2:50 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 75 year old man with cardiogenic shock s/p likely aspiration\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock s/p likely aspiration. pt also with\n possible trauma to SVC during cortis placement. pls confirm ETT placement and\n pls eval for hemothorax\n REASON FOR THIS EXAMINATION:\n 75 year old man with cardiogenic shock s/p likely aspiration. pt also with\n possible trauma to SVC during cortis placement. pls confirm ETT placement and\n pls eval for hemothorax\n ______________________________________________________________________________\n PFI REPORT\n ETT tip 2.3 cm above the carina. IABP 1.7 cm below the top of the aortic\n arch. Right internal jugular Swan-Ganz ends in the distal right lower lobe\n artery. Nasogastric tube ends in the stomach. Mild edema. Lining of the\n upper mediastinum is likely due to vascular congestion and volume overload.\n Bibasilar opacities could be due to aspiration.\n\n" }, { "category": "Radiology", "chartdate": "2176-04-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081028, "text": " 9:34 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: 75 year old man with cardiogenic shock. pls confirm swan pla\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock. pls confirm swan placement.\n REASON FOR THIS EXAMINATION:\n 75 year old man with cardiogenic shock. pls confirm swan placement.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Cardiogenic shock, catheter placement.\n\n One portable view. Comparison with . There is interval improvement in\n pulmonary vascular congestion with the patient is status post median\n sternotomy and CABG as before. An endotracheal tube, nasogastric tube, and\n Swan-Ganz catheter remain in place. A Swan-Ganz catheter has been pulled back\n and now terminates in the region of the right main pulmonary artery. An IABP\n remains in place.\n\n IMPRESSION: Repositioning of pulmonary arterial line. Interval improvement\n in pulmonary vascular congestion.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-04-26 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1080977, "text": " 2:50 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 75 year old man with cardiogenic shock s/p likely aspiration\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock s/p likely aspiration. pt also with\n possible trauma to SVC during cortis placement. pls confirm ETT placement and\n pls eval for hemothorax\n REASON FOR THIS EXAMINATION:\n 75 year old man with cardiogenic shock s/p likely aspiration. pt also with\n possible trauma to SVC during cortis placement. pls confirm ETT placement and\n pls eval for hemothorax\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 6:01 PM\n ETT tip 2.3 cm above the carina. IABP 1.7 cm below the top of the aortic\n arch. Right internal jugular Swan-Ganz ends in the distal right lower lobe\n artery. Nasogastric tube ends in the stomach. Mild edema. Lining of the\n upper mediastinum is likely due to vascular congestion and volume overload.\n Bibasilar opacities could be due to aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, PORT LINE\n\n REASON FOR EXAM: 75-year-old man with cardiogenic shock status post likely\n aspiration. The patient also with possible trauma to the SVC during Cordis\n placement. Please confirm placement and evaluate for pneumothorax.\n\n FINDINGS: Since , sternotomy wires for remote CABG are still\n intact and midline.\n\n The ETT tip is 2.3 cm above the carina, should be pulled back 2 cm for optimal\n placement. Right internal jugular inserted Swan-Ganz catheter, ends too\n distally, in the distal right lower lobe artery. Intra-aortic balloon pump\n metallic marker is 1.7 cm below the top of the aortic arch. The nasogastric\n tube ends in the stomach in expected position. Lung volumes are low.\n Interstitial edema is mild. Bibasilar opacities could be due to aspiration or\n atelectasis. Mediastinal widening is likely due to vascular congestion,\n should be followed given the clinical history. There is no pleural effusion.\n\n Results were discussed immediately with at the time of dictation.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2176-04-27 00:00:00.000", "description": "LP SHOULDER (AP, NEUTRAL & AXILLARY) SOFT TISSUE LEFT PORT", "row_id": 1081066, "text": " 8:11 AM\n SHOULDER (AP, NEUTRAL & AXILLARY) SOFT TISSUE LEFT PORT Clip # \n Reason: eval for post op changes\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with with STEMI and recent LEFT shoulder surgery\n REASON FOR THIS EXAMINATION:\n eval for post op changes\n ______________________________________________________________________________\n FINAL REPORT\n LEFT SHOULDER\n\n HISTORY: Shoulder surgery.\n\n Two AP portable views. Visualized cortical margins appear intact. Bony\n mineralization appears normal. There is no definite soft tissue abnormality.\n No radiopaque foreign body is identified.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-04-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081197, "text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval ETT tube\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock\n REASON FOR THIS EXAMINATION:\n eval ETT tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST\n\n HISTORY: Cardiogenic shock, evaluate ET tube placement.\n\n One portable view. Comparison with . Lung volumes are quite low. The\n patient is status post median sternotomy and CABG as before. There is an\n increased density in the retrocardiac area consistent with atelectasis or\n consolidation. No focal pulmonary abnormality is identified. The heart and\n mediastinal structures are unchanged. An endotracheal tube, nasogastric tube,\n Swan-Ganz catheter and IABP remain in place.\n\n IMPRESSION: Stable retrocardiac density consistent with atelectasis or\n consolidation. An area of increased density previously noted in the left mid\n lung is no longer apparent.\n\n" }, { "category": "Radiology", "chartdate": "2176-04-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081063, "text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: 75 year old man with ett, cardiogenic shock, R IJ CVL, ? asp\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with ett, cardiogenic shock, R IJ CVL, ? aspiration. pls eval\n interval change\n REASON FOR THIS EXAMINATION:\n 75 year old man with ett, cardiogenic shock, R IJ CVL, ? aspiration. pls eval\n interval change\n ______________________________________________________________________________\n FINAL REPORT\n CHEST X-RAY\n\n HISTORY: Cardiogenic shock. Right IJ line placement.\n\n One portable view. Comparison with the previous study done . Lungs\n volumes are somewhat low. The patient is status post median sternotomy and\n CABG, as before. There is ill defined increased parenchymal density but this\n is difficult to assess due to low lung volumes. There may be some new\n asymmetric density in the left mid lung. An endotracheal tube, nasogastric\n tube, IABP and pulmonary arterial line remain in place.\n\n IMPRESSION: Limited study demonstrating ill defined increased density in the\n left mid lung zone. Early focal infiltrate or asymmetric edema cannot\n definitely be excluded and continued chest x-ray follow-up is recommended.\n\n" }, { "category": "Radiology", "chartdate": "2176-04-29 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1081398, "text": " 1:35 PM\n PORTABLE ABDOMEN Clip # \n Reason: Please eval for ileus or obstruction\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with vomiting, intubated.\n REASON FOR THIS EXAMINATION:\n Please eval for ileus or obstruction\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, ONE VIEW\n\n COMPARISON: None.\n\n HISTORY: Vomiting and intubated, evaluate for ileus or obstruction.\n\n FINDINGS: There is air seen within the large and small bowel which appears\n nondilated. An NG tube is seen terminating in the left upper quadrant. There\n is no evidence of portal venous gas or pneumatosis. The osseous structures\n are grossly unremarkable.\n\n IMPRESSION: Nonspecific bowel gas pattern. Evaluation for free air is\n limited due to non-upright view.\n\n\n" }, { "category": "Physician ", "chartdate": "2176-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577102, "text": "Chief Complaint: None\n 24 Hour Events:\n - Given 1 unit pRBCs, 250cc bolus for hct 26.8, MAP 40s; repeat 1 unit\n pRBCS at 5pm given hct 27.2 (?hemodilulational as all cells down); 12am\n hct 29.0\n - Vomitted in AM; unclear if kept down ; written for 75mg\n PO x1. Vomit G positive.\n - 8pm: CO>7; going down on Levophed\n - PEEP decreased to 5\n - No ortho recs\n - Sputum culture with yeast; blood cultures remain no growth to date\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:01 PM\n Vancomycin - 08:21 PM\n Piperacillin - 02:22 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Heparin Sodium - 950 units/hour\n Midazolam (Versed) - 3 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n None\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Non verbal\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 64 (62 - 93) bpm\n BP: 119/46(85) {74/27(51) - 144/53(99)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 11 (7 - 23)mmHg\n PAP: (43 mmHg) / (20 mmHg)\n PCWP: 18 (18 - 18) mmHg\n CO/CI (Fick): (5.8 L/min) / (3.1 L/min/m2)\n Mixed Venous O2% Sat: 66 - 76\n Total In:\n 2,216 mL\n 450 mL\n PO:\n TF:\n IVF:\n 1,652 mL\n 450 mL\n Blood products:\n 564 mL\n Total out:\n 1,655 mL\n 405 mL\n Urine:\n 1,155 mL\n 205 mL\n NG:\n 500 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 561 mL\n 45 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/30/116/17/-4\n Ve: 11.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 121 K/uL\n 9.9 g/dL\n 125 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 02:22 PM\n 03:16 AM\n 03:42 AM\n 09:30 AM\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n WBC\n 8.2\n 7.5\n 6.1\n 6.6\n Hct\n 27.4\n 26.8\n 28\n 27.2\n 30\n 29.0\n 29.1\n Plt\n 170\n 144\n 115\n 121\n Cr\n 2.1\n 1.6\n 1.4\n TCO2\n 17\n 15\n 19\n 19\n Glucose\n 150\n 139\n 122\n 125\n Other labs: PT / PTT / INR:15.8/48.8/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.3,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 indicating a massive amount of\n ischemia. Given severity of MI cardiogenic shock is most likely due to\n ischemia. Hemodynamics improved with IABP, but hypotension persists.\n Levophed downtitrated over last 24 hrs. Latest CO/CI/SVR =5.8/3.1/1012\n (CI down from 4.2, SVR up from 843). TTE on day of admission with EF\n that was not very suppressed.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine and d/c levophed for enhanced cardiogenc shock\n pressor treatment.\n - Repeat Fick calculations with change in pressors\n - continue ASA 325\n - 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n - Repeat TTE today to assess for change in EF. I predict EF will be\n markedly reduced from TTE on admission.\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR.\n Now that HD improved, patient will likely benefit from continued\n afterolad reduction with diuretics given fluid overload on exam\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Anemia/thrombocytopenia: Patient did not have appropriate bump to\n PRBC transfusion yesterday. Platelets continue to downtrend. I suspect\n hemolysis from balloon pump. Guaiac positive NG output worrisome for\n UGIB. Plan for goal Hct greater than 26. TTP unlikely as this is\n relatively new. HIT unlikely as there is a another good explanation for\n thromobocytopenia (4T score\n meets criteria for > 50% plt fall, but\n plt drop in less than 5 days, no clots and pt has other good reason for\n low plts)\n - Add on hemolysis labs\n - Start IV PPI \n - Trend Hct \n - Consider HIT ab if .\n - Will continue heparin gtt/ for now. If Hct , \n need to address utility of continuing heparin in setting of bleed vs\n taking IABP out\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - KUB today to asses for obstruction\n - Start PPI as above\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Although this is usually chemically mediated, abx were started\n given dramatically low BPs. Hypoxia likely due to edema, consolidation,\n and underlying COPD. FiO2 increased last night back to 60 for hypoxia.\n Plan to reduce FiO2 today as anticipate diuresis will improve\n oxygenation.\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: AG trended down from 15 to 9 today. Non gap\n acidosis likely due to renal failure. Bicarb improved from 14 to 17 as\n renal function improved. Delta delta suggests nongap acidosis likely\n due to renal failure initially. Appears to have respiratory\n compensation with low CO2.\n - Improvement with dynamics should improve renal failure\n - trend ABGs daily\n .\n # ARF: Baseline Cr 1.3\n and now improved markedly to 1.4. FeUrea 25%\n suggests prerenal. regardless, suspect poor renal perfusion and ATN.\n Contrast nephropathy unlikely as 3 days post cath renal function is\n improving.\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since \n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Nursing", "chartdate": "2176-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577771, "text": "Shock, cardiogenic\n Assessment:\n Stable BPs on IABP 1:2 and Dopamine gtt at 3mcg/k./min\n Action:\n Dopa maintained at 3mcg. IABP switched to 1:4 at 01:00\n Response:\n HD stable on IABP 1:4, Gd augmentation and systolic/diastolic\n unloading. CO/CI/SVR 7/3.7/793 (5.4/2.9/833), MV02 69% (60%) on IABP\n 1:4 and Dopa 3mcg. Heparin gtt therapeutic, PTT 58.7\n Plan:\n DC IABP today. Wean Dopa as tol, follow hemodynamics, uop,\n distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats >95% on 70% FI02 and 8 PEEP\n Action:\n ABGs monitored, sxn\nd for sm/mod amts tan/bld tinged secretions.\n Response:\n Stable sats.\n Plan:\n Wean vent as tol, continue VAP bundle per protocol. Levoflox\n due today for empiric ASP PNA coverage\n Altered mental status (not Delirium)\n Assessment:\n Very restless/agitated on low dose fent/versed gtts resulting in HR up\n to 100s and SBPs 160s w/ MAPs 100s. Moving all extremities off bed.\n Not following commands/tracking. Grimacing at times\n Action:\n Pt re-oriented/re-directed. ABG drawn showing adequate oxygenation.\n Bolus sedation and gtt increased for comfort. R leg immobilizer placed\n Response:\n Short effect w/ bolus sedation, continues w/ freq periods of\n restlessness, lifting R leg (IABP) off bed. Not following commands.\n Rarely overbreathing vent 1-2 breaths.\n Plan:\n Wean sedation/daily wake ups once IABP out as pt currently\n easily agitated and restless. Reorient PRN. ***? Haldol for agitation\n instead of increasing fent/versed gtts.\n Pain management for recent L rotator cuff surgery\n Alteration in Nutrition\n Assessment:\n TF residuals 90-120cc, abd soft distended, no stool\n Action:\n TF rate not advanced residuals. Colace given.\n Response:\n 150cc residual at 03:30\n TF held for 1.5 hr and reduced to 15cc/hr at\n 05:00\n Plan:\n Increase TF as tol, FS QID\n tx as indicated. Continue bowel\n regimen. ? LBM\n Thrombocytopenia, acute\n Assessment:\n PLT 114 (111). Lg clot suctioned from mouth. Some bloody secretions\n from ETT\n Action:\n Team aware of clot. protonix, famotidine continue to be held \n potential causes of thrombocytopenia.\n Response:\n AM HCT 28.4 (30.6)\n Plan:\n monitor plt and assess for signs of bleeding.\n" }, { "category": "Physician ", "chartdate": "2176-04-29 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 577077, "text": "TITLE:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Able to wean Levophed but unable to reduce IABP support or dopamine\n dose. Will continue mechanical and inotropic support. Maximize\n cardiac output. ECHO today.\n Critical care time 50 minutes for management of cardiogenic shock,\n hypotension and IABP.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577257, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further complicated by\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordinly for PTT\n goal 50-70\n Response:\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Remains pressor dependent. Unable to wean Dopa below 5.5 mcg/k/min. AM\n PTT, PLT stable.\n Plan:\n Wean Dopa as tolerated, check hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn showing PO2 80\nMDI , FI02 increased to 60%. 20mg IV\n lasix given at 22:45\n Response:\n Sats slowly up to 92-96%. Gd response to lasix. Neg 262 at MN (goal\n -500cc)\n Plan:\n Wean vent as tol. Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Attempt PSV.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up. Rate decreased to 16\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Continues NOT to overbreath vent\n sedation\n restarted.\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS\n aspirating sm amts bilious material\n Plan:\n Continue PPI, limit sedation meds. Bowel regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Respiratory ", "chartdate": "2176-05-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577870, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n 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: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Exp Wheeze\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Exp Wheeze\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:\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\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": "2176-04-27 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 576642, "text": "TITLE:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s).\n I would add the following remarks:\n Medical Decision Making\n Critical Care time 70 minutes. Intermittently hypotensive.\n Respiratory failure with high oxygen requirement. IABP mechanical\n support and pressors for cardiogenic shock. Will wean as tolerated.\n Monitor for bleeding and emerging infection due to possible aspiration\n pneumonia.\n" }, { "category": "Physician ", "chartdate": "2176-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576644, "text": "Chief Complaint: None\n 24 Hour Events:\n - Maxed Dopamine at 14\n - Changed propafol to fentanyl versed to help improve maps\n - Gave Fluid bolus 500 cc x3 and 1 L x1\n - CI 2.8 > 3.5 > 2.7\n - MAPs less than 40 not responsive to IVF. Started levophed.\n - Vent - FIO2: 80 % > 60 %; PEEP 10 > 8 > 5\n - Ortho requested - Shoulder films\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:25 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Dopamine - 12 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:24 PM\n Fentanyl - 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 84 (82 - 104) bpm\n BP: 76/30(55) {59/24(42) - 118/59(90)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (4 - 20)mmHg\n PAP: (41 mmHg) / (18 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.1 L/min) / (2.7 L/min/m2)\n SVR: 1,083 dynes*sec/cm5\n Mixed Venous O2% Sat: 65 - 72\n SV: 49 mL\n SVI: 27 mL/m2\n Total In:\n 1,796 mL\n 3,404 mL\n PO:\n TF:\n IVF:\n 1,736 mL\n 3,404 mL\n Blood products:\n Total out:\n 1,010 mL\n 470 mL\n Urine:\n 1,010 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 786 mL\n 2,934 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/30/99./16/-6\n Ve: 12.5 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 214 K/uL\n 10.3 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.7 %\n 10.2 K/uL\n [image002.jpg]\n 01:57 PM\n 02:10 PM\n 03:30 PM\n 03:58 PM\n 06:32 PM\n 09:28 PM\n 09:36 PM\n 12:45 AM\n 01:24 AM\n 05:28 AM\n WBC\n 12.9\n 10.2\n Hct\n 40\n 39\n 35.5\n 33.0\n 29.7\n Plt\n \n Cr\n 2.5\n 2.4\n TropT\n 15.22\n 15.28\n TCO2\n 20\n 19\n 20\n 19\n 20\n 19\n 18\n Glucose\n 173\n 150\n Other labs: PT / PTT / INR:15.8/64.6/1.4, CK / CKMB /\n Troponin-T:4078/235/15.28, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: CK peaked at . Patient underwent cath\n with 3 BMS to distal SVG to OM with subsequent persistent low BPs so\n placed on dopamine and IABP.\n - cardiac index 3.3 on arrival to CVICU with dopa 15 and IABP 1:1\n - reassess CI later tonight\n - eval for tamponade now (prelim neg).\n - continue dopa 15 and titrate prn.\n - continue IABP 1:1\n - trend CE - still rising\n - continue ASA 325\n - plavix 600x1 then 75 daily\n - continue heparin gtt without bolus for his IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR\n so will diurese for goal I<O -500 tonight.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - continue dopa for inotrophy\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure: intubated for airway protection but now with\n hypoxic resp failure. Suspect underlying obstructive dz from 120 pack\n yrs tobb hx. Suspect asp pneumonitis and suspect pulm congestion from\n elevated LVEDP\n - continue FiO2 100% and PEEP 10 for O2 sat>92.\n - frequent suctioning\n - monitor Pplateau and Ppeak which have been normal thus far\n - diurese gently\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - vanco/zosyn\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n .\n # metabolic acidosis: AG 14 so some degree of anion gap acidosis likely\n lactate. Delta/delta suggests concomittant nongap likely from\n ARF. Based on winter's formula, pCO2 should be 31-34 so will increase\n minute ventilation to improve pH.\n - recheck gas after increasing rate to 24 and Vt to 550.\n - likely pressor activity will improve with improvement in acidosis.\n .\n # ARF: baseline Cr 1.3 - now 2.5. FeNa 5.7 (although had been given\n lasix) suggestive of ATN. FeUrea 25% suggests prerenal. regardless,\n suspect poor renal perfusion and ATN.\n - diurese as above for goal -500\n - treat hyperkalemia with insulin IV and recheck\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # question of SVC perforation: have occurred during placement of\n cortis. CXR with no significant widening of mediastinum and echo\n prelim without pericardial effusion.\n - monitor hct and xfuse for <28\n - repeat CXR in am\n - if becomes hypotensive with rising CVP, will consider tamponade as\n etiology and d/w cards team\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. if stabilizis o/n start tube feeds\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576647, "text": "Chief Complaint: None\n 24 Hour Events:\n - Maxed Dopamine at 14\n - Changed propafol to fentanyl versed to help improve maps\n - Gave Fluid bolus 500 cc x3 and 1 L x1\n - CI 2.8 > 3.5 > 2.7\n - MAPs less than 40 not responsive to IVF. Started levophed.\n - Vent - FIO2: 80 % > 60 %; PEEP 10 > 8 > 5\n - Ortho requested - Shoulder films\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:25 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Dopamine - 12 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:24 PM\n Fentanyl - 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 84 (82 - 104) bpm\n BP: 76/30(55) {59/24(42) - 118/59(90)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (4 - 20)mmHg\n PAP: (41 mmHg) / (18 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.1 L/min) / (2.7 L/min/m2)\n SVR: 1,083 dynes*sec/cm5\n Mixed Venous O2% Sat: 65 - 72\n SV: 49 mL\n SVI: 27 mL/m2\n Total In:\n 1,796 mL\n 3,404 mL\n PO:\n TF:\n IVF:\n 1,736 mL\n 3,404 mL\n Blood products:\n Total out:\n 1,010 mL\n 470 mL\n Urine:\n 1,010 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 786 mL\n 2,934 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/30/99./16/-6\n Ve: 12.5 L/min\n PaO2 / FiO2: 165\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 214 K/uL\n 10.3 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.7 %\n 10.2 K/uL\n [image002.jpg]\n 01:57 PM\n 02:10 PM\n 03:30 PM\n 03:58 PM\n 06:32 PM\n 09:28 PM\n 09:36 PM\n 12:45 AM\n 01:24 AM\n 05:28 AM\n WBC\n 12.9\n 10.2\n Hct\n 40\n 39\n 35.5\n 33.0\n 29.7\n Plt\n \n Cr\n 2.5\n 2.4\n TropT\n 15.22\n 15.28\n TCO2\n 20\n 19\n 20\n 19\n 20\n 19\n 18\n Glucose\n 173\n 150\n Other labs: PT / PTT / INR:15.8/64.6/1.4, CK / CKMB /\n Troponin-T:4078/235/15.28, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Nursing", "chartdate": "2176-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577150, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n Received pt on levophed .06 mc/g/g/min anad dopamine 3 mcg/kg/min, on\n IABP 1:1\n Actionresponse\n Attempted slow levophed wean. Ns bolus x1-250ml. CO/CI/SVR sent/pending\n on 0.03 levophed dose.\n Response:\n Unable to drop levophed gtt below 0.03mcg/kg/min with maps dropping\n into low 50\ns. without response to ns bolus. Decreasing uo when maps\n <60.\n Plan:\n Continue present management. Continue slow levophed wean as tolerated.\n ?further fluid boluses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated & vented. Minimal secretions. Breath\n sounds=essentially clear/diminished. Remains comfortable sedated on\n fent/versed gtts.\n Action:\n Unchged vent settings. Pulmonary toilet. Vap protocol followed.\n Response:\n Improving abg\n Plan:\n Continue vent support. Wean vent settings as tolerated.\n Neuro=sedated with fent/versed gtts. Responds to stimulation.\n Non-purposefull movement. Does not follow simple commands.\n Requires adequate sedation or becomes very agitated with resulting\n hypotension.\n GI=hypoactive bowel sounds. OGT to intermittent suction-bilious. If OGT\n kept clamped for long periods-vomits.\n Social=supportive family. Kept informed by nursing & medical staff.\n" }, { "category": "Nutrition", "chartdate": "2176-04-30 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 577382, "text": "Subjective\n Intub/sedated, family in room.\n Objective\n 86.9 kg ( 06:00 AM)\n Pertinent medications: DOPamine, Heparin, Fentanyl , Midazolam ,\n Insulin SC Sliding Scale, Aspirin, Levofloxacin , others noted\n Labs:\n Value\n Date\n Glucose\n 114 mg/dL\n 05:30 AM\n Glucose Finger Stick\n 139\n 12:00 PM\n BUN\n 16 mg/dL\n 05:30 AM\n Creatinine\n 1.6 mg/dL\n 05:30 AM\n Sodium\n 140 mEq/L\n 05:30 AM\n Potassium\n 3.8 mEq/L\n 05:30 AM\n Chloride\n 111 mEq/L\n 05:30 AM\n TCO2\n 19 mEq/L\n 05:30 AM\n PO2 (arterial)\n 165 mm Hg\n 12:32 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 33 mm Hg\n 12:32 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:32 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 22 mEq/L\n 12:32 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 7.5 mg/dL\n 05:30 AM\n Phosphorus\n 2.4 mg/dL\n 05:30 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 05:30 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n WBC\n 7.0 K/uL\n 05:30 AM\n Hgb\n 10.8 g/dL\n 05:30 AM\n Hematocrit\n 31.0 %\n 05:30 AM\n Current diet order / nutrition support: Nutren Pulmonary Full strength;\n Starting rate: 15 ml/hr; Advance rate by 10 ml q4h Goal rate: 55 ml/hr\n (1980kcal/90g protein)\n Residual Check: q4h Hold feeding for residual >= : 200 ml\n GI: abd obese, + bowel sounds\n Assessment of Nutritional Status\n 75 year old male admitted with STEMI in peri-operative period and now\n with cardiogenic shock s/p IABP. Noted patient vomited yesterday, KUB\n showed no evidence of obstruction or ileus, tube feed started this\n morning, spoke to RN, patient tolerated tube feed so far. Current tube\n feed order meeting patient\ns estimated needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n Tube feeding recommendations: cont to advance tube feed to goal as\n tolerated\n Check chemistry 10 panel daily, replete prn\n Continue insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u, if has question\n" }, { "category": "Physician ", "chartdate": "2176-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576602, "text": "Chief Complaint: None\n 24 Hour Events:\n - Maxed Dopamine at 14\n - Changed propafol to fentanyl versed to help improve maps\n - Gave Fluid bolus 500 cc x3 and 1 L x1\n - CI 2.8 > 3.5 > 2.7\n - MAPs less than 40 not responsive to IVF. Started levophed.\n - Vent - FIO2: 80 % > 60 %; PEEP 10 > 8 > 5\n - Ortho requested - Shoulder films\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:25 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Dopamine - 12 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:24 PM\n Fentanyl - 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 84 (82 - 104) bpm\n BP: 76/30(55) {59/24(42) - 118/59(90)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (4 - 20)mmHg\n PAP: (41 mmHg) / (18 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.1 L/min) / (2.7 L/min/m2)\n SVR: 1,083 dynes*sec/cm5\n Mixed Venous O2% Sat: 65 - 72\n SV: 49 mL\n SVI: 27 mL/m2\n Total In:\n 1,796 mL\n 3,404 mL\n PO:\n TF:\n IVF:\n 1,736 mL\n 3,404 mL\n Blood products:\n Total out:\n 1,010 mL\n 470 mL\n Urine:\n 1,010 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 786 mL\n 2,934 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/30/99./16/-6\n Ve: 12.5 L/min\n PaO2 / FiO2: 165\n Physical Examination\n General Appearance: intubated, sedate\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n dopplerable right PT pulse\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, cool lower extremitites\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 214 K/uL\n 10.3 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.7 %\n 10.2 K/uL\n [image002.jpg]\n 01:57 PM\n 02:10 PM\n 03:30 PM\n 03:58 PM\n 06:32 PM\n 09:28 PM\n 09:36 PM\n 12:45 AM\n 01:24 AM\n 05:28 AM\n WBC\n 12.9\n 10.2\n Hct\n 40\n 39\n 35.5\n 33.0\n 29.7\n Plt\n \n Cr\n 2.5\n 2.4\n TropT\n 15.22\n 15.28\n TCO2\n 20\n 19\n 20\n 19\n 20\n 19\n 18\n Glucose\n 173\n 150\n Other labs: PT / PTT / INR:15.8/64.6/1.4, CK / CKMB /\n Troponin-T:4078/235/15.28, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, hyperlipidemia here with STEMI.\n .\n # Cardiogenic shock and STEMI: likely from ischemic cause. Patient\n underwent cath with 3 BMS to distal SVG to OM with subsequent\n persistent low BPs so placed on dopamine and IABP.\n - cardiac index 3.3 on arrival to CVICU with dopa 15 and IABP 1:1\n - reassess CI later tonight\n - eval for tamponade now (prelim neg).\n - continue dopa 15 and titrate prn.\n - continue IABP 1:1\n - trend CE - still rising\n - continue ASA 325\n - plavix 600x1 then 75 daily\n - continue heparin gtt without bolus for his IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR\n so will diurese for goal I<O -500 tonight.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - continue dopa for inotrophy\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure: intubated for airway protection but now with\n hypoxic resp failure. Suspect underlying obstructive dz from 120 pack\n yrs tobb hx. Suspect asp pneumonitis and suspect pulm congestion from\n elevated LVEDP\n - continue FiO2 100% and PEEP 10 for O2 sat>92.\n - frequent suctioning\n - monitor Pplateau and Ppeak which have been normal thus far\n - diurese gently\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - vanco/zosyn\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n .\n # metabolic acidosis: AG 14 so some degree of anion gap acidosis likely\n lactate. Delta/delta suggests concomittant nongap likely from\n ARF. Based on winter's formula, pCO2 should be 31-34 so will increase\n minute ventilation to improve pH.\n - recheck gas after increasing rate to 24 and Vt to 550.\n - likely pressor activity will improve with improvement in acidosis.\n .\n # ARF: baseline Cr 1.3 - now 2.5. FeNa 5.7 (although had been given\n lasix) suggestive of ATN. FeUrea 25% suggests prerenal. regardless,\n suspect poor renal perfusion and ATN.\n - diurese as above for goal -500\n - treat hyperkalemia with insulin IV and recheck\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # question of SVC perforation: have occurred during placement of\n cortis. CXR with no significant widening of mediastinum and echo\n prelim without pericardial effusion.\n - monitor hct and xfuse for <28\n - repeat CXR in am\n - if becomes hypotensive with rising CVP, will consider tamponade as\n etiology and d/w cards team\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. if stabilizis o/n start tube feeds\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Respiratory ", "chartdate": "2176-04-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576776, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 21 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: 6 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: 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, Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577253, "text": "Levo weaned off 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordinly for PTT\n goal 50-70\n Response:\n Continues on IABP 1:1 w/ good augmentation and unloading. Continues to\n have labile BPs, unable to wean Dopa. AM PTT, PLT stable.\n Plan:\n Wean Dopa as tolerated, check hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn showing PO2 80\nMDI , FI02 increased to 60%. 20mg IV\n lasix given at 22:45\n Response:\n Sats slowly up to 92-96%. Gd response to lasix. Neg 262 at MN (goal\n -500cc)\n Plan:\n Wean vent as tol. Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Attempt PSV.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up. Rate decreased to 16\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Continues NOT to overbreath vent\n sedation\n restarted.\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS\n aspirating sm amts bilious material\n Plan:\n Continue PPI, limit sedation meds. Bowel regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577457, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577458, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577459, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2176-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577398, "text": "Chief Complaint:\n 24 Hour Events:\n - . Dr. is PCP. . wants a call in a day or\n two\n - vanco increased to 1 mg daily given improvement in Renal fx\n - Lasix 20 mg IVx1 in AM. Goal I/o negative 500 cc. - 300 at .\n Positive 30 cc at 22:00. Redosed Lasix 20 mv IVx1.\n - Decreased FiO2 from 0.6 to 0.5\n - Ortho recs - No recs\n - Hemolysis labs added on given anemia and thrombocytopenia.\n Haptoglobin nl. Fibrinogen elevated at 625. Indirect bili 0.6.\n - KUB to eval for ileus given NG output - Nondilated Large and Small\n bowel. No evidence of pneumoatosis. Limited given non upright view.\n - NG output G positive. Started on IV PPI. Repeat Hct 29.9 (from 29.1)\n - TTE - Left ventricular wall thicknesses and cavity size are normal.\n Overall left ventricular systolic function is mildly depressed (LVEF=\n 45-50 %). There is mild pulmonary artery systolic hypertension. There\n is no pericardial effusion. Compared with the prior study (images\n reviewed) of , the distal LV lateral wall function has\n improved slightly. There is LV inferolateral hypokinesis. The other\n findings are similar.\n - Repeat Fick #s - CI/CO/SVR - 5.8/3.1/1012 > 5.3/2.9/632\n - ABG 7.44/27/80/19 >> Decreased RR from 20 > 16 >> 7.38 /35/65/22 at 5\n am(increased FiO2 0.5 >0.6)\n - Family updated\n - RN informed housestaff that Mesalamine can not be crushed, so order\n was d/cd. Will need to d/w Pharm re: Pr formulation.\n - Failed SBT at 0530 before Rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:32 PM\n Famotidine (Pepcid) - 07:45 PM\n Furosemide (Lasix) - 10:45 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 08:16 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: 36.3\nC (97.3\n HR: 69 (65 - 96) bpm\n BP: 136/48(93) {73/31(53) - 146/75(108)} mmHg\n RR: 16 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 14 (11 - 18)mmHg\n PAP: (35 mmHg) / (25 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 63 - 70\n Total In:\n 2,289 mL\n 615 mL\n PO:\n TF:\n IVF:\n 2,249 mL\n 615 mL\n Blood products:\n Total out:\n 2,550 mL\n 1,750 mL\n Urine:\n 2,325 mL\n 1,725 mL\n NG:\n 225 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n -261 mL\n -1,135 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.38/35/65/19/-3\n Ve: 8.6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 111 K/uL\n 10.8 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 111 mEq/L\n 140 mEq/L\n 31.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n WBC\n 7.5\n 6.1\n 6.6\n 7.0\n Hct\n 27.2\n 30\n 29.0\n 29.1\n 29.9\n 31.0\n Plt\n 144\n 115\n 121\n 111\n Cr\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 19\n 19\n 22\n Glucose\n 122\n 125\n 109\n 114\n Other labs: PT / PTT / INR:13.8/57.8/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: Cardiogenic shock is most likely due to\n ischemia. Hemodynamics improving with IABP. Levophed has been weaned\n off and he remains on dopamine. Latest CO/CI/SVR = 7/3.8/801(\n 5.3/2.9/632). TTE yesterday demonstrated mildly depressed LVEF with EF\n 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment.\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterday. Cont\n afterload reduction with diuresis.\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct trending up though plts cont to trend\n down likely hemolysis from balloon pump. Hemolysis labs\n unremarkable. HIT is certainly possible and 4T score is intermediate.\n - Send Heparin dependent Ab\n - Stop meds that could be contributing: PPI, Vanc\n - Will continue heparin gtt/plavix for now\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - No e/o obstruction or ileus on KUB\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n FiO2 increased last night back to 60 for hypoxia. Hoping that cont\n diuresis will improve oxygenation.\n - Recheck a gas this morning\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Cr 1.6.-baseline around 1.3 Suspect poor renal perfusion and\n ATN.\n - recheck urine lytes\n - cont to monitor\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Holding asacol at this time since it cannot be\n crushed. Will discuss whether we should give PR asacol with outpatient\n gastroenterologist.\n .\n # depression: cont celexa\n .\n # hx of GERD: holding PPI and H2 blocker for now\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576713, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n TRAPONIN 15.2/PK CK 5977.BP LABILE C MINOR TITRATION OF DOPAMINE AND\n LEVOPHED ESPECIALLY WHEN TEMP INCREASED TO 101 .MAP AS LOW AS 49 WHEN\n DOPAMINE OFF,BUT MAPS 90 WHEN ON ONLY 3 MIC PER KG . CI 3.8 SVR 740\n 0N 3 MIC DOPAMINE ,.24 MIC LEVOPHED ,IABP 1 TO 1 .pt drops bp when\n turned . MAINTAINS UO 30 TO 40 CC.POS 4,600 CC .HCT 27 .3 .PT \n X1 ,NG HOOKED TO SX FOR CL GREEN.ASPIRIN GIVEN PER RECTUM, PLAVIX GIVEN\n LATER AT 3PM.TOL OG BEING CLAMPED THIS PM.\n Action:\n TITRATE PRESSERS FOR OPTIMUM HEMODYNAMICS .\n Response:\n SLOW WEAN OF LEVOPHED C MAPS ABOVE 60\n Plan:\n WEAN PRESSERS AS TOL ,FOLLOW HCT ,HEMODYNAMICS ,MONITOR FOR BLEEDING\n Pain control (acute pain, chronic pain)\n Assessment:\n SP L ROTATOR SX .DSD D/I,NO BLEEDING NOTED .ON FENTANYL DRIP\n Action:\n FENTANYL 100 MIC/KG CONT C 25 MIC BOLLUSES PRN FOR PAIN\n Response:\n APPEARS COMFORTABLE\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 7.38/27/93/95 ON 65%/CMV 550/HR 24/8 PEEP ,HX COPD.t max 101 .2\n Action:\n WEAN FIO2,SX PRN , MDI ,Tylenol for temp\n Response:\n SAT 94 TO 97\n Plan:\n PULMONARY TOILET ,WEAN AS,TOL SX PRN\n" }, { "category": "Respiratory ", "chartdate": "2176-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577239, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n ETT:\n Position: 23 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: 5 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: No RSBI. Pt still not breathing spontaneously.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2176-04-30 00:00:00.000", "description": "Cardiology Teaching Physician Note", "row_id": 577367, "text": "TITLE:\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Still requiring pressors and IABP for labile blood pressure. Will\n attempt to wean both. Supportive care for now.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577460, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577469, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n BP continues to be very labile, MAPS range from 40\ns to 100\ns. HR\n trending lower over shift now in 50\n Action:\n Dopa titrated to maintain MAPS>55 heparin remains at 1100 units with\n therapeutic PTT\n Response:\n Dopa ranged from 2-5.5mcg/kg/min now at 3. Last set of numbers\n CO/CI/SVR 6/3.2/725 on 3 of dopa.IABP 1:1 with systolic/ diastolic\n unloading and good augmentation.\n Plan:\n Wean dopa maintaining MAPS>55. cont to follow hemodynamics, urine\n output and pulses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 60% FIO2 this am. First ABG PaO2 165, suctioning thick tan\n secretions q2-3. lungs clear diminished at bases\n Action:\n Turned q2, frequent oral care,suctioned prn. Abx changed to po\n levoquin. Weaned FIO2 to 50%\n Response:\n Great ABG on 50% 7.41/34/98 ,turned down to 40%\n Plan:\n Check ABG on 40%, cont with frequent turning, suctioning as needed,wean\n vent as tolerated\n Altered mental status (not Delirium)\n Assessment:\n Received on fentanyl @ 50mcg/hr versed @1.5mg/hr very agitated/\n thrashing about. Requiring boluses of fent and versed. No response to\n voice and does not follow any commands\n Action:\n Fentatnyl increased to 75 and versed increased to 2mg.\n Response:\n Comfortable until any hands on care is delivered. Quickly becomes very\n agitated, attempting to bend both knees\n Plan:\n Wean sedation as tolerated. Pain control for left shoulder s/p rotator\n cuff surgery.\n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576597, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Received patient on 16 mcgs dopamine with persistent drop in maps to\n the 40-50\n cvp 2-4 with pad 12-14\n Action:\n BP support with frequent NS bolus .hct stable at 30\n Response:\n CVP 9-11. PAD 18-21 MAP 55-60, but continues to be labile\n Plan:\n Continue with fluid resuscitation and consider levophed\n" }, { "category": "Physician ", "chartdate": "2176-04-27 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576600, "text": "Chief Complaint: None\n 24 Hour Events:\n - Maxed Dopamine at 14\n - Changed propafol to fentanyl versed to help improve maps\n - Gave Fluid bolus 500 cc x3 and 1 L x1\n - CI 2.8 > 3.5 > 2.7\n - MAPs less than 40 not responsive to IVF. Started levophed.\n - Vent - FIO2: 80 % > 60 %; PEEP 10 > 8 > 5\n - Ortho requested - Shoulder films\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:25 PM\n Infusions:\n Heparin Sodium - 950 units/hour\n Fentanyl - 100 mcg/hour\n Midazolam (Versed) - 2.5 mg/hour\n Dopamine - 12 mcg/Kg/min\n Other ICU medications:\n Insulin - Humalog - 10:24 PM\n Fentanyl - 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 06:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.6\nC (101.5\n Tcurrent: 37.7\nC (99.9\n HR: 84 (82 - 104) bpm\n BP: 76/30(55) {59/24(42) - 118/59(90)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 10 (4 - 20)mmHg\n PAP: (41 mmHg) / (18 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.1 L/min) / (2.7 L/min/m2)\n SVR: 1,083 dynes*sec/cm5\n Mixed Venous O2% Sat: 65 - 72\n SV: 49 mL\n SVI: 27 mL/m2\n Total In:\n 1,796 mL\n 3,404 mL\n PO:\n TF:\n IVF:\n 1,736 mL\n 3,404 mL\n Blood products:\n Total out:\n 1,010 mL\n 470 mL\n Urine:\n 1,010 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 786 mL\n 2,934 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 24 cmH2O\n Plateau: 20 cmH2O\n Compliance: 55 cmH2O/mL\n SpO2: 96%\n ABG: 7.37/30/99./16/-6\n Ve: 12.5 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 214 K/uL\n 10.3 g/dL\n 150 mg/dL\n 2.4 mg/dL\n 16 mEq/L\n 4.1 mEq/L\n 30 mg/dL\n 104 mEq/L\n 135 mEq/L\n 29.7 %\n 10.2 K/uL\n [image002.jpg]\n 01:57 PM\n 02:10 PM\n 03:30 PM\n 03:58 PM\n 06:32 PM\n 09:28 PM\n 09:36 PM\n 12:45 AM\n 01:24 AM\n 05:28 AM\n WBC\n 12.9\n 10.2\n Hct\n 40\n 39\n 35.5\n 33.0\n 29.7\n Plt\n \n Cr\n 2.5\n 2.4\n TropT\n 15.22\n 15.28\n TCO2\n 20\n 19\n 20\n 19\n 20\n 19\n 18\n Glucose\n 173\n 150\n Other labs: PT / PTT / INR:15.8/64.6/1.4, CK / CKMB /\n Troponin-T:4078/235/15.28, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.1 mg/dL, Mg++:3.2 mg/dL, PO4:2.3\n mg/dL\n Assessment and Plan\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576896, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\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": "2176-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576897, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2176-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577044, "text": "Chief Complaint:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:01 PM\n Vancomycin - 08:21 PM\n Piperacillin - 02:22 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Heparin Sodium - 950 units/hour\n Midazolam (Versed) - 3 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 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 64 (62 - 93) bpm\n BP: 119/46(85) {74/27(51) - 144/53(99)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 11 (7 - 23)mmHg\n PAP: (43 mmHg) / (20 mmHg)\n PCWP: 18 (18 - 18) mmHg\n CO/CI (Fick): (5.8 L/min) / (3.1 L/min/m2)\n Mixed Venous O2% Sat: 66 - 76\n Total In:\n 2,216 mL\n 450 mL\n PO:\n TF:\n IVF:\n 1,652 mL\n 450 mL\n Blood products:\n 564 mL\n Total out:\n 1,655 mL\n 405 mL\n Urine:\n 1,155 mL\n 205 mL\n NG:\n 500 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 561 mL\n 45 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/30/116/17/-4\n Ve: 11.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 121 K/uL\n 9.9 g/dL\n 125 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 02:22 PM\n 03:16 AM\n 03:42 AM\n 09:30 AM\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n WBC\n 8.2\n 7.5\n 6.1\n 6.6\n Hct\n 27.4\n 26.8\n 28\n 27.2\n 30\n 29.0\n 29.1\n Plt\n 170\n 144\n 115\n 121\n Cr\n 2.1\n 1.6\n 1.4\n TCO2\n 17\n 15\n 19\n 19\n Glucose\n 150\n 139\n 122\n 125\n Other labs: PT / PTT / INR:15.8/48.8/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.3,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577046, "text": "Chief Complaint: None\n 24 Hour Events:\n - Given 1 unit pRBCs, 250cc bolus for hct 26.8, MAP 40s; repeat 1 unit\n pRBCS at 5pm given hct 27.2 (?hemodilulational as all cells down); 12am\n hct 29.0\n - Vomitted in AM; unclear if kept down ; written for 75mg\n PO x1\n - 8pm: CO>7; going down on Levophed\n - PEEP decreased to 5\n - No ortho recs\n - Sputum culture with yeast; blood cultures remain no growth to date\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:01 PM\n Vancomycin - 08:21 PM\n Piperacillin - 02:22 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Heparin Sodium - 950 units/hour\n Midazolam (Versed) - 3 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 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 64 (62 - 93) bpm\n BP: 119/46(85) {74/27(51) - 144/53(99)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 11 (7 - 23)mmHg\n PAP: (43 mmHg) / (20 mmHg)\n PCWP: 18 (18 - 18) mmHg\n CO/CI (Fick): (5.8 L/min) / (3.1 L/min/m2)\n Mixed Venous O2% Sat: 66 - 76\n Total In:\n 2,216 mL\n 450 mL\n PO:\n TF:\n IVF:\n 1,652 mL\n 450 mL\n Blood products:\n 564 mL\n Total out:\n 1,655 mL\n 405 mL\n Urine:\n 1,155 mL\n 205 mL\n NG:\n 500 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 561 mL\n 45 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/30/116/17/-4\n Ve: 11.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 121 K/uL\n 9.9 g/dL\n 125 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 02:22 PM\n 03:16 AM\n 03:42 AM\n 09:30 AM\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n WBC\n 8.2\n 7.5\n 6.1\n 6.6\n Hct\n 27.4\n 26.8\n 28\n 27.2\n 30\n 29.0\n 29.1\n Plt\n 170\n 144\n 115\n 121\n Cr\n 2.1\n 1.6\n 1.4\n TCO2\n 17\n 15\n 19\n 19\n Glucose\n 150\n 139\n 122\n 125\n Other labs: PT / PTT / INR:15.8/48.8/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.3,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-29 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577048, "text": "Chief Complaint: None\n 24 Hour Events:\n - Given 1 unit pRBCs, 250cc bolus for hct 26.8, MAP 40s; repeat 1 unit\n pRBCS at 5pm given hct 27.2 (?hemodilulational as all cells down); 12am\n hct 29.0\n - Vomitted in AM; unclear if kept down ; written for 75mg\n PO x1\n - 8pm: CO>7; going down on Levophed\n - PEEP decreased to 5\n - No ortho recs\n - Sputum culture with yeast; blood cultures remain no growth to date\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 02:01 PM\n Vancomycin - 08:21 PM\n Piperacillin - 02:22 AM\n Infusions:\n Norepinephrine - 0.04 mcg/Kg/min\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Heparin Sodium - 950 units/hour\n Midazolam (Versed) - 3 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 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.5\nC (99.5\n Tcurrent: 37\nC (98.6\n HR: 64 (62 - 93) bpm\n BP: 119/46(85) {74/27(51) - 144/53(99)} mmHg\n RR: 20 (20 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 11 (7 - 23)mmHg\n PAP: (43 mmHg) / (20 mmHg)\n PCWP: 18 (18 - 18) mmHg\n CO/CI (Fick): (5.8 L/min) / (3.1 L/min/m2)\n Mixed Venous O2% Sat: 66 - 76\n Total In:\n 2,216 mL\n 450 mL\n PO:\n TF:\n IVF:\n 1,652 mL\n 450 mL\n Blood products:\n 564 mL\n Total out:\n 1,655 mL\n 405 mL\n Urine:\n 1,155 mL\n 205 mL\n NG:\n 500 mL\n 200 mL\n Stool:\n Drains:\n Balance:\n 561 mL\n 45 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 20\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: Hemodynamic Instability\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n Compliance: 42.3 cmH2O/mL\n SpO2: 97%\n ABG: 7.40/30/116/17/-4\n Ve: 11.5 L/min\n PaO2 / FiO2: 193\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 121 K/uL\n 9.9 g/dL\n 125 mg/dL\n 1.4 mg/dL\n 17 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 137 mEq/L\n 29.1 %\n 6.6 K/uL\n [image002.jpg]\n 02:22 PM\n 03:16 AM\n 03:42 AM\n 09:30 AM\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n WBC\n 8.2\n 7.5\n 6.1\n 6.6\n Hct\n 27.4\n 26.8\n 28\n 27.2\n 30\n 29.0\n 29.1\n Plt\n 170\n 144\n 115\n 121\n Cr\n 2.1\n 1.6\n 1.4\n TCO2\n 17\n 15\n 19\n 19\n Glucose\n 150\n 139\n 122\n 125\n Other labs: PT / PTT / INR:15.8/48.8/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.3,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Latest\n CO/CI/SVR @ 0330=7/3.7/700.\n - Plan to con\nt IABP on 1:1-1:2\n - D/c Dopamine and continue levophed, but con\nt to wean, with goal MAPs\n 60\n - Repeat Fick calculations\n - continue ASA 325\n - 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: Previous AG up to 15 likely from lactate. Delta\n delta suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since \n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577330, "text": "Chief Complaint:\n 24 Hour Events:\n - . Dr. is PCP. . wants a call in a day or\n two\n - vanco increased to 1 mg daily given improvement in Renal fx\n - Lasix 20 mg IVx1 in AM. Goal I/o negative 500 cc. - 300 at .\n Positive 30 cc at 22:00. Redosed Lasix 20 mv IVx1.\n - Decreased FiO2 from 0.6 to 0.5\n - Ortho recs - No recs\n - Hemolysis labs added on given anemia and thrombocytopenia.\n Haptoglobin nl. Fibrinogen elevated at 625. Indirect bili 0.6.\n - KUB to eval for ileus given NG output - Nondilated Large and Small\n bowel. No evidence of pneumoatosis. Limited given non upright view.\n - NG output G positive. Started on IV PPI. Repeat Hct 29.9 (from 29.1)\n - TTE - Left ventricular wall thicknesses and cavity size are normal.\n Overall left ventricular systolic function is mildly depressed (LVEF=\n 45-50 %). There is mild pulmonary artery systolic hypertension. There\n is no pericardial effusion. Compared with the prior study (images\n reviewed) of , the distal LV lateral wall function has\n improved slightly. There is LV inferolateral hypokinesis. The other\n findings are similar.\n - Repeat Fick #s - CI/CO/SVR - 5.8/3.1/1012 > 5.3/2.9/632\n - ABG 7.44/27/80/19 >> Decreased RR from 20 > 16 >> 7.38 /35/65/22 at 5\n am(increased FiO2 0.5 >0.6)\n - Family updated\n - RN informed housestaff that Mesalamine can not be crushed, so order\n was d/cd. Will need to d/w Pharm re: Pr formulation.\n - Failed SBT at 0530 before Rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:32 PM\n Famotidine (Pepcid) - 07:45 PM\n Furosemide (Lasix) - 10:45 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 08:16 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: 36.3\nC (97.3\n HR: 69 (65 - 96) bpm\n BP: 136/48(93) {73/31(53) - 146/75(108)} mmHg\n RR: 16 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 14 (11 - 18)mmHg\n PAP: (35 mmHg) / (25 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 63 - 70\n Total In:\n 2,289 mL\n 615 mL\n PO:\n TF:\n IVF:\n 2,249 mL\n 615 mL\n Blood products:\n Total out:\n 2,550 mL\n 1,750 mL\n Urine:\n 2,325 mL\n 1,725 mL\n NG:\n 225 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n -261 mL\n -1,135 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.38/35/65/19/-3\n Ve: 8.6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Labs / Radiology\n 111 K/uL\n 10.8 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 111 mEq/L\n 140 mEq/L\n 31.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n WBC\n 7.5\n 6.1\n 6.6\n 7.0\n Hct\n 27.2\n 30\n 29.0\n 29.1\n 29.9\n 31.0\n Plt\n 144\n 115\n 121\n 111\n Cr\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 19\n 19\n 22\n Glucose\n 122\n 125\n 109\n 114\n Other labs: PT / PTT / INR:13.8/57.8/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577333, "text": "Chief Complaint:\n 24 Hour Events:\n - . Dr. is PCP. . wants a call in a day or\n two\n - vanco increased to 1 mg daily given improvement in Renal fx\n - Lasix 20 mg IVx1 in AM. Goal I/o negative 500 cc. - 300 at .\n Positive 30 cc at 22:00. Redosed Lasix 20 mv IVx1.\n - Decreased FiO2 from 0.6 to 0.5\n - Ortho recs - No recs\n - Hemolysis labs added on given anemia and thrombocytopenia.\n Haptoglobin nl. Fibrinogen elevated at 625. Indirect bili 0.6.\n - KUB to eval for ileus given NG output - Nondilated Large and Small\n bowel. No evidence of pneumoatosis. Limited given non upright view.\n - NG output G positive. Started on IV PPI. Repeat Hct 29.9 (from 29.1)\n - TTE - Left ventricular wall thicknesses and cavity size are normal.\n Overall left ventricular systolic function is mildly depressed (LVEF=\n 45-50 %). There is mild pulmonary artery systolic hypertension. There\n is no pericardial effusion. Compared with the prior study (images\n reviewed) of , the distal LV lateral wall function has\n improved slightly. There is LV inferolateral hypokinesis. The other\n findings are similar.\n - Repeat Fick #s - CI/CO/SVR - 5.8/3.1/1012 > 5.3/2.9/632\n - ABG 7.44/27/80/19 >> Decreased RR from 20 > 16 >> 7.38 /35/65/22 at 5\n am(increased FiO2 0.5 >0.6)\n - Family updated\n - RN informed housestaff that Mesalamine can not be crushed, so order\n was d/cd. Will need to d/w Pharm re: Pr formulation.\n - Failed SBT at 0530 before Rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:32 PM\n Famotidine (Pepcid) - 07:45 PM\n Furosemide (Lasix) - 10:45 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 08:16 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: 36.3\nC (97.3\n HR: 69 (65 - 96) bpm\n BP: 136/48(93) {73/31(53) - 146/75(108)} mmHg\n RR: 16 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 14 (11 - 18)mmHg\n PAP: (35 mmHg) / (25 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 63 - 70\n Total In:\n 2,289 mL\n 615 mL\n PO:\n TF:\n IVF:\n 2,249 mL\n 615 mL\n Blood products:\n Total out:\n 2,550 mL\n 1,750 mL\n Urine:\n 2,325 mL\n 1,725 mL\n NG:\n 225 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n -261 mL\n -1,135 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.38/35/65/19/-3\n Ve: 8.6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 111 K/uL\n 10.8 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 111 mEq/L\n 140 mEq/L\n 31.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n WBC\n 7.5\n 6.1\n 6.6\n 7.0\n Hct\n 27.2\n 30\n 29.0\n 29.1\n 29.9\n 31.0\n Plt\n 144\n 115\n 121\n 111\n Cr\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 19\n 19\n 22\n Glucose\n 122\n 125\n 109\n 114\n Other labs: PT / PTT / INR:13.8/57.8/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n Assessment and Plan\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577339, "text": "Chief Complaint:\n 24 Hour Events:\n - . Dr. is PCP. . wants a call in a day or\n two\n - vanco increased to 1 mg daily given improvement in Renal fx\n - Lasix 20 mg IVx1 in AM. Goal I/o negative 500 cc. - 300 at .\n Positive 30 cc at 22:00. Redosed Lasix 20 mv IVx1.\n - Decreased FiO2 from 0.6 to 0.5\n - Ortho recs - No recs\n - Hemolysis labs added on given anemia and thrombocytopenia.\n Haptoglobin nl. Fibrinogen elevated at 625. Indirect bili 0.6.\n - KUB to eval for ileus given NG output - Nondilated Large and Small\n bowel. No evidence of pneumoatosis. Limited given non upright view.\n - NG output G positive. Started on IV PPI. Repeat Hct 29.9 (from 29.1)\n - TTE - Left ventricular wall thicknesses and cavity size are normal.\n Overall left ventricular systolic function is mildly depressed (LVEF=\n 45-50 %). There is mild pulmonary artery systolic hypertension. There\n is no pericardial effusion. Compared with the prior study (images\n reviewed) of , the distal LV lateral wall function has\n improved slightly. There is LV inferolateral hypokinesis. The other\n findings are similar.\n - Repeat Fick #s - CI/CO/SVR - 5.8/3.1/1012 > 5.3/2.9/632\n - ABG 7.44/27/80/19 >> Decreased RR from 20 > 16 >> 7.38 /35/65/22 at 5\n am(increased FiO2 0.5 >0.6)\n - Family updated\n - RN informed housestaff that Mesalamine can not be crushed, so order\n was d/cd. Will need to d/w Pharm re: Pr formulation.\n - Failed SBT at 0530 before Rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:32 PM\n Famotidine (Pepcid) - 07:45 PM\n Furosemide (Lasix) - 10:45 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 08:16 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: 36.3\nC (97.3\n HR: 69 (65 - 96) bpm\n BP: 136/48(93) {73/31(53) - 146/75(108)} mmHg\n RR: 16 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 14 (11 - 18)mmHg\n PAP: (35 mmHg) / (25 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 63 - 70\n Total In:\n 2,289 mL\n 615 mL\n PO:\n TF:\n IVF:\n 2,249 mL\n 615 mL\n Blood products:\n Total out:\n 2,550 mL\n 1,750 mL\n Urine:\n 2,325 mL\n 1,725 mL\n NG:\n 225 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n -261 mL\n -1,135 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.38/35/65/19/-3\n Ve: 8.6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 111 K/uL\n 10.8 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 111 mEq/L\n 140 mEq/L\n 31.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n WBC\n 7.5\n 6.1\n 6.6\n 7.0\n Hct\n 27.2\n 30\n 29.0\n 29.1\n 29.9\n 31.0\n Plt\n 144\n 115\n 121\n 111\n Cr\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 19\n 19\n 22\n Glucose\n 122\n 125\n 109\n 114\n Other labs: PT / PTT / INR:13.8/57.8/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 indicating a massive amount of\n ischemia. Cardiogenic shock is most likely due to ischemia.\n Hemodynamics improved with IABP. Levophed has been weaned off and pt\n now only on dopamine. Latest CO/CI/SVR = 7/3.8/801( 5.3/2.9/632). TTE\n yesterday demonstrated mildly depressed LVEF with EF 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment.\n - Repeat Fick calculations with change in pressors\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterdayCont\n afterload reduction with diuretics.\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct trending up though plts cont to trend\n down likely hemolysis from balloon pump. Hemolysis labs\n unremarkable. TTP unlikely as this is relatively new. HIT unlikely as\n there is a another good explanation for thromobocytopenia (4T score\n meets criteria for > 50% plt fall, but plt drop in less than 5 days, no\n clots and pt has other good reason for low plts)\n - Cont IV PPI \n - Trend Hct \n - Will continue heparin gtt/plavix for now. If Hct , \n need to address utility of continuing heparin in setting of bleed vs\n taking IABP out\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - No e/o obstruction or ileus on KUB\n - PPI as above\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Although this is usually chemically mediated, abx were started\n given dramatically low BPs. Hypoxia likely due to edema, consolidation,\n and underlying COPD. FiO2 increased last night back to 60 for hypoxia.\n Hoping that cont diuresis will improve oxygenation.\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Improving non gap acidosis which was likely due\n to renal failure.\n - Improvement with dynamics should improve renal failure\n - trend ABGs daily\n .\n # ARF: Baseline Cr 1.3\n and now improved markedly to 1.6. FeUrea 25%\n suggests prerenal. Suspect poor renal perfusion and ATN.\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Discuss whether asacol can be given PR since\n can\nt be crushed. continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Physician ", "chartdate": "2176-04-30 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577340, "text": "Chief Complaint:\n 24 Hour Events:\n - . Dr. is PCP. . wants a call in a day or\n two\n - vanco increased to 1 mg daily given improvement in Renal fx\n - Lasix 20 mg IVx1 in AM. Goal I/o negative 500 cc. - 300 at .\n Positive 30 cc at 22:00. Redosed Lasix 20 mv IVx1.\n - Decreased FiO2 from 0.6 to 0.5\n - Ortho recs - No recs\n - Hemolysis labs added on given anemia and thrombocytopenia.\n Haptoglobin nl. Fibrinogen elevated at 625. Indirect bili 0.6.\n - KUB to eval for ileus given NG output - Nondilated Large and Small\n bowel. No evidence of pneumoatosis. Limited given non upright view.\n - NG output G positive. Started on IV PPI. Repeat Hct 29.9 (from 29.1)\n - TTE - Left ventricular wall thicknesses and cavity size are normal.\n Overall left ventricular systolic function is mildly depressed (LVEF=\n 45-50 %). There is mild pulmonary artery systolic hypertension. There\n is no pericardial effusion. Compared with the prior study (images\n reviewed) of , the distal LV lateral wall function has\n improved slightly. There is LV inferolateral hypokinesis. The other\n findings are similar.\n - Repeat Fick #s - CI/CO/SVR - 5.8/3.1/1012 > 5.3/2.9/632\n - ABG 7.44/27/80/19 >> Decreased RR from 20 > 16 >> 7.38 /35/65/22 at 5\n am(increased FiO2 0.5 >0.6)\n - Family updated\n - RN informed housestaff that Mesalamine can not be crushed, so order\n was d/cd. Will need to d/w Pharm re: Pr formulation.\n - Failed SBT at 0530 before Rounds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Infusions:\n Midazolam (Versed) - 1.5 mg/hour\n Fentanyl - 50 mcg/hour\n Heparin Sodium - 1,100 units/hour\n Dopamine - 4.5 mcg/Kg/min\n Other ICU medications:\n Pantoprazole (Protonix) - 12:32 PM\n Famotidine (Pepcid) - 07:45 PM\n Furosemide (Lasix) - 10:45 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 08:16 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: 36.3\nC (97.3\n HR: 69 (65 - 96) bpm\n BP: 136/48(93) {73/31(53) - 146/75(108)} mmHg\n RR: 16 (16 - 27) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 14 (11 - 18)mmHg\n PAP: (35 mmHg) / (25 mmHg)\n CO/CI (Fick): (7 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 63 - 70\n Total In:\n 2,289 mL\n 615 mL\n PO:\n TF:\n IVF:\n 2,249 mL\n 615 mL\n Blood products:\n Total out:\n 2,550 mL\n 1,750 mL\n Urine:\n 2,325 mL\n 1,725 mL\n NG:\n 225 mL\n 25 mL\n Stool:\n Drains:\n Balance:\n -261 mL\n -1,135 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 60%\n RSBI Deferred: No Spon Resp\n PIP: 20 cmH2O\n Plateau: 18 cmH2O\n SpO2: 99%\n ABG: 7.38/35/65/19/-3\n Ve: 8.6 L/min\n PaO2 / FiO2: 108\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 111 K/uL\n 10.8 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 19 mEq/L\n 3.8 mEq/L\n 16 mg/dL\n 111 mEq/L\n 140 mEq/L\n 31.0 %\n 7.0 K/uL\n [image002.jpg]\n 03:43 PM\n 04:22 PM\n 04:25 PM\n 12:22 AM\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n WBC\n 7.5\n 6.1\n 6.6\n 7.0\n Hct\n 27.2\n 30\n 29.0\n 29.1\n 29.9\n 31.0\n Plt\n 144\n 115\n 121\n 111\n Cr\n 1.4\n 1.4\n 1.6\n TCO2\n 19\n 19\n 19\n 22\n Glucose\n 122\n 125\n 109\n 114\n Other labs: PT / PTT / INR:13.8/57.8/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.5 mg/dL, Mg++:2.2 mg/dL, PO4:2.4 mg/dL\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 indicating a massive amount of\n ischemia. Cardiogenic shock is most likely due to ischemia.\n Hemodynamics improved with IABP. Levophed has been weaned off and pt\n now only on dopamine. Latest CO/CI/SVR = 7/3.8/801( 5.3/2.9/632). TTE\n yesterday demonstrated mildly depressed LVEF with EF 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment.\n - Repeat Fick calculations with change in pressors\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterdayCont\n afterload reduction with diuretics.\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct trending up though plts cont to trend\n down likely hemolysis from balloon pump. Hemolysis labs\n unremarkable. TTP unlikely as this is relatively new. HIT unlikely as\n there is a another good explanation for thromobocytopenia (4T score\n meets criteria for > 50% plt fall, but plt drop in less than 5 days, no\n clots and pt has other good reason for low plts)\n - Cont IV PPI \n - Trend Hct \n - Will continue heparin gtt/plavix for now. If Hct , \n need to address utility of continuing heparin in setting of bleed vs\n taking IABP out\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - No e/o obstruction or ileus on KUB\n - PPI as above\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Although this is usually chemically mediated, abx were started\n given dramatically low BPs. Hypoxia likely due to edema, consolidation,\n and underlying COPD. FiO2 increased last night back to 60 for hypoxia.\n Hoping that cont diuresis will improve oxygenation.\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Baseline Cr 1.3\n and now improved markedly to 1.6. FeUrea 25%\n suggests prerenal. Suspect poor renal perfusion and ATN.\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Discuss whether asacol can be given PR since\n can\nt be crushed. continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Respiratory ", "chartdate": "2176-04-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577451, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: Diagnostic lab\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 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 / 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: AC 550 x 16x peep 5 x 40%\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Hemodynamic\n instability, Underlying illness not resolved. Able to wean FiO2 this\n shift from 60-40%.\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578067, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI in perioperative period\n (s/p shoulder surgery), with cardiogenic shock s/p IABP, and observed\n aspiration for which patient was intubated/sedated. Patient had been\n receiving tube feeds however never reached goal high residuals\n (90-150cc) for which the tube feed was turned off/on. Patient was\n started on Reglan to help with high residuals. Patient was extubated\n today and OGT was removed. Per discussion with RN, team plans to see\n how patient improves post extubation before deciding to place new tube\n and restart feeds. If patient is unable to advance and tolerate diet\n within a couple of days, consider placing NGT and restarting tube feeds\n to previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If s&s of aspiration are\n present with pos, consider speech and swallow consult.\n 2. If unable to advance diet or if patient is unable to tolerate\n pos, consider placing NGT and restarting nutrition support. Tube feed\n goal: Nutren Pulmonary @ 55ml/hr providing kcal and 90g protein\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578068, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI in perioperative period\n (s/p shoulder surgery), with cardiogenic shock s/p IABP, and observed\n aspiration for which patient was intubated/sedated. Patient had been\n receiving tube feeds however never reached goal high residuals\n (90-150cc) for which the tube feed was turned off/on. Patient was\n started on Reglan to help with high residuals. Patient was extubated\n today and OGT was removed. Per discussion with RN, team plans to see\n how patient improves post extubation before deciding to place new tube\n and restart feeds. If patient is unable to advance and tolerate diet\n within a couple of days, consider placing NGT and restarting tube feeds\n to previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If s&s of aspiration are\n present with pos, consider speech and swallow consult.\n 2. If unable to advance diet or if patient is unable to tolerate\n pos, consider placing NGT and restarting nutrition support. Tube feed\n goal: Nutren Pulmonary @ 55ml/hr providing kcal and 90g protein\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n ------ Protected Section ------\n Agree with above note. Please page with any questions. #\n ------ Protected Section Addendum Entered By: , RD, \n on: 15:47 ------\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577461, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n BP continues to be very labile, MAPS range from 40\ns to 100\ns. HR\n trending lower over shift now in 50\n Action:\n Dopa titrated to maintain MAPS>55 heparin remains at 1100 units with\n therapeutic PTT\n Response:\n Dopa ranged from 2-5.5mcg/kg/min now at 3. last set of numbers\n CO/CI/SVR 6/3.2/725 on 3 of dopa.IABP 1:1 with systolic/ diastolic\n unloading and good augmentation.\n Plan:\n Wean dopa maintaining MAPS>55. cont to follow hemodynamics, urine\n output and pulses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577464, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n BP continues to be very labile, MAPS range from 40\ns to 100\ns. HR\n trending lower over shift now in 50\n Action:\n Dopa titrated to maintain MAPS>55 heparin remains at 1100 units with\n therapeutic PTT\n Response:\n Dopa ranged from 2-5.5mcg/kg/min now at 3. last set of numbers\n CO/CI/SVR 6/3.2/725 on 3 of dopa.IABP 1:1 with systolic/ diastolic\n unloading and good augmentation.\n Plan:\n Wean dopa maintaining MAPS>55. cont to follow hemodynamics, urine\n output and pulses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 60% FIO2 this am. First ABG PaO2 165, suctioning thick tan\n secretions q2-3. lungs clear diminished at bases\n Action:\n Turned q2, frequent oral care,suctioned prn. Abx changed to po\n levoquin. Weaned FIO2 to 50%\n Response:\n Great ABG on 50% 7.41/34/98 ,turned down to 40%\n Plan:\n Check ABG on 40%, cont with frequent turning, suctioning as needed,wean\n vent as tolerated\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2176-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577613, "text": "Chief Complaint:\n 24 Hour Events:\n - Goal fluid status -500 mL\n - Thrombocytopenia: will stop Vanc/Zosyn (Vanc could be contributing)\n and stop famotidine/pantoprazole. Most likely thrombocytopenia related\n to IABP.Did send off HIT Ab today.\n - ? Aspiration PNA: started Levaquin to replace Vanc/Zosyn\n -Holding Asacol per pharmacy (cannot crush PO and PR is only\n local).Emailed primary gastroenterologist re: PR Asacol.\n - Starting TF slowly\n - Afternoon gas showed improved O2 to 165 so FiO2 to 50%-->repeat\n ABG O2 98 so FiO2 weaned to 40%\n - I/Os at 1730 showed -740 fluid balance p midnight but +190 since 8AM,\n with hourly UOP as low as 15cc/hr. Will re-check at 11PM and consider\n bolus/lasix.\n - Per GI ( ), OK to hold Asacol if no signs of UC. If\n develops signs of , use low-dose prednisone.\n -O/N pressures remained labile. Small adjustements to dopamine\n corrects.\n -HR trending down, now in 50's--?autonomic dysregulation\n -2330 ABG: 7.41/36/74 on 40% FiO2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:39 AM\n Midazolam (Versed) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 74 (55 - 77) bpm\n BP: 92/42(68) {68/26(47) - 178/64(125)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 11 (9 - 15)mmHg\n PAP: (33 mmHg) / (20 mmHg)\n CO/CI (Fick): (7.3 L/min) / (3.9 L/min/m2)\n Mixed Venous O2% Sat: 66 - 71\n Total In:\n 1,677 mL\n 603 mL\n PO:\n TF:\n 232 mL\n 262 mL\n IVF:\n 1,415 mL\n 341 mL\n Blood products:\n Total out:\n 2,460 mL\n 540 mL\n Urine:\n 2,435 mL\n 540 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -783 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 93%\n ABG: 7.41/36/74/19/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 148\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT/ND, BS+\n Ext: 1+ edema to 6cm above ankle, dopplerable pulses bilaterally\n Labs / Radiology\n 111 K/uL\n 9.5 g/dL\n 118 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 139 mEq/L\n 27.8 %\n 6.4 K/uL\n [image002.jpg]\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n WBC\n 6.6\n 7.0\n 6.4\n Hct\n 29.1\n 29.9\n 31.0\n 31\n 27.8\n Plt\n 121\n 111\n 111\n Cr\n 1.4\n 1.4\n 1.6\n 1.3\n TCO2\n 19\n 19\n 22\n 22\n 22\n 24\n Glucose\n 125\n 109\n 114\n 118\n Other labs: PT / PTT / INR:13.8/61.9/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic Shock/STEMI. Latest Co/CI/SVR=7.3/3.9/722. Remains very\n labile O/N but less highs/lows than yesterday. Could be autonomic\n instability. Levophed has been weaned off yeaterday and he remains on\n dopamine. Latest CO/CI/SVR = TTE yesterday demonstrated mildly\n depressed LVEF with EF 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment,\n attempt to wean dopamine off today\n - Maintain MAP 60\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterday. Pt\n was negative 783 in last 24 hours. Lasix was held last night due to\n hypotension. Cont afterload reduction with diuresis.\n - Goal I/O\n 1000 -500 cc with aggressive diuresis\n - afterload reduce with IABP\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct dropped. Plts stable and likely \n hemolysis from balloon pump. Hemolysis labs unremarkable. HIT is\n certainly possible and 4T score is intermediate, although unlikely\n given likely explanation is balloon pump. Plts now stable\n - f/u Heparin dependent Ab, but will cont heparin given alternate more\n probable explanation\n - Stop meds that could be contributing: PPI, Vanc\n - Will continue heparin gtt/plavix for now\n - recheck Hct, hold on transfusion for now\n .\n # Vomiting: No episodes, restarted TF and tolerating. be due to\n UGIB or more likely ileus secondary to sedating meds.\n - No e/o obstruction or ileus on KUB\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n FiO2 changed to 50% FiO2 overnight. Hoping that cont diuresis will\n improve oxygenation.\n - Wean FiO2 as tolerated levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue levoflox for aspiration.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Cr 1.6.-baseline around 1.3 Suspect poor renal perfusion and\n ATN.\n - cont to monitor\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Can give pr asacol per primary GI. Can\nt crush\n po asocol\n .\n # depression: cont celexa\n .\n # hx of GERD: holding PPI and H2 blocker for now\n .\n FEN: NPO. cont TFs\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n" }, { "category": "Physician ", "chartdate": "2176-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577619, "text": "Chief Complaint:\n 24 Hour Events:\n - Goal fluid status -500 mL\n - Thrombocytopenia: will stop Vanc/Zosyn (Vanc could be contributing)\n and stop famotidine/pantoprazole. Most likely thrombocytopenia related\n to IABP.Did send off HIT Ab today.\n - ? Aspiration PNA: started Levaquin to replace Vanc/Zosyn\n -Holding Asacol per pharmacy (cannot crush PO and PR is only\n local).Emailed primary gastroenterologist re: PR Asacol.\n - Starting TF slowly\n - Afternoon gas showed improved O2 to 165 so FiO2 to 50%-->repeat\n ABG O2 98 so FiO2 weaned to 40%\n - I/Os at 1730 showed -740 fluid balance p midnight but +190 since 8AM,\n with hourly UOP as low as 15cc/hr. Will re-check at 11PM and consider\n bolus/lasix.\n - Per GI ( ), OK to hold Asacol if no signs of UC. If\n develops signs of , use low-dose prednisone.\n -O/N pressures remained labile. Small adjustements to dopamine\n corrects.\n -HR trending down, now in 50's--?autonomic dysregulation\n -2330 ABG: 7.41/36/74 on 40% FiO2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:39 AM\n Midazolam (Versed) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 74 (55 - 77) bpm\n BP: 92/42(68) {68/26(47) - 178/64(125)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 11 (9 - 15)mmHg\n PAP: (33 mmHg) / (20 mmHg)\n CO/CI (Fick): (7.3 L/min) / (3.9 L/min/m2)\n Mixed Venous O2% Sat: 66 - 71\n Total In:\n 1,677 mL\n 603 mL\n PO:\n TF:\n 232 mL\n 262 mL\n IVF:\n 1,415 mL\n 341 mL\n Blood products:\n Total out:\n 2,460 mL\n 540 mL\n Urine:\n 2,435 mL\n 540 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -783 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 93%\n ABG: 7.41/36/74/19/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 148\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT/ND, BS+\n Ext: 1+ edema to 6cm above ankle, dopplerable pulses bilaterally\n Labs / Radiology\n 111 K/uL\n 9.5 g/dL\n 118 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 139 mEq/L\n 27.8 %\n 6.4 K/uL\n [image002.jpg]\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n WBC\n 6.6\n 7.0\n 6.4\n Hct\n 29.1\n 29.9\n 31.0\n 31\n 27.8\n Plt\n 121\n 111\n 111\n Cr\n 1.4\n 1.4\n 1.6\n 1.3\n TCO2\n 19\n 19\n 22\n 22\n 22\n 24\n Glucose\n 125\n 109\n 114\n 118\n Other labs: PT / PTT / INR:13.8/61.9/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic Shock/STEMI. Latest Co/CI/SVR=7.3/3.9/722. Remains very\n labile O/N but less highs/lows than yesterday. Could be autonomic\n instability. Levophed has been weaned off yeaterday and he remains on\n dopamine. Latest CO/CI/SVR = TTE yesterday demonstrated mildly\n depressed LVEF with EF 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment,\n attempt to wean dopamine off today\n - Maintain MAP 60\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterday. Pt\n was negative 783 in last 24 hours. Lasix was held last night due to\n hypotension. Cont afterload reduction with diuresis.\n - Goal I/O\n 1000 -500 cc with aggressive diuresis\n - afterload reduce with IABP\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct dropped. Plts stable and likely \n hemolysis from balloon pump. Hemolysis labs unremarkable. HIT is\n certainly possible and 4T score is intermediate, although unlikely\n given likely explanation is balloon pump. Plts now stable\n - f/u Heparin dependent Ab, but will cont heparin given alternate more\n probable explanation\n - Stop meds that could be contributing: PPI, Vanc\n - Will continue heparin gtt/plavix for now\n - recheck Hct, hold on transfusion for now\n .\n # Vomiting: No episodes, restarted TF and tolerating. be due to\n UGIB or more likely ileus secondary to sedating meds.\n - No e/o obstruction or ileus on KUB\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n FiO2 changed to 50% FiO2 overnight. Hoping that cont diuresis will\n improve oxygenation.\n - Wean FiO2 as tolerated levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue levoflox for aspiration.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Cr 1.6.-baseline around 1.3 Suspect poor renal perfusion and\n ATN.\n - cont to monitor\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Can give pr asacol per primary GI. Can\nt crush\n po asocol\n .\n # depression: cont celexa\n .\n # hx of GERD: holding PPI and H2 blocker for now\n .\n FEN: NPO. cont TFs\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n intubated, hypotensive, iabp, hypoxic,\n ------ Protected Section Addendum Entered By: ,MD\n on: 10:56 ------\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578055, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: fentanyl, propofol currently @ 6.9ml/hr,\n simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI for which patient was\n intubated and sedated. Patient had been receiving tube feeds of Nutren\n Pulmonary with goal @ 55ml/hr providing kcal and 90g protein which\n are now off as patient was extubated today and OGT was removed. While\n on tube feeds, patient had been having some high residuals for which\n the tube feed was turned off/on. Per discussion with RN, team plans to\n see how patient improves post extubation before placing new tube and\n restarting feeds. If patient is unable to advance and tolerate diet\n within a couple of days, consider placing NGT and restarting tube feeds\n to previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If unable to advance, consider\n restarting nutrition support.\n 2. ? speech and swallow evaluation post extubation\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578057, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: fentanyl, propofol currently @ 6.9ml/hr,\n simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI in perioperative period\n (s/p shoulder surgery), with cardiogenic shock s/p IABP, and observed\n aspiration for which patient was intubated/sedated. Patient had been\n receiving tube feeds of Nutren Pulmonary with goal @ 55ml/hr providing\n kcal and 90g protein which are now turned off as patient was\n extubated today and OGT was removed. While on tube feeds, patient had\n been having some high residuals (90-150cc) for which the tube feed was\n turned off/on. Per discussion with RN, team plans to see how patient\n improves post extubation before deciding to place new tube and restart\n feeds. If patient is unable to advance and tolerate diet within a\n couple of days, consider placing NGT and restarting tube feeds to\n previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If unable to advance, consider\n restarting nutrition support.\n 2. ? speech and swallow evaluation post extubation\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578058, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: fentanyl, propofol currently @ 6.9ml/hr,\n simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI in perioperative period\n (s/p shoulder surgery), with cardiogenic shock s/p IABP, and observed\n aspiration for which patient was intubated/sedated. Patient had been\n receiving tube feeds of Nutren Pulmonary with goal @ 55ml/hr providing\n kcal and 90g protein which are now turned off as patient was\n extubated today and OGT was removed. While on tube feeds, patient had\n been having some high residuals (90-150cc) for which the tube feed was\n turned off/on. Per discussion with RN, team plans to see how patient\n improves post extubation before deciding to place new tube and restart\n feeds. If patient is unable to advance and tolerate diet within a\n couple of days, consider placing NGT and restarting tube feeds to\n previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If s&s of aspiration are\n present with pos, consider speech and swallow consult.\n 2. If unable to advance diet or if patient is unable to tolerate\n pos, consider placing NGT and restarting nutrition support.\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n" }, { "category": "Nursing", "chartdate": "2176-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576530, "text": "Pt transferred to CCU without incident on appropriate critical care\n monitoring. Pt had labile bp during 4 hour shift. Md aware, swan\n now measured at 53. was originally documented at 60. Md aware,\n cxr done to confirm swan placement, due to unable to wedge. Dopamine\n tritrated for sbp>90. see flowsheet. See flowsheet for abg\ns and vent\n changes, Goal of vent to wean fio2 to 60% slowly. Balloon currently at\n 1:1 assisted. See flowsheet for numbers. Pt has a dsd to left shoulder.\n Ortho in to see patient, dressing taken down by ortho resident c/d/i.\n Aware of unable to have completely in sling due to et tube placement,\n and ok to have arm elevated on pillow and ortho will follow. Md \n aware of labile bp and need for dopamine increasing. No new orders at\n this time. Monitor urine output, and cvp\ns. Swan still unable to wedge.\n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576706, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n TRAPONIN 15.2/PK CK 5977.BP LABILE C MINOR TITRATION OF DOPAMINE AND\n LEVOPHED ESPECIALLY WHEN TEMP INCREASED TO 101 .MAP AS LOW AS 49 WHEN\n DOPAMINE OFF,BUT MAPS 90 WHEN ON ONLY 3 MIC PER KG . CI 3.8 SVR 740\n 0N 3 MIC DOPAMINE ,.24 MIC LEVOPHED ,IABP 1 TO 1 . MAINTAINS UO 30 TO\n 40 CC.POS 4,600 CC .HCT 27 .3 .PT X1 ,NG HOOKED TO SX FOR CL\n GREEN.ASPIRIN GIVEN PER RECTUM, PLAVIX GIVEN LATER AT 3PM.TOL OG BEING\n CLAMPED THIS PM.\n Action:\n TITRATE PRESSERS FOR OPTIMUM HEMODYNAMICS .\n Response:\n SLOW WEAN OF LEVOPHED C MAPS ABOVE 60\n Plan:\n WEAN PRESSERS AS TOL ,FOLLOW HCT ,HEMODYNAMICS ,MONITOR FOR BLEEDING\n Pain control (acute pain, chronic pain)\n Assessment:\n SP L ROTATOR SX .DSD D/I,NO BLEEDING NOTED .ON FENTANYL DRIP\n Action:\n FENTANYL 100 MIC/KG CONT C 25 MIC BOLLUSES PRN FOR PAIN\n Response:\n APPEARS COMFORTABLE\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 7.38/27/93/95 ON 65%/CMV 550/HR 24/8 PEEP ,HX COPD\n Action:\n WEAN FIO2,SX PRN , MDI\n Response:\n SAT 94 TO 97\n Plan:\n PULMONARY TOILET ,WEAN AS,TOL SX PRN\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577524, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs ranging from mid 40s-90s on Dopamine gtt and IABP w/o\n any change in gtt rate or stimulation. Lower BPs with any stimulation.\n Very sensitive to few drops/changes in dopa wean. Gd perfusion\n distally. Heparin gtt therapeutic\n Action:\n Dopa titrated for MAPs > 55.\n Response:\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Remains pressor dependent. Unable to wean Dopa below 3.5 mcg/k/min. AM\n PTT pnd. PLT 111 (121). CO/CI/SVR (6/3.2/725) on 5.5 mcg/k/min.\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 89% on 40% FI02\n Action:\n MDI , FI02 increased to 50%.\n Response:\n Sats slowly up to 92-96% on 50% Fi02\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. Occas poor waveform, positional. TEAM\n AWARE)\n Continue VAP bundle per protocol.\n Altered mental status (not Delirium)\n Assessment:\n On 75mcg/hr fent, 2 mg/hr versed. Not following commands or\n overbreathing vent. Spontaneous mvmts to all extremities. Agitated,\n moving in bed w/ stimulation (repositioning, mouth care) w/ subsequent\n hypotension\n Action:\n Mental status monitored, daily wake up.\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Sedation restarted at previous dose, rarely\n overbreathing vent\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577526, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs ranging from mid 40s-90s on Dopamine gtt and IABP w/o\n any change in gtt rate or stimulation. HR ^ 60-70s w/ lower BPs with\n any stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally. Heparin gtt therapeutic x2\n Action:\n Dopa titrated for MAPs > 55.\n Response:\n Remains pressor dependent. Unable to wean Dopa below 3.5 mcg/k/min\n (range 3-5mcg overnight). CO/CI/SVR (6/3.2/725) on 5.5 mcg/k/min.\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics, uop, distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desat to 89% on 40% FI02\n Action:\n Pt sxn\nd for sm amts thick tan secretions, MDI , FI02 increased\n to 50%.\n Response:\n Sats slowly up to 92-95% on 50% Fi02. PO2 74 on 50%--team aware\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. Occas poor waveform, positional. TEAM\n AWARE)\n Continue VAP bundle per protocol.\n Altered mental status (not Delirium)\n Assessment:\n On 75mcg/hr fent, 2 mg/hr versed. Not following commands or\n overbreathing vent. Spontaneous mvmts to all extremities. Agitated,\n moving in bed w/ stimulation (repositioning, mouth care) w/ subsequent\n hypotension\n Action:\n Mental status monitored, daily wake up.\n Response:\n Sedation weaned and off x30 min. Pt easily agitated, thrashing in bed,\n not following commands. Sedation restarted at previous dose,\n rarely overbreathing vent\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n Heme: PLT now 111 down from 230. famotidine,protonix, vanco and zosyn\n d/ced as they can cause a thrombocytopenia. Blood sent for HIT.\n Plan: cont to monitor plt ct and assess for signs of bleeding.\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577527, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs ranging from mid 40s-90s on Dopamine gtt and IABP w/o\n any change in gtt. HR ^ 60-70s w/ lower BPs with any stimulation. Very\n sensitive to few drops/changes in dopa. Gd perfusion distally. Heparin\n gtt therapeutic x2\n Action:\n Dopa titrated for MAPs > 55.\n Response:\n Remains pressor dependent. Unable to wean Dopa below 3.5 mcg/k/min\n (range 3-5mcg overnight). CO/CI/SVR (6/3.2/725) on 5.5 mcg/k/min.\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics, uop, distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desat to 89% on 40% FI02\n Action:\n Pt sxn\nd for sm amts thick tan secretions, MDI , FI02 increased\n to 50%.\n Response:\n Sats slowly up to 92-95% on 50% Fi02. PO2 74 on 50%--team aware\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. Occas poor waveform, positional. TEAM\n AWARE)\n Continue VAP bundle per protocol.\n Altered mental status (not Delirium)\n Assessment:\n On 75mcg/hr fent, 2 mg/hr versed. Not following commands or\n overbreathing vent. Spontaneous mvmts to all extremities. Agitated,\n moving in bed w/ stimulation (repositioning, mouth care) w/ subsequent\n hypotension\n Action:\n Mental status monitored, daily wake up.\n Response:\n Sedation weaned and off x30 min. Pt easily agitated, thrashing in bed,\n not following commands. Sedation restarted at previous dose,\n rarely overbreathing vent\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n Heme: PLT now 111 down from 230. famotidine,protonix, vanco and zosyn\n d/ced as they can cause a thrombocytopenia. Blood sent for HIT.\n Plan: cont to monitor plt ct and assess for signs of bleeding.\n" }, { "category": "Physician ", "chartdate": "2176-04-26 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 576512, "text": "Chief Complaint: STEMI\n HPI:\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, hyperlipidemia who presents from OSH with STEMI on\n POD#1 s/p left shoulder surgery. He tolerated surgery well then was\n noted to be tachypneic and hypercarbic last night while on dilaudid\n PCA. ABG 7.15/61/57 so went to ICU for Bipap. Apparently improved\n then started vomitting at 5am. EKG at 8am showed NSR, NA, Q in III and\n aVF, STE II and aVF, <1mm STE V5-V6. TropI elevated to 90. He was\n sent here for cath.\n .\n In the cath lab, LIMA-LAD patent, OM and diag grafts closed, and SVG-OM\n was diffusely diseased w tight distal lesion. Thrombectomy performed\n on SVG-OM and dilatation with balloon improved lumen and flow. The\n distal SVG-OM anastomosis was stented with Vision x3 stents with\n initially normal flow. Flow then noted to be decreased followed by\n drop in systemic BP and increased STE inferiorly requiring increasing\n dopamine. IABP placed for elevated LVEDP to 25 and hypotension. Lasix\n 40iv given. Patient also with vomiting so anesthesia called for urgent\n intubation for airway protection. Difficult to oxygenate thereafter\n with O2 sat 88% which improved with increasing PEEP and suction.\n .\n Upon transfer to ICU, patient stable on dopamine 15, IABP at 1:1, and\n intubated with AC 500/18 FiO2 100% and Peep 10. Sedate so no ROS.\n Patient admitted from: Transfer from other hospital\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:30 PM\n Infusions:\n Dopamine - 15 mcg/Kg/min\n Propofol - 40 mcg/Kg/min\n Heparin Sodium - 800 units/hour\n Other ICU medications:\n Insulin - Humalog - 05:26 PM\n Fentanyl - 05:39 PM\n Other medications:\n :\n asacol 1600 \n atenolol 25 daily\n celexa 20 daily\n Lisinopril 20 \n Simvastatin 80\n ASA 325 - had been on hold x10d according to OSH notes\n pantoprazole 40\n vitamin C and E\n Past medical history:\n Family history:\n Social History:\n PAST MEDICAL HISTORY:\n 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension\n 2. CARDIAC HISTORY:\n -CABG: LIMA to LAD, SVG to PDA, OM and Diagonal\n 3. OTHER PAST MEDICAL HISTORY:\n s/p L and R CEA\n chronic impingement left shoulder w arthritis s/p acromioplasty \n GERD\n hyperlipidemia\n ulcerative colitis\n colonic polyps\n lef\n DJD of back\n spinal stenosis\n anxiety/depression\n arthritis hip\n carpal tunnel sx\n Mom s/p appy\n Father s/p AMI\n sister w DM\n brother w \n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: prior tobb quit 15 yrs ago - approx 120 pack years\n social etoh\n lives w wife\n Review of systems:\n Flowsheet Data as of 07:18 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 37.9\nC (100.2\n Tcurrent: 37.9\nC (100.2\n HR: 95 (82 - 97) bpm\n BP: 113/51(84) {74/34(53) - 113/51(84)} mmHg\n RR: 24 (14 - 24) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 13 (8 - 20)mmHg\n PAP: (40 mmHg) / (21 mmHg)\n CO/CI (Thermodilution): (4.8 L/min) / (2.6 L/min/m2)\n CO/CI (Fick): (5.4 L/min) / (2.9 L/min/m2)\n SVR: -2,400 dynes*sec/cm5\n Mixed Venous O2% Sat: 68 - 68\n SV: 51 mL\n SVI: 27 mL/m2\n Total In:\n 511 mL\n PO:\n TF:\n IVF:\n 511 mL\n Blood products:\n Total out:\n 0 mL\n 705 mL\n Urine:\n 705 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -194 mL\n Respiratory\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST\n Vt (Set): 550 (500 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 2\n PEEP: 10 cmH2O\n FiO2: 100%\n PIP: 29 cmH2O\n Plateau: 25 cmH2O\n Compliance: 40.7 cmH2O/mL\n SpO2: 93%\n ABG: 7.36/32/163/17/-6\n Ve: 13.2 L/min\n PaO2 / FiO2: 163\n Physical Examination\n General Appearance: intubated, sedate\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Endotracheal tube, OG tube\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t) S3,\n No(t) S4, (Murmur: No(t) Systolic)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Diminished), (Left DP pulse: Diminished),\n dopplerable right PT pulse\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Crackles :\n )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: Right: Trace, Left: Trace, cool lower extremitites\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Sedated,\n Tone: Not assessed\n Labs / Radiology\n 234 K/uL\n 11.9 g/dL\n 173 mg/dL\n 2.5 mg/dL\n 31 mg/dL\n 17 mEq/L\n 104 mEq/L\n 5.5 mEq/L\n 135 mEq/L\n 35.5 %\n 12.9 K/uL\n [image002.jpg]\n \n 2:33 A5/29/ 01:57 PM\n \n 10:20 P5/29/ 02:10 PM\n \n 1:20 P5/29/ 03:30 PM\n \n 11:50 P5/29/ 03:58 PM\n \n 1:20 A5/29/ 06:32 PM\n \n 7:20 P\n 1//11/006\n 1:23 P\n \n 1:20 P\n \n 11:20 P\n \n 4:20 P\n WBC\n 12.9\n Hct\n 40\n 39\n 35.5\n Plt\n 234\n Cr\n 2.5\n TropT\n 15.22\n TC02\n 20\n 19\n 20\n 19\n Glucose\n 173\n Other labs: PT / PTT / INR:14.2/30.3/1.2, CK / CKMB /\n Troponin-T:5977//15.22, ALT / AST:50/442, Alk Phos / T Bili:64/1.0,\n Differential-Neuts:86.3 %, Lymph:9.0 %, Mono:3.9 %, Eos:0.3 %, Lactic\n Acid:2.1 mmol/L, LDH:1102 IU/L, Ca++:8.2 mg/dL, Mg++:1.6 mg/dL, PO4:4.1\n mg/dL\n Fluid analysis / Other labs: EKG at 8am: NSR rate 100 NA Q III and\n aVF, STE III and aVF and <1mm V5-V6\n EKG at 11am: NSR NA QIII, STE II, III, aVF, STD V1-V3\n .\n 2D-ECHOCARDIOGRAM: \n The left atrium is normal in size. Left ventricular wall thickness,\n cavity size, and systolic function are normal (LVEF>55%). Right\n ventricular chamber size and free wall motion are normal. The aortic\n root is mildly dilated. The aortic valve leaflets are mildly thickened.\n The mitral valve leaflets are structurally normal. The pulmonary artery\n systolic pressure could not be determined. Significant pulmonic\n regurgitation is seen. There is no pericardial effusion.\n .\n ECHO post intervention (Prelim):\n The left atrium is normal in size. No atrial septal defect is seen by\n 2D or color Doppler. There is mild symmetric left ventricular\n hypertrophy. The left ventricular cavity size is normal. No masses or\n thrombi are seen in the left ventricle. Overall left ventricular\n systolic function is mildly depressed (LVEF= 40-45 %) with lateral\n hypokinesis. with depressed free wall contractility. The aortic valve\n leaflets (3) are mildly thickened but aortic stenosis is not present.\n No aortic regurgitation is seen. The mitral valve leaflets are mildly\n thickened. Trivial mitral regurgitation is seen. The tricuspid valve\n leaflets are mildly thickened. There is mild pulmonary artery systolic\n hypertension. There is no pericardial effusion.\n .\n ETT :\n 1) Moderate, partially reversible perfusion defect in the inferior\n wall. 2) Left ventricular ejection fraction of 65% with mild\n hypokinesis in the inferior wall.\n INTERPRETATION: This 68 year old male was referred for a CAD\n evaluation. He exercised for 10.5 minutes using the protocol and\n stopped due to fatigue (good physical working capacity). No arm, neck,\n chest or back discomforts were reported by the patient. There were no\n significant ST segment changes noted during exercise or recovery. The\n rhythm was sinus with rare APBs and 1 VPB. The hemodynamic response to\n exercise was appropriate.\n IMPRESSION: No anginal-type symptoms or ischemic ECG changes at\n achieved workload. Nuclear report sent separately\n .\n CARDIAC CATH: today:\n Cath:\n LMCA diffuse mild disease\n LCx ostial occlusion, OM fills via SVG\n LAD occluded after S1 and D1, distal vessel fill s via with no sig\n dz\n RCA prox occlusion, collaterals to distal vessel from grafted OM\n SVG-OM long subtotal occlusion from mid graft to distal anastomosis\n with severe ulcerated/thrombotic dz\n LIMA-LAD nl\n SVG-D2 chronic ostial occlusion\n SVG-RCA chronic ostial occlusion\n .\n LABORATORY DATA:\n 135 104 31\n -------------< 173\n 5.5 17 2.5\n CK: 5977 MB: >500 Trop-T: 15.22\n Ca: 8.2 Mg: 1.6 P: 4.1\n ALT: 50 AP: 64 Tbili: 1.0 Alb:\n AST: 442 LDH: 1102\n .\n WBC: 12.9\n HCT: 35\n PLT: 234\n N:86.3 L:9.0 M:3.9 E:0.3 Bas:0.5\n .\n CXR: pulm edema, Swan into right Pulm artery, NGT ok, ETT 2.3cm above\n carina. No definite infiltrate.\n Assessment and Plan\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, hyperlipidemia here with STEMI.\n .\n # Cardiogenic shock and STEMI: likely from ischemic cause. Patient\n underwent cath with 3 BMS to distal SVG to OM with subsequent\n persistent low BPs so placed on dopamine and IABP.\n - cardiac index 3.3 on arrival to CVICU with dopa 15 and IABP 1:1\n - reassess CI later tonight\n - eval for tamponade now (prelim neg).\n - continue dopa 15 and titrate prn.\n - continue IABP 1:1\n - trend CE - still rising\n - continue ASA 325\n - plavix 600x1 then 75 daily\n - continue heparin gtt without bolus for his IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR\n so will diurese for goal I<O -500 tonight.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - continue dopa for inotrophy\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure: intubated for airway protection but now with\n hypoxic resp failure. Suspect underlying obstructive dz from 120 pack\n yrs tobb hx. Suspect asp pneumonitis and suspect pulm congestion from\n elevated LVEDP\n - continue FiO2 100% and PEEP 10 for O2 sat>92.\n - frequent suctioning\n - monitor Pplateau and Ppeak which have been normal thus far\n - diurese gently\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - vanco/zosyn\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n .\n # metabolic acidosis: AG 14 so some degree of anion gap acidosis likely\n lactate. Delta/delta suggests concomittant nongap likely from\n ARF. Based on winter's formula, pCO2 should be 31-34 so will increase\n minute ventilation to improve pH.\n - recheck gas after increasing rate to 24 and Vt to 550.\n - likely pressor activity will improve with improvement in acidosis.\n .\n # ARF: baseline Cr 1.3 - now 2.5. FeNa 5.7 (although had been given\n lasix) suggestive of ATN. FeUrea 25% suggests prerenal. regardless,\n suspect poor renal perfusion and ATN.\n - diurese as above for goal -500\n - treat hyperkalemia with insulin IV and recheck\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # question of SVC perforation: have occurred during placement of\n cortis. CXR with no significant widening of mediastinum and echo\n prelim without pericardial effusion.\n - monitor hct and xfuse for <28\n - repeat CXR in am\n - if becomes hypotensive with rising CVP, will consider tamponade as\n etiology and d/w cards team\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. if stabilizis o/n start tube feeds\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control: Comments: HISS\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 PM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , Family\n meeting held , ICU consent signed Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nutrition", "chartdate": "2176-05-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 578062, "text": "Subjective Unable to speak w/ patient. Patient sedated.\n Objective\n Current Weight: 86.9 kg () - fluid\n Admit Weight: 76.4 kg\n Pertinent medications: simvastatin, HISS, colace, reglan, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:33 AM\n Glucose Finger Stick\n 136\n 10:30 AM\n BUN\n 21 mg/dL\n 04:33 AM\n Creatinine\n 1.3 mg/dL\n 04:33 AM\n Sodium\n 139 mEq/L\n 04:33 AM\n Potassium\n 4.1 mEq/L\n 04:33 AM\n Chloride\n 106 mEq/L\n 04:33 AM\n TCO2\n 23 mEq/L\n 04:33 AM\n PO2 (arterial)\n 82. mm Hg\n 12:04 PM\n PO2 (venous)\n 40 mm Hg\n 05:47 AM\n PCO2 (arterial)\n 37 mm Hg\n 12:04 PM\n PCO2 (venous)\n 41 mm Hg\n 05:47 AM\n pH (arterial)\n 7.42 units\n 12:04 PM\n pH (venous)\n 7.35 units\n 05:47 AM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 12:04 PM\n CO2 (Calc) venous\n 24 mEq/L\n 05:47 AM\n Albumin\n 2.7 g/dL\n 03:16 AM\n Calcium non-ionized\n 8.3 mg/dL\n 04:33 AM\n Phosphorus\n 3.6 mg/dL\n 04:33 AM\n Ionized Calcium\n 1.12 mmol/L\n 03:42 AM\n Magnesium\n 2.2 mg/dL\n 04:33 AM\n ALT\n 20 IU/L\n 05:10 AM\n Alkaline Phosphate\n 71 IU/L\n 05:10 AM\n AST\n 71 IU/L\n 05:10 AM\n Total Bilirubin\n 1.0 mg/dL\n 02:36 PM\n Triglyceride\n 367 mg/dL\n 04:33 AM\n WBC\n 7.8 K/uL\n 04:33 AM\n Hgb\n 9.5 g/dL\n 04:33 AM\n Hematocrit\n 27.9 %\n 04:33 AM\n Current diet order / nutrition support: NPO\n GI: abd soft, non-tender, mild distention, +BS\n Assessment of Nutritional Status\n Specifics: 75 year old man admitted with NSTEMI in perioperative period\n (s/p shoulder surgery), with cardiogenic shock s/p IABP, and observed\n aspiration for which patient was intubated/sedated. Patient had been\n receiving tube feeds of Nutren Pulmonary with goal @ 55ml/hr providing\n kcal and 90g protein which are now turned off as patient was\n extubated today and OGT was removed. While on tube feeds, patient had\n been having some high residuals (90-150cc) for which the tube feed was\n turned off/on. Per discussion with RN, team plans to see how patient\n improves post extubation before deciding to place new tube and restart\n feeds. If patient is unable to advance and tolerate diet within a\n couple of days, consider placing NGT and restarting tube feeds to\n previous goal.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1. Advance diet as able/tolerated. If s&s of aspiration are\n present with pos, consider speech and swallow consult.\n 2. If unable to advance diet or if patient is unable to tolerate\n pos, consider placing NGT and restarting nutrition support.\n 3. CHEM 10 daily. Monitor and replete lytes PRN.\n 4. Monitor BG. Correct if >150 with HISS.\n Will follow.\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578199, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Altered mental status (not Delirium)\n Assessment:\n Pt oriented to person and place, restless at times, cooperative, unable\n to sleep, anxious to get up and start moving about. Confused about\n recent events. Awake all night, has had some hallucinations: things\n flying in his room. Has had some\n comments. Reorients easily.\n Action:\n Reoriented as needed, maintains safety measures\n Response:\n Pt without attempts to get out of bed\n Plan:\n Increase daytime activity as tolerated. Reorient prn, maintain safety\n measures. Cont to explain course of events to pt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Initially on mask ventilation, pt removed at 2100 and tried on high\n flow neg at 95%, maintained good sats and ventilation. Pt bothered by\n sound of high flow neb. Cough productive of blood tinged sputum.\n Action:\n Weaned high flow mask to NC 6L, enc coughing and deep breathing.\n Response:\n Maintaining sats 92-95% on 6L NC, clearing secretions wel, sputum blood\n tinged.\n Plan:\n Cont pul toilet, wean O2 as able. Monitor fluid balance, UO and adm.\n diuretics as indicated\n Shock, cardiogenic\n Assessment:\n Pt weaned from IABP and pressors, extubated yesterday. Stabilized from\n episode of acute pul edema yest eve. Diuresed well.\n Action:\n Weaned off IV NTG, titrated oxygen, monitored lytes with diuresis\n Response:\n BP improved, pt had good diuresis and NTG weaned to off.\n Plan:\n Cont to follow lung exam, sats, UO, fluid balance.\n" }, { "category": "Respiratory ", "chartdate": "2176-04-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577130, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: 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: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: 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: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved\n" }, { "category": "Physician ", "chartdate": "2176-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577609, "text": "Chief Complaint:\n 24 Hour Events:\n - Goal fluid status -500 mL\n - Thrombocytopenia: will stop Vanc/Zosyn (Vanc could be contributing)\n and stop famotidine/pantoprazole. Most likely thrombocytopenia related\n to IABP.Did send off HIT Ab today.\n - ? Aspiration PNA: started Levaquin to replace Vanc/Zosyn\n -Holding Asacol per pharmacy (cannot crush PO and PR is only\n local).Emailed primary gastroenterologist re: PR Asacol.\n - Starting TF slowly\n - Afternoon gas showed improved O2 to 165 so FiO2 to 50%-->repeat\n ABG O2 98 so FiO2 weaned to 40%\n - I/Os at 1730 showed -740 fluid balance p midnight but +190 since 8AM,\n with hourly UOP as low as 15cc/hr. Will re-check at 11PM and consider\n bolus/lasix.\n - Per GI ( ), OK to hold Asacol if no signs of UC. If\n develops signs of , use low-dose prednisone.\n -O/N pressures remained labile. Small adjustements to dopamine\n corrects.\n -HR trending down, now in 50's--?autonomic dysregulation\n -2330 ABG: 7.41/36/74 on 40% FiO2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:39 AM\n Midazolam (Versed) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 74 (55 - 77) bpm\n BP: 92/42(68) {68/26(47) - 178/64(125)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 11 (9 - 15)mmHg\n PAP: (33 mmHg) / (20 mmHg)\n CO/CI (Fick): (7.3 L/min) / (3.9 L/min/m2)\n Mixed Venous O2% Sat: 66 - 71\n Total In:\n 1,677 mL\n 603 mL\n PO:\n TF:\n 232 mL\n 262 mL\n IVF:\n 1,415 mL\n 341 mL\n Blood products:\n Total out:\n 2,460 mL\n 540 mL\n Urine:\n 2,435 mL\n 540 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -783 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 93%\n ABG: 7.41/36/74/19/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 148\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT/ND, BS+\n Ext: 1+ edema to 6cm above ankle, dopplerable pulses bilaterally\n Labs / Radiology\n 111 K/uL\n 9.5 g/dL\n 118 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 139 mEq/L\n 27.8 %\n 6.4 K/uL\n [image002.jpg]\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n WBC\n 6.6\n 7.0\n 6.4\n Hct\n 29.1\n 29.9\n 31.0\n 31\n 27.8\n Plt\n 121\n 111\n 111\n Cr\n 1.4\n 1.4\n 1.6\n 1.3\n TCO2\n 19\n 19\n 22\n 22\n 22\n 24\n Glucose\n 125\n 109\n 114\n 118\n Other labs: PT / PTT / INR:13.8/61.9/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic Shock/STEMI. Latest Co/CI/SVR=7.3/3.9/722. Remains very\n labile O/N but less highs/lows than yesterday. Likely a component of\n autonomic dysregulation.\n - Plan to cont IABP on 1:1\n - Continue dopamine for pressure support\n - Repeat Fick calculations with change in pressors\n - Continue ASA 325, Plavix 75, heparin gtt for IABP, simva 80.\n - Try to wean FiO2 again today.\n .\n # PUMP: Still volume up. Did not receive lasix yesterday \n hypotension. Pt was negative 781 over last 24 hrs, but even since\n midnight.\n - 20 mg this AM. Goal I/O -500 cc if BP allows\n - Continue afterload reduction with IABP, consider ACE if Cre allows.\n .\n # RHYTHM: Mostly NSR with rate 50s-60s, sporadic PVCs. Hold BB.\n .\n # Anemia: PLT stabilized but Hct dropping. Will follow today and\n consider transfusion if continues to drop.\n - Continue to avoid drugs that may cause thrombocytopenia\n .\n # Vomiting: resolved\n .\n # Resp Failure/Aspiration:\n - Try to wean FiO2 again today to 40%\n - frequent suctioning\n - continue COPD meds\n - Continue levaquin instead of Vanc/Zosyn\n .\n # ARF. Cre improved O/N.\n - monitor daily lytes, renally dose meds\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # GERD. conitnue to avoue H2b or PPI for now due to thrombocytopenia.\n # FEN: Tolerating TFs.\n # Cardiogenic shock and STEMI: Cardiogenic shock is most likely due to\n ischemia. Hemodynamics improving with IABP. Levophed has been weaned\n off and he remains on dopamine. Latest CO/CI/SVR = 7/3.8/801(\n 5.3/2.9/632). TTE yesterday demonstrated mildly depressed LVEF with EF\n 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment.\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterday. Cont\n afterload reduction with diuresis.\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct trending up though plts cont to trend\n down likely hemolysis from balloon pump. Hemolysis labs\n unremarkable. HIT is certainly possible and 4T score is intermediate.\n - Send Heparin dependent Ab\n - Stop meds that could be contributing: PPI, Vanc\n - Will continue heparin gtt/plavix for now\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - No e/o obstruction or ileus on KUB\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n FiO2 increased last night back to 60 for hypoxia. Hoping that cont\n diuresis will improve oxygenation.\n - Recheck a gas this morning\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Cr 1.6.-baseline around 1.3 Suspect poor renal perfusion and\n ATN.\n - recheck urine lytes\n - cont to monitor\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Holding asacol at this time since it cannot be\n crushed. Will discuss whether we should give PR asacol with outpatient\n gastroenterologist.\n .\n # depression: cont celexa\n .\n # hx of GERD: holding PPI and H2 blocker for now\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:46 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576509, "text": ".H/O coronary artery disease (CAD, ischemic heart disease)s/p cath lab\n for stents\n Assessment:\n Neuro: Sedated with iv propofol, able to squeeze my hand, wiggle toes\n on command.\n Cardiac: heart rate NSR, Swan in place, IABP in Rt femerol, Dopplerable\n pulses. Iv dopamine infusing\n Resp: Cs diminished in bases, suctioned for tan\n GI; Og placed by resident, placement checked\n Gu: Foley in place, patent for clear yellow\n Endo: glucose elevated\n Action:\n Neuro: Propofol increased.\n Cardiac: CO done, acceptable, svo2 60\ns. Heparin at 800 units/hr added.\n Resp: Sputum for c/s sent\n Endo: glucose treated with 5 units humulog insulin\n Response:\n Neuro: appears comfortable\n Plan:\n Neuro: Orient as needed.\n Cardiac: ? wean Dopamine-need B/p parameters\n Resp: Suction as needed.\n Endo: check glucose at -2130\n Pain control (acute pain, chronic pain)s/p rotator cuff surgery\n Assessment:\n Grimaces with any movement of left shoulder/arm\n Action:\n Arm supported with pillow/ unable to use sling due to intubation.\n Medicated with fentanyl\n Response:\n Appears more comfortable\n Plan:\n See nursing care plan. Medicate as needed with iv fentanyl\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578345, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\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": "Respiratory ", "chartdate": "2176-04-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576703, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type: Standard\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: 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: 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: 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": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576872, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1. PADs 17-22 & CVP 11-13.\n Latest CO/CI/SVR @ 0330=7/3.7/700.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 PM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: No changes\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support CMV/AS 550X24 60% +8\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Latest\n CO/CI/SVR @ 0330=7/3.7/700.\n - Plan to con\nt IABP on 1:1-1:2\n - D/c Dopamine and continue levophed, but con\nt to wean, with goal MAPs\n 60\n - Repeat Fick calculations\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: Previous AG up to 15 likely from lactate. Delta\n delta suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I have also reviewed the notes of Dr(s). .\n I would add the following remarks:\n Medical Decision Making\n Critical care time 60 minutes. Unstable hemodynamics and pressor\n dependent. Spiked fever. Some component of distributive shock on top\n of cardiogenic shock. Needs to maintain IABP for now since when we\n wean, he becomes hypotensive. Aspiration pneumonia being presumptively\n treated with antibiotics. Remains very tenuous.\n ------ Protected Section Addendum Entered By: , MD\n on: 10:26 ------\n" }, { "category": "Nursing", "chartdate": "2176-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576952, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Shock, cardiogenic\n Assessment:\n SR C PAC,PVC.BP LABILE UNABLE TO WEAN DOWN LEVOPHED AND DOPAMINE\n .TOLERATED 1UNIT PRBC AND FLUID BOLLUS.LATEST CI 4.2,SVR 842 ON 3 MIC\n DOPAMINE,.084 MIC LEVOPHED .IABP 1:1 12 TO 20,DU 10 TO 15 . DISTAL\n PULSES BY DOPPLER .PAD 16 TO 21 ,W 18 TO 9 .MV SAT 76 .CVP 8 TO 14\n .HEPARIN 950 UNITS .\n Action:\n ATTEMPTED TO WEAN PRESSERS SLOWLY ,TRANSFUSED 2CD UNIT PRBC\n Response:\n REMAINS PRESSER DEPENDENT\n Plan:\n FOLLOW HEMODYNAMICS,WEAN PRESSERS SLOWLY ,RECHECK HCT AFTER 2CD UNIT\n SUPPORT C FLUID BOLLUSES PER RESIDENT\n Pain control (acute pain, chronic pain)\n Assessment:\n SP SX INCISION C/D GRIMACES WHEN MOVED\n Action:\n FENTANYL DRIP\n Response:\n APPEARS COMFORTABLE EXCEPT WHEN MOVING\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PT C COPD AND ASP PNA .PT AGAIN TODAY\n Action:\n OG TO SX MOST OF DAY,READMINISTERED PLAVIX P PT . SX PRN\n Response:\n ABG ON 5PEEP/60%/550 /20 736/32/112/19/100\n Plan:\n VAP PROTOCOLS,MONITOR CLOSELY FOR VOMITING\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578347, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies CP. HR 70-80\ns SR. no VEA. BP 120-130\ns/ K+ 3.2\n Action:\n Repleted 20meq KCL po. Started lopressor 12.5mg PO.\n Response:\n VSS. Reporting mild dizziness when turning in bed but not when sitting\n up. Resolves on own. Laying flat in bed tolerated well.\n Plan:\n Contin. Lisinopril and lopressor. Monitor lytes. Monitor for further\n dizzy spells.\n Nausea / vomiting\n \nt feel that good\n Assessment:\n Pt. c/o slight nausea in the eve. Asking for basin but did not spit\n up. Asking for water and gingerale.\n Action:\n Zofran 4mg IV x1\n Response:\n Passing flatus. Multiple reports of thinking he had BM but false. Had\n small loose stool- incontinent. c/o stomach rumblings but no further\n nausea.\n Plan:\n Contin. Stool regiman. Commode in room.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n (-) 300cc at 2100 with goal of 1L. had not voided since foley d/c\n earlier in the day.\n Action:\n Lasix 20mg IV x1. pt. with strong urge to void following lasix but\n unable . sat up on side of bed etc.\n Foley was replaced ~ 2200 with 500cc u/o.\n Response:\n Neg. 900cc for .\n Plan:\n Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576841, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts; CI's best with baloon\n at 1:1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576843, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts; CI's best with baloon\n at 1:1.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576845, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1. PADs 17-22 & CVP 11-13.\n Latest CO/CI/SVR @ 0330=7/3.7/700.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 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 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Cardiac index\n down to 2.7 from 3.5 but may not be reliable given dramatic shifts in\n O2 saturation and hg.\n - Plan to trial IABP on 1:2 pump\n - D/c Dopamine and continue levophed for septic physiology and\n cardiogenic shock with goal MAPs 60\n - Repeat Fick calculations\n hour after pump change\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: AG up to 15 likely from lactate. Delta delta\n suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577225, "text": "Levo weaned off 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordinly for PTT\n goal 50-70\n Response:\n Continues on IABP 1:1 w/ good augmentation and unloading. Continues to\n have labile BPs, unable to wean Dopa. AM PTT, PLT stable.\n Plan:\n Wean Dopa as tolerated, check hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn showing PO2 80\nMDI , FI02 increased to 60%. 20mg IV\n lasix given at 22:45\n Response:\n Sats slowly up to 92-96%. Gd response to lasix. Neg 262 at MN (goal\n -500cc)\n Plan:\n Wean vent as tol. Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Attempt PSV.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up.\n Response:\n Plan:\n Continue daily wake ups/RSBIs. Wean sedation as tol.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS\n aspirating sm amts bilious material\n Plan:\n Continue PPI, limit sedation meds. Bowel regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Respiratory ", "chartdate": "2176-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577515, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 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: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Exp Wheeze\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments: Albuterol and atrovent given Q6 per \n Secretions\n Sputum color / consistency: Yellow / 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: Frequent desaturation episodes;\n Comments: Patient noted with episode of desaturation in evenings. Fio2\n increased to 50%. Suctioned for small amounts of thick yellow. oxygen\n saturations still remain 93-94% dispite increased fio2. Saturations\n during the day were greater then 95% with good pao2. Pao2 now down to\n 74 from 94.\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 Maintain PEEP at current level and reduce FiO2 as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Hemodynimic instability, Underlying illness not\n resolved; Comments: Continues to have episodes of desaturations.\n" }, { "category": "Respiratory ", "chartdate": "2176-04-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576561, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / 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 claim of dyspnea)\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, Reduce PEEP as tolerated; Comments: wean as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576683, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n 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": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576685, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n 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": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576692, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n TRAPONIN 15.2/PK CK 5977.BP LABILE C MINOR TITRATION OF DOPAMINE AND\n LEVOPHED ESPECIALLY WHEN TEMP INCREASED TO 101 .MAP AS LOW AS 49 WHEN\n DOPAMINE OFF,BUT MAPS 90 WHEN ON ONLY 3 MIC PER KG . CI 3.8 SVR 740\n 0N 3 MIC DOPAMINE ,.24 MIC LEVOPHED ,IABP 1 TO 1 . MAINTAINS UO 30 TO\n 40 CC.POS 4,600 CC .HCT 27 .3 .\n Action:\n TITRATE PRESSERS FOR OPTIMUM HEMODYNAMICS .\n Response:\n SLOW WEAN OF LEVOPHED C MAPS ABOVE 60\n Plan:\n WEAN PRESSERS AS TOL ,FOLLOW HCT ,MONITOR FOR BLEEDING\n 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": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576736, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n TRAPONIN 15.2/PK CK 5977.BP LABILE C MINOR TITRATION OF DOPAMINE AND\n LEVOPHED ESPECIALLY WHEN TEMP INCREASED TO 101 .MAP AS LOW AS 49 WHEN\n DOPAMINE OFF,BUT MAPS 90 WHEN ON ONLY 3 MIC PER KG . CI 3.8 SVR 740\n 0N 3 MIC DOPAMINE ,.24 MIC LEVOPHED ,IABP 1 TO 1 .pt drops bp when\n turned . MAINTAINS UO 30 TO 40 CC.POS 4,600 CC .HCT 27 .3 .PT \n X1 ,NG HOOKED TO SX FOR CL GREEN.ASPIRIN GIVEN PER RECTUM, PLAVIX GIVEN\n LATER AT 3PM.TOL OG BEING CLAMPED THIS PM.\n Action:\n TITRATE PRESSERS FOR OPTIMUM HEMODYNAMICS .\n Response:\n SLOW WEAN OF LEVOPHED C MAPS ABOVE 60\n Plan:\n WEAN PRESSERS AS TOL ,FOLLOW HCT ,HEMODYNAMICS ,MONITOR FOR BLEEDING\n Pain control (acute pain, chronic pain)\n Assessment:\n SP L ROTATOR SX .DSD D/I,NO BLEEDING NOTED .ON FENTANYL DRIP\n Action:\n FENTANYL 100 MIC/KG CONT C 25 MIC BOLLUSES PRN FOR PAIN\n Response:\n APPEARS COMFORTABLE\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 7.38/27/93/95 ON 65%/CMV 550/HR 24/8 PEEP ,HX COPD.t max 101 .2\n Action:\n WEAN FIO2,SX PRN , MDI ,Tylenol for temp\n Response:\n SAT 94 TO 97\n Plan:\n PULMONARY TOILET ,WEAN AS,TOL SX PRN\n" }, { "category": "Physician ", "chartdate": "2176-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578423, "text": "Chief Complaint: cardiogenic shock/STEMI s/p L shoulder surgery\n Hour Events:\n ARTERIAL LINE - STOP 09:19 AM\n CORDIS/INTRODUCER - STOP 12:45 PM\n - Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n - Iron labs unrevealing for low Hct: fe=53, ferritin=176, transferrin =\n 228, TIBC=296\n -I/O: 8pm -400cc. Did not put out for 6 hrs after foley removed despite\n 20 mg Lasix at 930 PM. Re-inserted foley at 10:30, put out additioal\n 700cc.\n -Cr increased from 1.2 to 1.5\n - complaining of anterior L knee pain with movement; not swollen,\n bruised or tender to light pressure. no calf pain. likely r/t forceful\n restraining during periods of agitation while he was sedated. treating\n with ice packs and , monitor.\n - this AM: felt\ngassy\n then N/V x1; passed very small BM last night\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:30 AM\n Furosemide (Lasix) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.1\n HR: 73 (70 - 94) bpm\n BP: 129/58(75) {113/57(70) - 155/77(107)} mmHg\n RR: 27 (13 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n Total In:\n 1,182 mL\n 240 mL\n PO:\n 1,000 mL\n 240 mL\n TF:\n IVF:\n 182 mL\n Blood products:\n Total out:\n 2,170 mL\n 395 mL\n Urine:\n 2,170 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -988 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GEN: awake, alert, oriented, NAD\n Eyes/conjunctiva: PERRL\n CV: RRR, no m/r/g appreciate, JVP flat\n Chest: CTAB, No c/r/w\n Abd: Soft, NT, mildly distended, +BS\n Ext: No edema, radial pulses 2+ bilaterally, DP 1+ bilaterally\n MSK: Anterior L knee pain to deep palpation\n Labs / Radiology\n 280 K/uL\n 10.5 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 31.6 %\n 9.9 K/uL\n [image002.jpg]\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n 07:38 PM\n 05:32 AM\n WBC\n 6.0\n 7.8\n 9.1\n 9.9\n Hct\n 25.8\n 27.9\n 27.7\n 31.6\n Plt\n 127\n 150\n 205\n 280\n Cr\n 1.3\n 1.2\n 1.5\n TCO2\n 25\n 25\n 22\n 27\n 28\n Glucose\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:72.8 %, Lymph:20.7 %, Mono:3.4 %, Eos:2.6 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG (LIMA to\n LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia here with\n STEMI s/p acromioplasty\n # Cardiogenic shock and STEMI:\n - BPs continue to stabilize, hemodynamically stable with no episodes of\n hypotension.\n - continue ASA 325, plavix 600, SQ heparin, simvastatin 80, metoprolol\n 12.5 mg PO BID\n - Increase lisinopril to 10 mg PO daily\n # Cards Pump: Met diuresis goal of -1L yesterday to 20 mg lasix x2 but\n failed to put out urine without foley\n - Cre bump 1.2 - 1.5\n - Clinically euvolemic, resp status continuing to improve on O2 by NC.\n - Goal even today.\n # RHYTHM: NSR with rate 80s.\n # Resp Failure: Pt with increased WOB and crackles. Significantly\n improved, now 95-97% on 2L NC.\n - repeat CXR\n - diuresis as above pending volume status and CXR\n - finished abx course for aspiration, remains afebrile\n - incentive spirometry\n #Anemia: Slightly improved from yesterday, Hct 31.1. No iron\n deficiency, no rectal blood loss, no hemolysis. Will trend.\n #N/V: remains constipated and likely needs aggressive bowel regimen\n - Fleet enema today, Zofran PRN; follow clinically\n # Acid/Base: Acidemia has resolved, but Alkalemic yesterday pH\n 7.48/36/143, suggestive of respiratory alkalosis.\n - ABG today to trend acid/base status\n # ARF: baseline Cr 1.3 - now 1.5. Likely r/t aggressive diuresis\n - hold diuresis for now, trend creatinine and lytes, renally dose meds\n - if cont urine output will bolus IVF\n # s/p shoulder surgery - pain control w fentanyl bolus prn.\n - will schedule f/u with Dr. for \n - per ortho: ROM as tolerated, WB < 5 lbs, sling until \n # Ulcerative colitis: all guaiacs negative. continue asacol 1600 \n # depression: celexa\n # hx of GERD: use H2 blocker instead of PPI since plavix\n FEN: tolerating POs; replete electrolytes as needed\n ACCESS: PIVs\n PROPHYLAXIS:\n -DVT ppx: SC heparin\n -Pain management with fentanyl PRN\n -Bowel regimen with senna/colace, with reglan, dulcolax as needed\n CODE: full, discussed\n DISPO: to floor today pending full 24 hours hemodynamically stable\n CONTACT: wife is HCP verified. Cell-- :\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2176-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578425, "text": "Chief Complaint: cardiogenic shock/STEMI s/p L shoulder surgery\n Hour Events:\n ARTERIAL LINE - STOP 09:19 AM\n CORDIS/INTRODUCER - STOP 12:45 PM\n - Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n - Iron labs unrevealing for low Hct: fe=53, ferritin=176, transferrin =\n 228, TIBC=296\n -I/O: 8pm -400cc. Did not put out for 6 hrs after foley removed despite\n 20 mg Lasix at 930 PM. Re-inserted foley at 10:30, put out additioal\n 700cc.\n -Cr increased from 1.2 to 1.5\n - complaining of anterior L knee pain with movement; not swollen,\n bruised or tender to light pressure. no calf pain. likely r/t forceful\n restraining during periods of agitation while he was sedated. treating\n with ice packs and , monitor.\n - this AM: felt\ngassy\n then N/V x1; passed very small BM last night\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:30 AM\n Furosemide (Lasix) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.1\n HR: 73 (70 - 94) bpm\n BP: 129/58(75) {113/57(70) - 155/77(107)} mmHg\n RR: 27 (13 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n Total In:\n 1,182 mL\n 240 mL\n PO:\n 1,000 mL\n 240 mL\n TF:\n IVF:\n 182 mL\n Blood products:\n Total out:\n 2,170 mL\n 395 mL\n Urine:\n 2,170 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -988 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GEN: awake, alert, oriented, NAD\n Eyes/conjunctiva: PERRL\n CV: RRR, no m/r/g appreciate, JVP flat\n Chest: CTAB, No c/r/w\n Abd: Soft, NT, mildly distended, +BS\n Ext: No edema, radial pulses 2+ bilaterally, DP 1+ bilaterally\n MSK: Anterior L knee pain to deep palpation\n Labs / Radiology\n 280 K/uL\n 10.5 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 31.6 %\n 9.9 K/uL\n [image002.jpg]\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n 07:38 PM\n 05:32 AM\n WBC\n 6.0\n 7.8\n 9.1\n 9.9\n Hct\n 25.8\n 27.9\n 27.7\n 31.6\n Plt\n 127\n 150\n 205\n 280\n Cr\n 1.3\n 1.2\n 1.5\n TCO2\n 25\n 25\n 22\n 27\n 28\n Glucose\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:72.8 %, Lymph:20.7 %, Mono:3.4 %, Eos:2.6 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG (LIMA to\n LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia here with\n STEMI s/p acromioplasty\n # Cardiogenic shock and STEMI:\n - BPs continue to stabilize, hemodynamically stable with no episodes of\n hypotension.\n - continue ASA 325, plavix 600, SQ heparin, simvastatin 80, metoprolol\n 12.5 mg PO BID\n - Increase lisinopril to 10 mg PO daily\n # Cards Pump: Met diuresis goal of -1L yesterday to 20 mg lasix x2 but\n failed to put out urine without foley\n - Cre bump 1.2 - 1.5\n - Clinically euvolemic, resp status continuing to improve on O2 by NC.\n - Goal even today.\n # RHYTHM: NSR with rate 80s.\n # Resp Failure: Pt with increased WOB and crackles. Significantly\n improved, now 95-97% on 2L NC.\n - repeat CXR\n - diuresis as above pending volume status and CXR\n - finished abx course for aspiration, remains afebrile\n - incentive spirometry\n #Anemia: Slightly improved from yesterday, Hct 31.1. No iron\n deficiency, no rectal blood loss, no hemolysis. Will trend.\n #N/V: remains constipated and likely needs aggressive bowel regimen\n - Fleet enema today, Zofran PRN; follow clinically\n # Acid/Base: Acidemia has resolved, but Alkalemic yesterday pH\n 7.48/36/143, suggestive of respiratory alkalosis.\n - ABG today to trend acid/base status\n # ARF: baseline Cr 1.3 - now 1.5. Likely r/t aggressive diuresis\n - hold diuresis for now, trend creatinine and lytes, renally dose meds\n - if cont urine output will bolus IVF\n # s/p shoulder surgery - pain control w fentanyl bolus prn.\n - will schedule f/u with Dr. for \n - per ortho: ROM as tolerated, WB < 5 lbs, sling until \n # Ulcerative colitis: all guaiacs negative. continue asacol 1600 \n # depression: celexa\n # hx of GERD: use H2 blocker instead of PPI since plavix\n FEN: tolerating POs; replete electrolytes as needed\n ACCESS: PIVs\n PROPHYLAXIS:\n -DVT ppx: SC heparin\n -Pain management with fentanyl PRN\n -Bowel regimen with senna/colace, with reglan, dulcolax as needed\n CODE: full, discussed\n DISPO: to floor today pending full 24 hours hemodynamically stable\n CONTACT: wife is HCP verified. Cell-- :\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n Nothing to add\n Physical Examination\n Nothing to add\n Medical Decision Making\n Nothing to add\n Total time spent on patient care: 35 minutes.\n ------ Protected Section Addendum Entered By: ,MD\n on: 10:03 ------\n" }, { "category": "Physician ", "chartdate": "2176-04-28 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 576862, "text": "Chief Complaint:\n 24 Hour Events:\n EKG - At 10:16 AM\n FEVER - 101.1\nC - 09:00 PM\n - Cultures negative to date\n - 3pm lytes w/ k 4.3, Cr 2.1\n - Ortho notified of wnl shoulder films\n - Levophed at .3; failed levo weaning attempts, then successfully\n reduced to .18; CI's best with balloon at 1:1. PADs 17-22 & CVP 11-13.\n Latest CO/CI/SVR @ 0330=7/3.7/700.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:39 PM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Dopamine - 3 mcg/Kg/min\n Norepinephrine - 0.21 mcg/Kg/min\n Fentanyl - 125 mcg/hour\n Heparin Sodium - 950 units/hour\n Other ICU medications:\n Famotidine (Pepcid) - 06:25 PM\n Other medications:\n Changes to medical and family history: No changes\n Review of systems is unchanged from admission except as noted below\n Review of systems: No changes\n Flowsheet Data as of 07:38 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.4\nC (101.1\n Tcurrent: 37.2\nC (99\n HR: 83 (73 - 95) bpm\n BP: 75/30(54) {75/30(52) - 139/75(107)} mmHg\n RR: 24 (21 - 24) insp/min\n SpO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Height: 66 Inch\n CVP: 15 (11 - 21)mmHg\n PAP: (55 mmHg) / (23 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 55 - 75\n Total In:\n 5,011 mL\n 269 mL\n PO:\n TF:\n IVF:\n 5,011 mL\n 269 mL\n Blood products:\n Total out:\n 1,370 mL\n 510 mL\n Urine:\n 1,370 mL\n 510 mL\n NG:\n Stool:\n Drains:\n Balance:\n 3,641 mL\n -241 mL\n Respiratory support CMV/AS 550X24 60% +8\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 24\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 60%\n PIP: 21 cmH2O\n Plateau: 19 cmH2O\n SpO2: 96%\n ABG: 7.39/27/146/14/-6\n Ve: 13.8 L/min\n PaO2 / FiO2: 243\n Physical Examination\n Gen: intubated, sedate, responds to sternal rub but not verbal stimuli\n Eyes / Conjunctiva: PERRL\n Cardiovascular: RRR, no m/r/g, JVP not appreciated\n Chest: CTA bilaterally in anterior fields\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended\n Extremities: 1+ edema to 6 cm above ankle, soft 1+ PT pulses\n bilaterally\n Labs / Radiology\n 170 K/uL\n 8.9 g/dL\n 150 mg/dL\n 1.6 mg/dL\n 14 mEq/L\n 4.0 mEq/L\n 23 mg/dL\n 111 mEq/L\n 137 mEq/L\n 26.8 %\n 8.2 K/uL\n [image002.jpg]\n 05:28 AM\n 08:17 AM\n 08:37 AM\n 09:43 AM\n 10:52 AM\n 12:23 PM\n 01:40 PM\n 02:22 PM\n 03:16 AM\n 03:42 AM\n WBC\n 8.2\n Hct\n 29.0\n 32\n 29\n 32\n 31\n 31\n 27.4\n 26.8\n Plt\n 230\n 170\n Cr\n 2.1\n 2.1\n 1.6\n TCO2\n 18\n 19\n 16\n 16\n 16\n 17\n 17\n Glucose\n 125\n 150\n Other labs: PT / PTT / INR:15.8/69.1/1.4, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:23/157, Alk Phos / T Bili:62/1.1,\n Differential-Neuts:65.5 %, Lymph:24.1 %, Mono:5.9 %, Eos:4.0 %, Lactic\n Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:1102 IU/L, Ca++:7.6 mg/dL,\n Mg++:2.0 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: .Patient underwent cath with 3 BMS to\n distal SVG to OM CK peaked at 6000 and now downtrending. Given severity\n of MI cardiogenic shock is most likely due to ischemia. Hemodynamics\n improved with IABP, but hypotension persists. Doing better now on\n levophed, which may imply some septic physiology as well. Latest\n CO/CI/SVR @ 0330=7/3.7/700.\n - Plan to con\nt IABP on 1:1-1:2\n - D/c Dopamine and continue levophed, but con\nt to wean, with goal MAPs\n 60\n - Repeat Fick calculations\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis on prelim echo post intervention.\n Support cardiac outpt as above. LVEDP 25 in lab and pulm edema on CXR,\n but patient will require frequent boluses over thecourse of the day.\n - hold on ACE in setting of ARF\n - afterload reduce with IABP\n - consider milrinone if SVR goes up and peripherally clamps down. Hold\n for now.\n - Goal I/o positive 1-2 liters with boluses as needed\n .\n # RHYTHM: NSR with rate 80s for now. Hold BB\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n - Wean FiO2 to nontoxic levels as tolerated\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n .\n # Aspiration pneumonitis: witnessed aspiration in cath lab and now\n intubated primarily for airway protection. Although usually a\n chemically mediated process, will treat with abx since large volume\n aspiration and resp failure.\n - pan culture\n - taper down abx if able\n - treat resp failure as above.\n - vanco/zosyn\n .\n # metabolic acidosis: Previous AG up to 15 likely from lactate. Delta\n delta suggests nongap acidosis likely due to renal failure.\n - Improvement with dynamics should improve renal failure and lactate\n - trend ABGs daily\n .\n # ARF: baseline Cr 1.3\n stable for last 24 hours at mid 2s. FeUrea\n 25% suggests prerenal. regardless, suspect poor renal perfusion and\n ATN.\n - monitor daily lytes and renally dose meds\n - monitor for contrast nephropathy in 2-3d\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: continue asacol 1600 \n .\n # depression: celexa\n .\n # hx of GERD: use H2 blocker instead of PPI since plavix\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577006, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n Remains pressor & iabp dependent. Continues on dopamine & levophed.\n iabp 1:1.\n Action:\n Attempted slow levophed wean. Ns bolus x1-250ml. CO/CI/SVR sent/pending\n on 0.03 levophed dose.\n Response:\n Unable to drop levophed gtt below 0.03mcg/kg/min with maps dropping\n into low 50\ns. without response to ns bolus. Decreasing uo when maps\n <60.\n Plan:\n Continue present management. Continue slow levophed wean as tolerated.\n ?further fluid boluses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains intubated & vented. Minimal secretions. Breath\n sounds=essentially clear/diminished. Remains comfortable sedated on\n fent/versed gtts.\n Action:\n Unchged vent settings. Pulmonary toilet. Vap protocol followed.\n Response:\n Improving abg\n Plan:\n Continue vent support. Wean vent settings as tolerated.\n Neuro=sedated with fent/versed gtts. Responds to stimulation.\n Non-purposefull movement. Does not follow simple commands.\n Requires adequate sedation or becomes very agitated with resulting\n hypotension.\n GI=hypoactive bowel sounds. OGT to intermittent suction-bilious. If OGT\n kept clamped for long periods-vomits.\n Social=supportive family. Kept informed by nursing & medical staff.\n" }, { "category": "Nursing", "chartdate": "2176-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577175, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n Received pt on levophed .06 mc/g/g/min anad dopamine 3 mcg/kg/min, on\n IABP 1:1\n Actionresponse\n Weaned levophed to off, dopamine titrated between 3-6 mcg/kg/min to\n maintain maps >50. BP very labile w/ MAPs 46-108 often with no\n intervention. Co/ci off levophed 5.3/2.9/632, PAD 23-28, CVP 8-17\n Plan:\n Continue present management, attempt to wean dopamine Maintain MAPS >\n 55.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received pt on AC60% 550/20/5peep, sm to mod amts thick tan secretions.\n Lungs sounds diminished at bases, otherwise clear.\n Action:\n FIO2 weaned to 50% w/ SATs remaining >96%, VAP protocol followed.\n Response:\n Itolerating O2 wean\n Plan:\n Continue vent support. Wean vent settings as tolerated.\n Neuro=sedated with fent/versed gtts. Responds to stimulation.\n Non-purposefull movement. Does not follow simple commands.\n Requires adequate sedation or becomes very agitated with resulting\n hypotension.\n GI=hypoactive bowel sounds. OGT to intermittent suction-bilious.\n Minimal amt drainage from OGT, but OB+\n Social=supportive family. Kept informed by nursing & medical staff.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577294, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordingly for PTT\n goal 50-70\n Response:\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Remains pressor dependent. Unable to wean Dopa below 5.5 mcg/k/min. AM\n PTT, PLT pnd. CO/CI/SVR pnd\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn, PO2 80\nMDI , FI02 increased to 60%. 20mg IV lasix\n given\n Response:\n Sats slowly up to 92-97% on 60%, then FI02 decreased again to 50%. Gd\n response to lasix. Neg 262 at MN (goal -500cc), neg 1L at 06:00. PO2 on\n 50% this AM 65\n Fi02 increased to 60% w/ sats WNL\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. TEAM AWARE)\n Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up. Rate decreased to 16\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Sedation restarted at previous dose and now\n overbreathing vent 1-4 breaths.\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS at 06:30\n aspirating sm amts bilious\n material, OB neg\n Plan:\n Continue PPI, limit sedation meds if possible. Bowel\n regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577295, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordingly for PTT\n goal 50-70\n Response:\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Remains pressor dependent. Unable to wean Dopa below 5.5 mcg/k/min. AM\n PTT, PLT pnd. CO/CI/SVR pnd\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn, PO2 80\nMDI , FI02 increased to 60%. 20mg IV lasix\n given\n Response:\n Sats slowly up to 92-97% on 60%, then FI02 decreased again to 50%. Gd\n response to lasix. Neg 262 at MN (goal -500cc), neg 1L at 06:00. PO2 on\n 50% this AM 65\n Fi02 increased to 60% w/ sats WNL\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. TEAM AWARE)\n Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up. Rate decreased to 16\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Sedation restarted at previous dose, rarely\n overbreathing vent\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS at 06:30\n aspirating sm amts brown\n material, OB neg\n Plan:\n Continue PPI, limit sedation meds if possible. Bowel\n regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577301, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 .\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs 48-80s on Dopamine gtt and IABP 1:1. Lower BPs with\n stimulation. Very sensitive to few drops/changes in dopa wean. Gd\n perfusion distally.\n Action:\n Dopa titrated for MAPs > 55. Heparin gtt adjusted accordingly for PTT\n goal 50-70\n Response:\n IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n Remains pressor dependent. Unable to wean Dopa below 5.5 mcg/k/min. AM\n PTT pnd. PLT 111 (121). CO/CI/SVR 7/3.8/801 (5.3/2.9/632) on 5.5\n mcg/k/min.\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 02 sats down to 88% on 50% FI02\n Action:\n ABG drawn, PO2 80\nMDI , FI02 increased to 60%. 20mg IV lasix\n given\n Response:\n Sats slowly up to 92-97% on 60%, then FI02 decreased again to 50%. Gd\n response to lasix. Neg 262 at MN (goal -500cc), neg 1L at 06:00. PO2 on\n 50% this AM 65\n Fi02 increased to 60% w/ sats WNL\n Plan:\n Wean vent as tol. Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. TEAM AWARE)\n Continue VAP bundle per protocol.\n Vanc/zosyn for empiric Asp PNA coverage.\n Altered mental status (not Delirium)\n Assessment:\n On 100mcg/hr fent, 3 mg/hr versed. Not following commands or\n overbreathing vent when set at 20. Spontaneous mvmts to all\n extremities. Agitated, moving in bed w/ stimulation (repositioning,\n mouth care) w/ subsequent hypotension\n Action:\n Mental status monitored, daily wake up. Rate decreased to 16\n Response:\n Sedation weaned and off x30 min. Pt agitated, thrashing in bed, not\n following commands. Sedation restarted at previous dose, rarely\n overbreathing vent\n Plan:\n Wean sedation as tol. Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n vomiting\n Assessment:\n Vomitted previous shifts. Hypoactive BS. KUB yesterday showed no\n obstruction. No stool overnight.\n Action:\n Meds given thru NGT/clamped. Colace given.\n Response:\n No further vomited. NGT to LIS at 06:30\n aspirating sm amts brown\n material, OB neg\n Plan:\n Continue PPI, limit sedation meds if possible. Bowel\n regimen.\n ? start TF. Monitor FS QID.\n" }, { "category": "Physician ", "chartdate": "2176-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577595, "text": "Chief Complaint:\n 24 Hour Events:\n - Goal fluid status -500 mL\n - Thrombocytopenia: will stop Vanc/Zosyn (Vanc could be contributing)\n and stop famotidine/pantoprazole. Most likely thrombocytopenia related\n to IABP.Did send off HIT Ab today.\n - ? Aspiration PNA: started Levaquin to replace Vanc/Zosyn\n -Holding Asacol per pharmacy (cannot crush PO and PR is only\n local).Emailed primary gastroenterologist re: PR Asacol.\n - Starting TF slowly\n - Afternoon gas showed improved O2 to 165 so FiO2 to 50%-->repeat\n ABG O2 98 so FiO2 weaned to 40%\n - I/Os at 1730 showed -740 fluid balance p midnight but +190 since 8AM,\n with hourly UOP as low as 15cc/hr. Will re-check at 11PM and consider\n bolus/lasix.\n - Per GI ( ), OK to hold Asacol if no signs of UC. If\n develops signs of , use low-dose prednisone.\n -O/N pressures remained labile. Small adjustements to dopamine\n corrects.\n -HR trending down, now in 50's--?autonomic dysregulation\n -2330 ABG: 7.41/36/74 on 40% FiO2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:39 AM\n Midazolam (Versed) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 74 (55 - 77) bpm\n BP: 92/42(68) {68/26(47) - 178/64(125)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 11 (9 - 15)mmHg\n PAP: (33 mmHg) / (20 mmHg)\n CO/CI (Fick): (7.3 L/min) / (3.9 L/min/m2)\n Mixed Venous O2% Sat: 66 - 71\n Total In:\n 1,677 mL\n 603 mL\n PO:\n TF:\n 232 mL\n 262 mL\n IVF:\n 1,415 mL\n 341 mL\n Blood products:\n Total out:\n 2,460 mL\n 540 mL\n Urine:\n 2,435 mL\n 540 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -783 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 93%\n ABG: 7.41/36/74/19/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 111 K/uL\n 9.5 g/dL\n 118 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 139 mEq/L\n 27.8 %\n 6.4 K/uL\n [image002.jpg]\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n WBC\n 6.6\n 7.0\n 6.4\n Hct\n 29.1\n 29.9\n 31.0\n 31\n 27.8\n Plt\n 121\n 111\n 111\n Cr\n 1.4\n 1.4\n 1.6\n 1.3\n TCO2\n 19\n 19\n 22\n 22\n 22\n 24\n Glucose\n 125\n 109\n 114\n 118\n Other labs: PT / PTT / INR:13.8/61.9/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:46 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-05-01 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577596, "text": "Chief Complaint:\n 24 Hour Events:\n - Goal fluid status -500 mL\n - Thrombocytopenia: will stop Vanc/Zosyn (Vanc could be contributing)\n and stop famotidine/pantoprazole. Most likely thrombocytopenia related\n to IABP.Did send off HIT Ab today.\n - ? Aspiration PNA: started Levaquin to replace Vanc/Zosyn\n -Holding Asacol per pharmacy (cannot crush PO and PR is only\n local).Emailed primary gastroenterologist re: PR Asacol.\n - Starting TF slowly\n - Afternoon gas showed improved O2 to 165 so FiO2 to 50%-->repeat\n ABG O2 98 so FiO2 weaned to 40%\n - I/Os at 1730 showed -740 fluid balance p midnight but +190 since 8AM,\n with hourly UOP as low as 15cc/hr. Will re-check at 11PM and consider\n bolus/lasix.\n - Per GI ( ), OK to hold Asacol if no signs of UC. If\n develops signs of , use low-dose prednisone.\n -O/N pressures remained labile. Small adjustements to dopamine\n corrects.\n -HR trending down, now in 50's--?autonomic dysregulation\n -2330 ABG: 7.41/36/74 on 40% FiO2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 3 mg/hour\n Heparin Sodium - 1,100 units/hour\n Fentanyl - 100 mcg/hour\n Dopamine - 3 mcg/Kg/min\n Other ICU medications:\n Fentanyl - 06:39 AM\n Midazolam (Versed) - 06:39 AM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:47 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.5\nC (97.7\n Tcurrent: 36.3\nC (97.3\n HR: 74 (55 - 77) bpm\n BP: 92/42(68) {68/26(47) - 178/64(125)} mmHg\n RR: 16 (16 - 22) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 11 (9 - 15)mmHg\n PAP: (33 mmHg) / (20 mmHg)\n CO/CI (Fick): (7.3 L/min) / (3.9 L/min/m2)\n Mixed Venous O2% Sat: 66 - 71\n Total In:\n 1,677 mL\n 603 mL\n PO:\n TF:\n 232 mL\n 262 mL\n IVF:\n 1,415 mL\n 341 mL\n Blood products:\n Total out:\n 2,460 mL\n 540 mL\n Urine:\n 2,435 mL\n 540 mL\n NG:\n 25 mL\n Stool:\n Drains:\n Balance:\n -783 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI Deferred: Hemodynamic Instability, No Spon Resp\n PIP: 24 cmH2O\n Plateau: 17 cmH2O\n SpO2: 93%\n ABG: 7.41/36/74/19/0\n Ve: 8.9 L/min\n PaO2 / FiO2: 148\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 111 K/uL\n 9.5 g/dL\n 118 mg/dL\n 1.3 mg/dL\n 19 mEq/L\n 3.7 mEq/L\n 17 mg/dL\n 112 mEq/L\n 139 mEq/L\n 27.8 %\n 6.4 K/uL\n [image002.jpg]\n 05:10 AM\n 05:21 AM\n 02:36 PM\n 10:21 PM\n 05:30 AM\n 05:53 AM\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n WBC\n 6.6\n 7.0\n 6.4\n Hct\n 29.1\n 29.9\n 31.0\n 31\n 27.8\n Plt\n 121\n 111\n 111\n Cr\n 1.4\n 1.4\n 1.6\n 1.3\n TCO2\n 19\n 19\n 22\n 22\n 22\n 24\n Glucose\n 125\n 109\n 114\n 118\n Other labs: PT / PTT / INR:13.8/61.9/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:2.1 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:7.3 mg/dL, Mg++:1.9 mg/dL, PO4:2.3 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n 75yo man with hx of CAD s/p CABG (LIMA to LAD, SVG to PDA, OM and\n Diagonal), PVD, HTN, admitted with STEMI in perioperative period and\n now with cardiogenic shock s/p IABP.\n .\n # Cardiogenic shock and STEMI: Cardiogenic shock is most likely due to\n ischemia. Hemodynamics improving with IABP. Levophed has been weaned\n off and he remains on dopamine. Latest CO/CI/SVR = 7/3.8/801(\n 5.3/2.9/632). TTE yesterday demonstrated mildly depressed LVEF with EF\n 45-50%.\n - Plan to con\nt IABP on 1:1\n - Continue dopamine for enhanced cardiogenc shock pressor treatment.\n - continue ASA 325\n - plavix 75 daily\n - continue heparin gtt for IABP\n - continue simvastatin 80\n .\n # Cards Pump: Inferiolat hypokinesis persisted on ECHO yesterday. Cont\n afterload reduction with diuresis.\n - Lasix 20 mg IV x1. Goal I/O\n 500 cc if BP will allow\n - afterload reduce with IABP\n .\n # RHYTHM: NSR with rate 60-70\ns for now. Hold BB\n .\n # Anemia/thrombocytopenia: Hct trending up though plts cont to trend\n down likely hemolysis from balloon pump. Hemolysis labs\n unremarkable. HIT is certainly possible and 4T score is intermediate.\n - Send Heparin dependent Ab\n - Stop meds that could be contributing: PPI, Vanc\n - Will continue heparin gtt/plavix for now\n .\n # Vomiting: be due to UGIB or more likely ileus secondary to\n sedating meds.\n - No e/o obstruction or ileus on KUB\n - Limit sedating meds as much as possible\n .\n # Hypoxic Resp Failure/Aspiration: Likely due to aspiration in Cath\n lab. Hypoxia likely due to edema, consolidation, and underlying COPD.\n FiO2 increased last night back to 60 for hypoxia. Hoping that cont\n diuresis will improve oxygenation.\n - Recheck a gas this morning\n - Wean FiO2 to nontoxic levels as tolerated pending diuresis\n - frequent suctioning\n - MDI albuterol and atrovent for suspected COPD underlying\n - Continue Vanco/Zosyn for now. Will uptitrate vanco to 1 g daily given\n improved renal function.\n - F/u cx data and CIS\n .\n # Metabolic acidosis: Resolved.\n .\n # ARF: Cr 1.6.-baseline around 1.3 Suspect poor renal perfusion and\n ATN.\n - recheck urine lytes\n - cont to monitor\n - monitor daily lytes and renally dose meds\n .\n # s/p shoulder surgery - pain control w fentanyl bolus prn\n - f/u XR\n - Ortho recs\n .\n # Ulcerative colitis: Holding asacol at this time since it cannot be\n crushed. Will discuss whether we should give PR asacol with outpatient\n gastroenterologist.\n .\n # depression: cont celexa\n .\n # hx of GERD: holding PPI and H2 blocker for now\n .\n FEN: NPO. Start TFs today.\n ACCESS: cortis and swan\n PROPHYLAXIS:\n -DVT ppx covered by heparin gtt (50-70)\n -Pain management with fentanyl\n -Bowel regimen with senna/colace\n CODE: full, discussed\n DISPO: CCU\n CONTACT: wife is HCP \n ICU Care\n Nutrition:\n Nutren Pulmonary (Full) - 10:46 AM 40 mL/hour\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 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": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576680, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\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": "Nutrition", "chartdate": "2176-04-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 576681, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 76.4 kg\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 119 %\n Diagnosis: STEMI/cardiac cath\n PMH : CAD s/p CABG ', PVD, HTN, hyperlipidemia, GERD,\n anxiety/depression, Ulcerative colitis, colonic polyps\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl drip, Heparin drip, Versed drip,\n Norepinephrine drip, Dopamine drip, Colace, HISS, ABX, NaCl bolus,\n Mesalamine\n Labs:\n Value\n Date\n Glucose\n 125 mg/dL\n 01:40 PM\n Glucose Finger Stick\n 145\n 07:00 AM\n BUN\n 28 mg/dL\n 08:17 AM\n Creatinine\n 2.1 mg/dL\n 08:17 AM\n Sodium\n 135 mEq/L\n 12:45 AM\n Potassium\n 4.5 mEq/L\n 08:17 AM\n Chloride\n 104 mEq/L\n 12:45 AM\n TCO2\n 16 mEq/L\n 12:45 AM\n PO2 (arterial)\n 92. mm Hg\n 01:40 PM\n PCO2 (arterial)\n 27 mm Hg\n 01:40 PM\n pH (arterial)\n 7.38 units\n 01:40 PM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 17 mEq/L\n 01:40 PM\n Calcium non-ionized\n 8.1 mg/dL\n 12:45 AM\n Phosphorus\n 2.3 mg/dL\n 12:45 AM\n Magnesium\n 3.2 mg/dL\n 12:45 AM\n ALT\n 50 IU/L\n 03:30 PM\n Alkaline Phosphate\n 64 IU/L\n 03:30 PM\n AST\n 442 IU/L\n 03:30 PM\n Total Bilirubin\n 1.0 mg/dL\n 03:30 PM\n WBC\n 10.2 K/uL\n 12:45 AM\n Hgb\n 10.3\n 01:43 PM\n Hematocrit\n 27.4 %\n 02:22 PM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren Pulmonary @ 10ml/hr, goal = 50ml/hr\n GI: soft/distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: NPO\n Estimated Nutritional Needs\n per admit wt\n Calories: -2140 (BEE x or / 25-28 cal/kg)\n Protein: 76-92 (1-1.2 g/kg)\n Fluid: team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n Assessment and Plan\n 75 YO man admitted with STEMI in perioperative period (s/p shoulder\n surgery) and now with cardiogenic shock s/p IABP. Witnessed aspiration\n in cath lab and emergently intubated. Patient remains\n intubated/sedated and on pressor support. Also with ARF, MD note,\n suspect poor renal fusion and ATN. Consulted for tube feed\n recommendations, patients with OGT. Tube feed ordered, not yet\n started. Agree with current tube feed formula, however will need to\n increase goal rate to provide adequate calories. Noted low phos.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: via tube feed\n Tube feeding / TPN recommendations: Begin Nutren Pulmonary @ 15ml/hr,\n advance as tol to goal of 55ml/hr = calories and 90g protein\n Check residuals, hold tube feed if greater than 200ml\n If need for pressor support increases, may need to hold tube feed until\n patient more stable\n Check chemistry 10 panel daily\n Replete phos\n Will follow, page if questions *\n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576735, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n TRAPONIN 15.2/PK CK 5977.BP LABILE C MINOR TITRATION OF DOPAMINE AND\n LEVOPHED ESPECIALLY WHEN TEMP INCREASED TO 101 .MAP AS LOW AS 49 WHEN\n DOPAMINE OFF,BUT MAPS 90 WHEN ON ONLY 3 MIC PER KG . CI 3.8 SVR 740\n 0N 3 MIC DOPAMINE ,.24 MIC LEVOPHED ,IABP 1 TO 1 .pt drops bp when\n turned . MAINTAINS UO 30 TO 40 CC.POS 4,600 CC .HCT 27 .3 .PT \n X1 ,NG HOOKED TO SX FOR CL GREEN.ASPIRIN GIVEN PER RECTUM, PLAVIX GIVEN\n LATER AT 3PM.TOL OG BEING CLAMPED THIS PM.\n Action:\n TITRATE PRESSERS FOR OPTIMUM HEMODYNAMICS .\n Response:\n SLOW WEAN OF LEVOPHED C MAPS ABOVE 60\n Plan:\n WEAN PRESSERS AS TOL ,FOLLOW HCT ,HEMODYNAMICS ,MONITOR FOR BLEEDING\n Pain control (acute pain, chronic pain)\n Assessment:\n SP L ROTATOR SX .DSD D/I,NO BLEEDING NOTED .ON FENTANYL DRIP\n Action:\n FENTANYL 100 MIC/KG CONT C 25 MIC BOLLUSES PRN FOR PAIN\n Response:\n APPEARS COMFORTABLE\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n 7.38/27/93/95 ON 65%/CMV 550/HR 24/8 PEEP ,HX COPD.t max 101 .2\n Action:\n WEAN FIO2,SX PRN , MDI ,Tylenol for temp\n Response:\n SAT 94 TO 97\n Plan:\n PULMONARY TOILET ,WEAN AS,TOL SX PRN\n" }, { "category": "Nursing", "chartdate": "2176-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576807, "text": "Shock, cardiogenic/Septic.\n Assessment:\n Pressor & IABP dependent. Pressors-dopamine @ 3mcg/kg/min & levophed @\n 0.11mcg/kg/min. IABP 1:1 with MAPs 60-70\ns, good augmentation, & good\n systolic/diastolic unloading. PADs 17-22 & CVP 11-13. Latest CO/CI/SVR\n @ 0330=7/3.7/700. Heparin gtt @ 950u/hr. Temp max 101.2 core @\n 2100-0500 temp 99.1. Easily agitated-drops MAPs when agitated. Does not\n follow commands. Sedated with fentanyl & versed gtts.Soft restraints to\n upper extrem & leg immobilizer right leg for patient safety.Overall I&O\n positive-uo approximately >50mlhr. Intubated/vented with present\n setting-CMV/AS 550X24 60% +8. Hypoactive bowel sounds-OGT to\n intermittent suction-bilious. Requiring insulin coverage for FSBS.\n Action:\n Levophed slowly weaned. Appropriate safety measures inplace. Fentanyl &\n versed gtts increased slightly. VAP protocol followed-Good pulmonary\n toilet. ABX given as ordered. Without Tylenol. OGT to intermittent\n suction-bilious. FSBS covered as indicated. Frequent position chgs &\n skin care.\n Response:\n Remains pressor & IABP dependent. Tolerating slow levophed wean-does\n drop MAPs @ times with decrease, but returns to baseline quickly.\n Tolerating turnjing-without significant drop in MAPs. Improved\n hemodynamics with increase in sedation-not as labile. Stable CO?CI?SVR\n with decrease in levophed. Improved ABG. Skin intact.\n Plan:\n Continue present management . contin slow levophed wean/dc. ?needs\n higher PAD-fluids. Continue adeq safety measures/sedation. Support\n pt/family as indicated.\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577577, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs ranging from mid 40s-90s on Dopamine gtt and IABP w/o\n any change in gtt. HR ^ 60-70s w/ lower BPs with any stimulation. Very\n sensitive to few drops/changes in dopa. Gd perfusion distally. Heparin\n gtt therapeutic\n Action:\n Dopa titrated for MAPs > 55.\n Response:\n Remains pressor dependent. Unable to wean Dopa below 3 mcg/k/min (range\n 3-5mcg overnight). CO/CI/SVR 7.3/3.9/722 (6/3.2/725) on 3 mcg/k/min\n Dopa. IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n -700cc at MN (goal -500cc)\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics, uop, distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desat to 89% on 40% FI02\n Action:\n sxn\nd for sm amts thick tan secretions, MDI , FI02 increased to\n 50%.\n Response:\n Sats slowly up to 92-96% on 50% Fi02. PO2 74 on 50%--team aware\n Plan:\n Wean vent as . Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. Occas poor waveform, positional. TEAM\n AWARE)\n Continue VAP bundle per protocol.\n Altered mental status (not Delirium)\n Assessment:\n On 75mcg/hr fent, 2 mg/hr versed. Not following commands or\n overbreathing vent. Spontaneous mvmts to all extremities. Agitated,\n moving in bed w/ stimulation (repositioning, mouth care) w/ subsequent\n hypotension\n Action:\n Mental status monitored, re-oriented. Freq sm adjustments made in bed\n labile BPs and IABP\n Response:\n Daily wake not done tenuous BPs\n Pt easily agitated, thrashing in\n bed, lifting both legs off bed.\n Plan:\n Wean sedation as . Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n Thrombocytopenia, acute\n Assessment:\n PLT 111\n Action:\n protonix, famotidine, vanco and zosyn d/ced yesterday as they can cause\n a thrombocytopenia. Blood sent for HIT yesterday.\n Response:\n No evidence of bleeding. AM HCT 27.8 (31)\n Plan:\n monitor plt and assess for signs of bleeding. Continue\n heparin gtt for now.\n Alteration in Nutrition\n Assessment:\n TF started yesterday. KUB showed no ileus/obstruction. No further\n vomiting since . No stool overnight\n Action:\n TF slowly advanced recent vomiting. Residuals checked frequently.\n Colace given\n Response:\n Tolerating TF, currently at 40ml/hr.\n Plan:\n Advance TF as , advance at 08:00 if residuals WNL.\n GOAL RATE 55,\n Limit sedation if possible\n FS QID, tx w/ HISS\n" }, { "category": "Nursing", "chartdate": "2176-04-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576501, "text": ".H/O coronary artery bypass graft (CABG)\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": "2176-04-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576502, "text": "Demographics\n Day of intubation: 1\n Day of mechanical ventilation: 1\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location: Diagnostic lab\n Reason: Emergent (1st time); Comments: arrested in the cath lab.\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: cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: Sputum specimen was obtained and sent to micro.\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:\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt will T/Fer to CCU after shift change\nS/P arrest in the Cath Lab.\n, RRT 18:34\n" }, { "category": "Nutrition", "chartdate": "2176-04-27 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 576676, "text": "Subjective\n unable to assess due to intubation\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 168 cm\n 76.4 kg\n 27.1\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64.4 kg\n 119 %\n Diagnosis: STEMI/cardiac cath\n PMH : CAD s/p CABG ', PVD, HTN, hyperlipidemia, GERD,\n anxiety/depression, Ulcerative colitis, colonic polyps\n Food allergies and intolerances: none noted\n Pertinent medications: Fentanyl drip, Heparin drip, Versed drip,\n Norepinephrine drip, Dopamine drip, Colace, HISS, ABX, NaCl bolus,\n Mesalamine\n Labs:\n Value\n Date\n Glucose\n 125 mg/dL\n 01:40 PM\n Glucose Finger Stick\n 145\n 07:00 AM\n BUN\n 28 mg/dL\n 08:17 AM\n Creatinine\n 2.1 mg/dL\n 08:17 AM\n Sodium\n 135 mEq/L\n 12:45 AM\n Potassium\n 4.5 mEq/L\n 08:17 AM\n Chloride\n 104 mEq/L\n 12:45 AM\n TCO2\n 16 mEq/L\n 12:45 AM\n PO2 (arterial)\n 92. mm Hg\n 01:40 PM\n PCO2 (arterial)\n 27 mm Hg\n 01:40 PM\n pH (arterial)\n 7.38 units\n 01:40 PM\n pH (urine)\n 5.0 units\n 03:31 PM\n CO2 (Calc) arterial\n 17 mEq/L\n 01:40 PM\n Calcium non-ionized\n 8.1 mg/dL\n 12:45 AM\n Phosphorus\n 2.3 mg/dL\n 12:45 AM\n Magnesium\n 3.2 mg/dL\n 12:45 AM\n ALT\n 50 IU/L\n 03:30 PM\n Alkaline Phosphate\n 64 IU/L\n 03:30 PM\n AST\n 442 IU/L\n 03:30 PM\n Total Bilirubin\n 1.0 mg/dL\n 03:30 PM\n WBC\n 10.2 K/uL\n 12:45 AM\n Hgb\n 10.3\n 01:43 PM\n Hematocrit\n 27.4 %\n 02:22 PM\n Current diet order / nutrition support: Diet: NPO\n Tube feed: Nutren Pulmonary @ 10ml/hr, goal = 50ml/hr\n GI: soft/distended, hypoactive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs\n per admit wt\n Calories: -2140 (BEE x or / 25-28 cal/kg)\n Protein: 76-92 (1-1.2 g/kg)\n Fluid: team\n Estimation of previous intake: likely adequate\n Estimation of current intake: Inadequate due to NPO\n Specifics:\n Assessment and Plan\n 75 YO man admitted with STEMI in perioperative period (s/p shoulder\n surgery) and now with cardiogenic shock s/p IABP. Witnessed aspiration\n in cath lab and emergently intubated. Patient remains\n intubated/sedated and on pressor support.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement:\n Tube feeding / TPN recommendations:\n Check chemistry 10 panel daily\n Comments:\n" }, { "category": "Nursing", "chartdate": "2176-04-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576677, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\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": "2176-04-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576937, "text": "75 year old male with hx of CABG ( LIMA to LAD, SVG to PDA, OM and\n Diag ) Transferred from OSH POD #1 following left rotator surgery. EKG\n with q\ns INF and STE in III and AVF.To the cath lab on for\n intervention. OM and Diag grafts closed and svg to om was diffusely\n diseased with a tight distal lesion. Thrombectomy to SVG-OM and distal\n aspect stented times 3 but sudden drop in BP with increased STE inf\n requiring dopamine. IABP for hypotension. Emergent intubation for\n vomiting and aspiration.\n Shock, cardiogenic\n Assessment:\n SR C PAC,PVC.BP LABILE UNABLE TO WEAN DOWN LEVOPHED AND DOPAMINE\n .TOLERATED 1UNIT PRBC AND FLUID BOLLUS.LATEST CI 4.2,SVR 842 ON 3 MIC\n DOPAMINE,.084 MIC LEVOPHED .IABP 1:1 12 TO 20,DU 10 TO 15 . DISTAL\n PULSES BY DOPPLER .PAD 16 TO 21 ,W 18 TO 9 .MV SAT 76 .CVP 8 TO 14\n .HEPARIN 950 UNITS .\n Action:\n ATTEMPTED TO WEAN PRESSERS SLOWLY ,TRANSFUSED 2CD UNIT PRBC\n Response:\n REMAINS PRESSER DEPENDENT\n Plan:\n FOLLOW HEMODYNAMICS,WEAN PRESSERS SLOWLY ,RECHECK HCT AFTER 2CD UNIT\n SUPPORT C FLUID BOLLUSES PER RESIDENT\n Pain control (acute pain, chronic pain)\n Assessment:\n SP SX INCISION C/D GRIMACES WHEN MOVED\n Action:\n FENTANYL DRIP\n Response:\n APPEARS COMFORTABLE EXCEPT WHEN MOVING\n Plan:\n CONTINUE FENTANYL\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PT C COPD AND ASP PNA .PT AGAIN TODAY\n Action:\n OG TO SX MOST OF DAY,READMINISTERED PLAVIX P PT . SX PRN\n Response:\n ABG ON 5PEEP/60%/550 /20 736/32/112/19/100\n Plan:\n VAP PROTOCOLS,MONITOR CLOSELY FOR VOMITING\n" }, { "category": "Nursing", "chartdate": "2176-04-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577496, "text": "75 year old male transferred from OSH s/p perioperative STEMI. Cardiac\n Cath:3 BMS to distal SVG to OM. Cardiac Cath complicated by hypotension\n requiring pressors-dopamine/levophed & IABP placement. Further\n complicated by vomiting/aspiration requiring emergent intubation.\n Admitted to CCU-intubated & vented, PA Line & IABP, & pressors.\n Shock, cardiogenic\n Assessment:\n BP continues to be very labile, MAPS range from 40\ns to 100\ns. HR\n trending lower over shift now in 50\n Action:\n Dopa titrated to maintain MAPS>55 heparin remains at 1100 units with\n therapeutic PTT\n Response:\n Dopa ranged from 2-5.5mcg/kg/min now at 3. Last set of numbers\n CO/CI/SVR 6/3.2/725 on 3 of dopa.IABP 1:1 with systolic/ diastolic\n unloading and good augmentation.\n Plan:\n Wean dopa maintaining MAPS>55. cont to follow hemodynamics, urine\n output and pulses.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n On 60% FIO2 this am. First ABG PaO2 165, suctioning thick tan\n secretions q2-3. lungs clear diminished at bases\n Action:\n Turned q2, frequent oral care,suctioned prn. Abx changed to po\n levoquin. Weaned FIO2 to 50%\n Response:\n Great ABG on 50% 7.41/34/98 ,turned down to 40%\n Plan:\n Check ABG on 40%, cont with frequent turning, suctioning as needed,wean\n vent as tolerated\n Altered mental status (not Delirium)\n Assessment:\n Received on fentanyl @ 50mcg/hr versed @1.5mg/hr very agitated/\n thrashing about. Requiring boluses of fent and versed. No response to\n voice and does not follow any commands\n Action:\n Fentatnyl increased to 75 and versed increased to 2mg.\n Response:\n Comfortable until any hands on care is delivered. Quickly becomes very\n agitated, attempting to bend both knees\n Plan:\n Wean sedation as tolerated. Pain control for left shoulder s/p rotator\n cuff surgery.\n Heme: plt ct now down from 230,000. famotidine,protonix, vanco\n and zosyn d/ced as they can cause a thrombocytopenia. Blood sent for\n HIT.\n Plan: cont to monitor plt ct and assess for signs of bleeding.\n" }, { "category": "Respiratory ", "chartdate": "2176-04-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576923, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 5 mL /\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 Comments:\n Secretions\n Sputum color / consistency: Tan / 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: Not triggering\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: Underlying illness\n not resolved\n :\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577563, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK\n Shock, cardiogenic\n Assessment:\n Labile BPs, MAPs ranging from mid 40s-90s on Dopamine gtt and IABP w/o\n any change in gtt. HR ^ 60-70s w/ lower BPs with any stimulation. Very\n sensitive to few drops/changes in dopa. Gd perfusion distally. Heparin\n gtt therapeutic\n Action:\n Dopa titrated for MAPs > 55.\n Response:\n Remains pressor dependent. Unable to wean Dopa below 3 mcg/k/min (range\n 3-5mcg overnight). CO/CI/SVR 7.3/3.9/722 (6/3.2/725) on 3 mcg/k/min\n Dopa. IABP 1:1 w/ good augmentation and systolic/diastolic unloading.\n -700cc at MN (goal -500cc)\n Plan:\n Wean Dopa as tolerated\n follow hemodynamics, uop, distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Desat to 89% on 40% FI02\n Action:\n sxn\nd for sm amts thick tan secretions, MDI , FI02 increased to\n 50%.\n Response:\n Sats slowly up to 92-95% on 50% Fi02. PO2 74 on 50%--team aware\n Plan:\n Wean vent as . Follow ABGs. (of note: art line off IABP\n very dampened w/ no bld rtn. Occas poor waveform, positional. TEAM\n AWARE)\n Continue VAP bundle per protocol.\n Altered mental status (not Delirium)\n Assessment:\n On 75mcg/hr fent, 2 mg/hr versed. Not following commands or\n overbreathing vent. Spontaneous mvmts to all extremities. Agitated,\n moving in bed w/ stimulation (repositioning, mouth care) w/ subsequent\n hypotension\n Action:\n Mental status monitored, re-oriented\n Response:\n Daily wake not done tenuous BPs\n Pt easily agitated, thrashing in\n bed, lifting both legs off bed.\n Plan:\n Wean sedation as . Attempt daily wake ups/RSBIs.\n Pain management as pt had recent L rotator cuff .\n Thrombocytopenia, acute\n Assessment:\n PLT 111\n Action:\n protonix, famotidine, vanco and zosyn d/ced yesterday as they can cause\n a thrombocytopenia. Blood sent for HIT yesterday.\n Response:\n No evidence of bleeding. AM HCT 27.8 (31)\n Plan:\n monitor plt and assess for signs of bleeding. Continue\n heparin gtt for now.\n Alteration in Nutrition\n Assessment:\n TF started yesterday. KUB showed no ileus/obstruction. No further\n vomiting since . No stool overnight\n Action:\n TF slowly advanced recent vomiting. Residuals checked frequently.\n Colace given\n Response:\n Tolerating TF, currently at 40ml/hr.\n Plan:\n Advance TF as , advance at 08:00 if residuals WNL.\n GOAL RATE 55,\n Limit sedation if possible\n FS QID, tx w/ HISS\n" }, { "category": "Nursing", "chartdate": "2176-04-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 576997, "text": "Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2176-04-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 576998, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Tube Type\n ETT:\n Position: 23 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: 5 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n 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: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2176-05-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578241, "text": "Chief Complaint:\n 24 Hour Events:\n INVASIVE VENTILATION - STOP 01:06 PM\n PA CATHETER - STOP 04:13 PM\n NON-INVASIVE VENTILATION - START 05:30 PM\n NON-INVASIVE VENTILATION - STOP 06:18 PM\n NON-INVASIVE VENTILATION - START 06:37 PM\n - Extubated, satting 92-97% on 6L NC this AM, but O/N Hypertensive,\n hypoxic to mid 80's--crackles on exam gave 100mg IV lasix and started\n BIPAP--> resp status and vitals improved\n - Gave 2.5 mg IV lopressor for hr in low 100's\n - Started nitro drip titrated for SBP < 150\n - I/O check (20mg lasix in AM, 100mg in PM): -3L\n - had bowel movement\n - Vomited this AM while suctioning himself; denied nausea\n - c/o dizziness, feeling \"vertical\"\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Carafate (Sucralfate) - 11:24 AM\n Heparin Sodium (Prophylaxis) - 11:24 AM\n Metoprolol - 04:00 PM\n Furosemide (Lasix) - 05:15 PM\n Morphine Sulfate - 05:15 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 36.5\nC (97.7\n HR: 94 (78 - 114) bpm\n BP: 152/64(94) {101/57(75) - 152/70(95)} mmHg\n RR: 34 (14 - 42) insp/min\n SpO2: 93%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 20 (13 - 26)mmHg\n PAP: (56 mmHg) / (35 mmHg)\n Total In:\n 739 mL\n 183 mL\n PO:\n 100 mL\n TF:\n 252 mL\n IVF:\n 487 mL\n 83 mL\n Blood products:\n Total out:\n 3,985 mL\n 450 mL\n Urine:\n 3,985 mL\n 450 mL\n NG:\n Stool:\n Drains:\n Balance:\n -3,246 mL\n -267 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 661 (560 - 1,383) mL\n PS : 8 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 95%\n RSBI: 10\n PIP: 14 cmH2O\n SpO2: 93%\n ABG: 7.48/36/143/24/4\n Ve: 5.1 L/min\n PaO2 / FiO2: 238\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t) Systolic,\n No(t) Diastolic)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Bronchial:\n , Rhonchorous: )\n Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended,\n No(t) Tender:\n Extremities: Right: 2+, Left: 2+\n Skin: Not assessed\n Neurologic: Attentive, Follows simple commands, Responds to: Not\n assessed, Oriented (to): (\" ,\" \"Saturday\" but thinks it's\n , \"\"), Movement: Not assessed, Tone: Not assessed\n Labs / Radiology\n 205 K/uL\n 9.2 g/dL\n 97 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 3.8 mEq/L\n 22 mg/dL\n 106 mEq/L\n 145 mEq/L\n 27.7 %\n 9.1 K/uL\n [image002.jpg]\n 04:18 PM\n 04:42 PM\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n WBC\n 6.0\n 7.8\n 9.1\n Hct\n 25.8\n 27.9\n 27.7\n Plt\n 127\n 150\n 205\n Cr\n 1.2\n 1.3\n 1.2\n TCO2\n 25\n 25\n 25\n 22\n 27\n 28\n Glucose\n 104\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:1.9 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n # Cardiogenic Shock/STEMI. Pressures from 101/53 - 157/76.\n - Marked improvement yesterday, will monitor today.\n - Continue to hold ACE-I for now given continuing BP lability\n - Continue ASA 325, Plavix 75, simva 80, sq heparin\n - nitro drip for SBP > 150\n .\n # PUMP: Received lasix 20mg, 100mg, is -3L and clinically euvolemic.\n - Goal even\n .\n # RHYTHM: NSR with more volatile HR 85-114, sporadic PVCs. Received\n lopressor x1 2.5mg\n - Lopressor 2.5 mg if needed for HR > 110\n .\n # Resp Failure/Aspiration: SaO2 92-97% on 6L NC.\n - ABG 7.48/36/143; respiratory alkalosis. Will monitor for improvement\n as respiratory status improves. Likely related to agitation as sedation\n was weaned.\n - frequent suctioning\n - continue COPD meds, now with standing albuterol and ipratropium q4h\n - Day Abx course (levaquin) for suspected aspiration\n .\n # Vomiting: Likely related to self-suctioning, RN.\n - Ondansetron PRN, monitor\n .\n # Dizziness: Thinks he is vertical. Given normotensive, may be related\n to weaning sedation or inner-ear process.\n - Check orthostatics given prior concern for autonomic dysregulation\n - Use zofran PRN\n - If not improved this PM, ENT consult\n .\n # Rash on back: be related to heating pad used for home PT for\n spinal stenosis. Will monitor for change.\n .\n # Anemia: Hct stable since yesterday, now 27.7.\n - Check iron studies\n .\n # Sedation: Off of propofol. Did not require haldol.\n - PT consult and OOB today.\n .\n # Abdominal distension. Resolved with BM overnight. No pain.\n - Continue bowel regimen PRN (senna, colace)\n - Continue to monitor by physical exam\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n - Will contact OSH for rec's\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # FEN: Cont maintenance fluids. will monitor PO intake today. Now on\n sucralfate.\n - D/C foley today.\n # Access: Cortis, 2x forearm IVs, A-line.\n - Can likely D/C Cortis, A-line today.\n # Dispo: To floor\n FULL CODE\n" }, { "category": "Respiratory ", "chartdate": "2176-05-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577971, "text": "TITLE:\n Demographics\n Day of intubation: \n Day of mechanical ventilation: 8\n Ideal body weight: 64.4\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location: ICU\n Reason: Emergent (1st time)\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 5 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: A/C 550x16/+8 peep/.7\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: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Comments: RSBI held d/t fio2/peep level\n" }, { "category": "Nursing", "chartdate": "2176-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577973, "text": "Shock, cardiogenic\n Assessment:\n Tolerating iabp dc & dopamine wean & dc with stable co/ci/svr. Without\n change in pa #\n Action:\n Response:\n Hemodynamically stable off iabp & dopamine gtt.\n Plan:\n Contin to monitor hemodynamics. Contin present management. ?dc pa\n line-chg to mlc.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on peep 8 with stable abg\ns & sats.\n Action:\n ABGs monitored, sxn\nd for sm/mod amts tan/bld tinged secretions.\n Response:\n Stable sats.\n Plan:\n Wean vent as tol, continue VAP bundle per protocol. Contin pna abx\n coverage.\n Altered mental status (not Delirium)\n Assessment:\n Very restless/agitated on fent/versed gtts. Moving all extremities off\n bed. Not following commands/tracking. Grimacing at times\n Action:\n Pt re-oriented/re-directed. Attempting slow sedation wean. Haldol prn\n fro increased agitation.\n Response:\n Continued periods of increased restlessness/agitation.\n Plan:\n Wean sedation. Reorient PRN. ***? Haldol for agitation. Pain\n management for recent L rotator cuff surgery\n Alteration in Nutrition\n Assessment:\n TF restarted after iabp dc. Presently @ 25ml/hr with goal 55ml/hr.\n minimal residuals.\n Action:\n Bowel meds given. Follow residuals.\n Response:\n Minimal residuals.\n Plan:\n Increase to goal as tolerated.\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578156, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Altered mental status (not Delirium)\n Assessment:\n Pt oriented to person and place, restless at times, cooperative, unable\n to sleep, anxious to get up and start moving about. Confused about\n recent events.\n Action:\n Reoriented as needed, maintains safety measures\n Response:\n Pt without attempts to get out of bed\n Plan:\n Increase daytime activity as tolerated. Reorient prn, maintain safety\n measures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Initially on mask ventilation, pt removed at 2100 and tried on high\n flow neg at 95%, maintained good sats and ventilation. Pt bothered by\n sound of high flow neb. Cough productive of blood tinged sputum.\n Action:\n Weaned high flow mask to NC 6L, enc coughing and deep breathing.\n Response:\n Maintaining sats 92-95% on 6L NC, clearing secretions well.\n Plan:\n Cont pul toilet, wean O2 as able. Monitor fluid balance, UO and adm.\n diuretics as indicated\n Shock, cardiogenic\n Assessment:\n Pt weaned from IABP and pressors, extubated yesterday. Stabilized from\n episode of acute pul edema yest eve. Diuresed well.\n Action:\n Weaned off IV NTG, titrated oxygen, monitored lytes with diuresis\n Response:\n BP improved, pt had good diuresis and NTG weaned to off.\n Plan:\n Cont to follow lung exam, sats, UO, fluid balance.\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578378, "text": "Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Denies CP. HR 70-80\ns SR. no VEA. BP 120-130\ns/ K+ 3.2\n Action:\n Repleted 20meq KCL po. Started lopressor 12.5mg PO.\n Response:\n VSS. Reporting mild dizziness when turning in bed but not when sitting\n up. Resolves on own. Laying flat in bed tolerated well. No further\n c/o\n Plan:\n Contin. Lisinopril and lopressor. Monitor lytes. Monitor for further\n dizzy spells.\n Nausea / vomiting\n \nt feel that good\n Assessment:\n Pt. c/o slight nausea in the eve. Asking for basin but did not spit\n up. Asking for water and gingerale.\n Action:\n Zofran 4mg IV x1\n Response:\n Passing flatus. Multiple reports of thinking he had BM but false. Had\n small loose stool- incontinent. c/o stomach rumblings but no further\n nausea. Having sips of clear liqs tolerated well.\n Plan:\n Contin. Stool regiman. Commode in room.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n (-) 300cc at 2100 with goal of 1L. had not voided since foley d/c\n earlier in the day.\n Action:\n Lasix 20mg IV x1. pt. with strong urge to void following lasix but\n unable . sat up on side of bed etc.\n Foley was replaced ~ 2200 with 500cc u/o.\n Response:\n Neg. 900cc for . prod. Strong cough of thick tan secretions.\n Plan:\n ? d/c foley again today. Monitor plan for further diuresis. Monitor\n sats.\n Pain control (acute pain, chronic pain)\n Assessment:\n c/o left shoulder pain ~ 2200. also reporting left knee pain but\n only . asking for icepacks.\n Action:\n Tylenol x1 in eve. Ice packs to shoulder and knee in the eve. Med\n with 25mg trazadone x1 for sleep\n Response:\n Difficulty falling asleep but eventually did sleep for a few hours.\n At 0600- pt. awake and denied shoulder and knee pain. refused\n Tylenol.\n Plan:\n OOB today. Tylenol prn.\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578153, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt oriented to person and place, restless at times, cooperative, unable\n to sleep, anxious to get up and start moving about.\n Action:\n Reoriented as needed, maintains safety measures\n Response:\n Pt without attempts to get out of bed\n Plan:\n Increase daytime activity as tolerated. Reorient prn, maintain safety\n measures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Initially on mask ventilation, pt removed at 2100 and tried on high\n flow neg at 95%, maintained good sats and ventilation. Pt bothered by\n sound of high flow neb. Cough productive of blood tinged sputum.\n Action:\n Weaned high flow mask to NC 6L, enc coughing and deep breathing.\n Response:\n Maintaining sats 92-95% on 6L NC, clearing secretions well.\n Plan:\n Cont pul toilet, wean O2 as able. Monitor fluid balance, UO and adm.\n diuretics as indicated\n Shock, cardiogenic\n Assessment:\n Pt weaned from IABP and pressors, extubated yesterday. Stabilized from\n episode of acute pul edema yest eve. Diuresed well.\n Action:\n Weaned off IV NTG, titrated oxygen, monitored lytes with diuresis\n Response:\n BP improved, pt had good diuresis and NTG weaned to off.\n Plan:\n Cont to follow lung exam, sats, UO, fluid balance.\n" }, { "category": "Nursing", "chartdate": "2176-05-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577699, "text": "Shock, cardiogenic\n Assessment:\n Pt with IABP, in cardigemnic shock on dopamine drip. At 0400 AM CI 3.9\n MVo2 71 MAP 60-70\n Action:\n Shut off dopamine per Dr. , MAPS trended down and after two hours\n MAPs 47-48 on 1:1 IABP\n This was after pt rec lasix and Dopamine was shut off. CI droped to\n 2.5 MVo2 dropped to 59\n Response:\n PT MAPS were low and cardiology decided to restart Dopamine. We then\n decided to decrease IABP to 1:2 as pt appears to have improved MAPS on\n that. MAPs up after measures current;y 70-90 CI 2.9 CVP 9 ( was \n in AM) PAD down also 15-18 ( was 20-24\n Plan:\n Wean IABP to OFF, keep dopamine for now, wean sedation on MINIMAL\n sedation but Bolus inbetween to keep pt calm and pain free.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n PT became restless early this AM with daily wake up. VERY restless\n thrashing about in bed. Desaturated to 88 and stayed there.\n Action:\n Team eval pt, Respiratory increased O2 to 70 percent, we did suction\n mod tan secreatoins, CXR was done.\n Response:\n Pt responded to vent changes and sedation, See ABG\n Plan:\n Not ready to wean vent yet, continue follow ABG via Art line\n Alteration in Nutrition\n Assessment:\n Pt with distended belly, + hypoactive bowel sounds, 180cc tube\n feeding residual this am at 0800\n Action:\n Held feeding x 4 hours restarted at 30 cc per hour\n Response:\n Tolerating currently check TF residual again at 8 PM\n Plan:\n Increase tube feed as tolerated, ? reglan\n Altered mental status (not Delirium)\n Assessment:\n Pt woken up today for daily wake up. Pt thrashes, does turn head toward\n voice to command but inconsistently, did not squeeze my hand , not\n follow any other simple commands, does move all 4 extremities non\n purposefully and spontaneously.\n Action:\n Lightened pt to 1mg versed and 25 Fentanyl with Bolus doses PRN as\n discussed with team\n Response:\n Pt restless at times but sleeping after bolus. Arousable to light\n stimulation.\n Plan:\n Follow neuro exam keep pt lightly sedated.\n" }, { "category": "Respiratory ", "chartdate": "2176-05-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577704, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 6\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\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: Tan / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Pt received on AC as noted.\n PEEP increased from 5 to 8 and FiO2 increased from 50% to 70% secondary\n to PaO2 of 60; follow up PaO2 68.\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: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578151, "text": "Altered mental status (not Delirium)\n Assessment:\n Pt oriented to person and place, restless at times, cooperative, unable\n to sleep, anxious to get up and start moving about.\n Action:\n Reoriented as needed, maintains safety measures\n Response:\n Pt without attempts to get out of bed\n Plan:\n Increase daytime activity as tolerated. Reorient prn, maintain safety\n measures.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Initially on mask ventilation, pt removed at 2100 and tried on high\n flow neg at 95%, maintained good sats and ventilation. Pt bothered by\n sound of high flow neb. Cough productive of blood tinged sputum.\n Action:\n Weaned high flow mask to NC 6L, enc coughing and deep breathing.\n Response:\n Maintaining sats 92-95% on 6L NC, clearing secretions well.\n Plan:\n Cont pul toilet, wean O2 as able. Monitor fluid balance, UO and adm.\n diuretics as indicated\n Shock, cardiogenic\n Assessment:\n Pt weaned from IABP and pressors, extubated yesterday. Stabilized from\n episode of acute pul edema yest eve. Diuresed well.\n Action:\n Weaned off IV NTG, titrated oxygen, monitored lytes with diuresis\n Response:\n BP improved, pt had good diuresis and NTG weaned to off.\n Plan:\n Cont to follow lung exam, sats, UO, fluid balance.\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 578446, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Alteration in Nutrition\n Assessment:\n Due to episodes of vomiting and intermittent dizziness has not had much\n of an appetite and has not eaten today. Tolerating liquid.\n Action:\n Offering small amounts of food\n Response:\n Not feeling like eating at this time\n Plan:\n Now that pt has had good BM appetite may improve. Cont to offer food\n especially while OOB to chair\n Nausea / vomiting\n Assessment:\n With episode of coughing this am,vomited mod amount. Has not had good\n BM since admission, still gets dizzy with turns especially to right\n side\n Action:\n Given zofran,and fleets enema\n Response:\n No more vomiting, able to tolerate pills, good BM post enema\n Plan:\n Give zofran as needed, monitor bowels and cont with colace and senna,\n turn slowly\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hemodynamically stable. lisinopril and lopressor both started\n yesterday. HR 70-88 NSR, BP 120-148/60-70\n Action:\n Lisinopril increased to 10mg daily, OOB to chair.\n Response:\n Remains hemodynamically stable, easier get OOB from yesterday\n Plan:\n Titrate lisinopril and lopressor as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Cont to have shoulder pain s/p surgery.\n Action:\n Tylenol and ice pack and sling\n Response:\n Pain decreased with above interventions\n Plan:\n Cont with Tylenol and ice packs,sling.\n Impaired Skin Integrity\n Assessment:\n Has yeasty looking rash in groin. Pink/red not open. Mid back has area\n that appears to be the site of a previous burn maybe with heating pad\n which the pt has used for pain control in the past. Area is unbroken\n Action:\n Cleansed with aloe vesta and miconazole powder applied\n Response:\n Looks less better than yesterday, does not appear as inflamed as\n yesterday\n Plan:\n Cont with miconazole powder\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breathing became more labored, crackles throughout with wheezes\n Action:\n Team notified and examined pt, chest xray taken and atroven MDI\n Response:\n Improved, now with bibasilar crackles. Started incentive spirometry\n Plan:\n Cont with incentive spirometer and monitor resp and volume status.\n GU: unable to void with foley out , once foley placed put out 500cc.\n urine output greatly reduced and urine amber with sediment\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n Demographics\n Attending MD:\n J.\n Admit diagnosis:\n ST-SEGMENT ELEVATION MYOCARIAL INFARCTION CARDIAC CATH\n Code status:\n Full code\n Height:\n 66 Inch\n Admission weight:\n 76.4 kg\n Daily weight:\n 86.9 kg\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions:\n PMH: Anemia\n CV-PMH: CAD, Hypertension, PVD\n Additional history: ulcerative colitis in remission, CAd s/p bypass,\n history of adenomatous colon polyps, s/p carotid artery surgery.\n Surgery / Procedure and date: Stent x 3\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:140\n D:82\n Temperature:\n 97.8\n Arterial BP:\n S:152\n D:67\n Respiratory rate:\n 27 insp/min\n Heart Rate:\n 77 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 94% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 95% %\n 24h total in:\n 480 mL\n 24h total out:\n 615 mL\n Pertinent Lab Results:\n Sodium:\n 144 mEq/L\n 05:32 AM\n Potassium:\n 3.8 mEq/L\n 05:32 AM\n Chloride:\n 103 mEq/L\n 05:32 AM\n CO2:\n 25 mEq/L\n 05:32 AM\n BUN:\n 29 mg/dL\n 05:32 AM\n Creatinine:\n 1.5 mg/dL\n 05:32 AM\n Glucose:\n 103 mg/dL\n 05:32 AM\n Hematocrit:\n 31.6 %\n 05:32 AM\n Finger Stick Glucose:\n 123\n 05:00 PM\n Valuables / Signature\n Patient valuables: Dentures: (Upper, Lower, Partial / Bridge )\n Other valuables:\n Clothes: Transferred with patient\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with:\n Jewelry:\n Transferred from: \n Transferred to: \n Date & time of Transfer: 12:00 pm\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578287, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. Now off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Pain control (acute pain, chronic pain)\n Assessment:\n Having no pain in left shoulder\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n 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": "2176-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577894, "text": "Shock, cardiogenic\n Assessment:\n Today pt BP had improved as well as CI ( see metavision for numbers) ,\n IABP was weaned and then to be pulled today. Pt was also diuresed\n again today with 20mg IV lasix. stim done and pt thought to have\n insufficient response so hydrocortisone was ordered. Heparin was shut\n off at 0900 AM and IABP was pulled at 3 PM. One hour later Mixed venous\n sat and CI were done, then dopamine was shut off. Pt tolerated this\n although his CI did drop somewhat. His SVR remains 700-800 Pt had been\n sedated for IABP removal.\n At 5 PM pt stared oozing from IABP insertion site, pressure was held\n immediately. No hematoma\n Action:\n Pt weaned off IABP and dopamine\n CI remains WNL mix venous 71 off IABP\n and 67 off both IABP and Dopamine.\n Response:\n CI remains WNL mix venous 71 off IABP and 67 off both IABP and\n Dopamine. Right femoral groin site stable\n At this time.\n Plan:\n Keep pt sedated for six hours so that he does not thrash and re-bleed\n from IABP insertion site. start dopamine if MAPS drop ( check with\n team 0 but goal is to keep pt from being hypertensive in setting of re\n bleeding. Discussed with feloow hydrocortisone to start after 1130 PM\n keep maps 65-70. continue sedation for six hours then re-evaluate\n lowering sedation for plan weaning off ventilator.\n Altered mental status (not Delirium)\n Assessment:\n PT thrashing in bed moving all extremities disloged NGT today and was\n replaced then cxr then replaced again and another xray done results\n pending. Pt was lightened up for daily wake up in AM, Did attempt to\n maintain pt on light sedation most of day, with bolus when restless.\n However we did have to increase sedation for agitation several times.\n Pt does turn head toward you when called by name- but follows no other\n commands.\n Action:\n Pt sedated to keep lines in place, restrained and sedated for pt safety\n family aware they came to visit this AM.\n Currently on high dose versed and fentanyl to keep him from thrashing\n and rebleeding.\n Response:\n Pt very sedated currently. Airway stable on ventilator.\n Plan:\n Keep him sedated tonight, re evaluate with team after six hours- 1130\n PM. The team said they may order haldol.\n" }, { "category": "Nursing", "chartdate": "2176-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578125, "text": "SP STEMI POST OP SHOULDER SX ,CARDIOGENIC SHOCK,ASP PNA REQUIRED\n IABP,DOPAMINE ,LEVOPHED,INTUBATION,3 BMS PLACED .IABP DC ,DOPAMINE OFF\n \n Respiratory failure, acute (not ARDS/)INE\n Assessment:\n PT 12 NOON ,BECAME INCREASINGLY RESTLESS,DESATED,AUDIBLE\n WHEEZING AND RHONCHI . C/R BLOOD TINGED SPUTUM\n Action:\n 100MG LASIX,2MG MORHINE ,2.5 MG IV LOPRESSER.IV NITRO GTT\n Response:\n SAT 95,RESP 20, PT ORIENTED COOPERATIVE\n Plan:\n CONTINUE DIURESIS,RECHECK K, TITRATE IV NITRO ,CPAP AS TOL .E,NPO\n CONTINUE ANTIBX\n Shock, cardiogenic\n Assessment:\n SR TO ST C OCC PVCS,HYPERTENSIVE\n Action:\n IV LOPRESSER X1 , NOW ON IV NITRO,PA LINE DC ,CORDIS LEFT IN PLACE\n Response:\n BP UNDER 150 SYSTOLIC WHICH IS GOAL\n Plan:\n MONITOR FOR TACHYCARDIA\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578284, "text": "Pain control (acute pain, chronic pain)\n Assessment:\n Action:\n Response:\n Plan:\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n 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": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578327, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. Now off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Pain control (acute pain, chronic pain)\n Assessment:\n Having no pain in left shoulder while lying bed. After getting up to\n chair c/o pain, while in chair c/o pain in left knee, no swelling\n noted\n Action:\n Given 650mg Tylenol and ice pack applied to area. Sling placed on arm,\n ice to be applied to knee once in bed\n Response:\n Pain after Tylenol went to and with ice packs staying around a\n which pt says is acceptable.\n Plan:\n Offer Tylenol q6. ice packs as needed. Assess pain level at least q4.\n house staff notified of new knee pain. assess knee pain after ice\n applied.\n Alteration in Nutrition\n Assessment:\n Had episode of vomiting early this morning. Received zofran with\n relief. Couple episodes of fleeting moments of nausea. Poor appetite.\n Has been having very very small amounts of loose to semi formed stool.\n Action:\n Receiving reglan q6. given senna this evening, encouraging po intake\n especially while OOB to chair.\n Response:\n No improvement in appetite. No vomiting.\n Plan:\n Cont to encourage po intake. benefit from nutrition consult.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hemodynamically stable with HR 70-90 NSR, BP 113-155/57-73\n Action:\n Started lisinopril 5mg this morning.\n Response:\n BP maintained with no need for NTG for HTN\n Plan:\n Cont to monitor HR and BP, increase lisinopril as ordered and consider\n adding lopressor\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Received on 6l NP resp rate 22-30, productive cough, thick tan\n secretions, lungs clear diminished at bases\n Action:\n Given 20mg lasix this am\n Response:\n Good response to lasix initially put out 300cc, maintained good urine\n output via foley until 5pm when foley discontinued. Currently negative\n 600cc. weaned O2 to 4l NP\n Plan:\n Cont to monitor sats, resp rate and urine output\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 578432, "text": "Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\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": "Radiology", "chartdate": "2176-05-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081941, "text": " 10:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please confirm placement of new OG tube, thank you\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with OG tube ETT and IABP-Please confirm placement of new OG\n tube, thank you\n REASON FOR THIS EXAMINATION:\n Please confirm placement of new OG tube, thank you\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE AP CHEST, \n\n INDICATION: New OG tube placement.\n\n FINDINGS: Comparison made to .\n\n OG tube is seen in place, extending below the diaphragm and out of view.\n Endotracheal tube remains slightly high, just reaching the thoracic inlet,\n roughly 6 cm above the carina. Intraaortic balloon pump is unchanged in\n position, 1.3 cm above the top of the left main stem bronchus, 3.4 cm below\n the top of the aortic arch. Swan-Ganz catheter is unchanged in position, tip\n in the region of the right main pulmonary artery. Cardiomegaly is not\n significantly changed. Lung volumes are low, with stable areas of bibasilar\n atelectasis. There is no significant pleural effusion. There is no\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082130, "text": " 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with STEMI on vent\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc FRI 11:06 AM\n Left pleural effusion increased, with increasing adjacent atelectasis. Lung\n volumes are lower.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE\n\n REASON FOR EXAM: 75-year-old man with STEMI, on vent, evaluate interval\n change.\n\n Since yesterday, ETT tip is 5.7 cm above the carina, at the level of the upper\n clavicular heads. Nasogastric tube tip is below the diaphragm, not imaged on\n this study. Sternotomy wires are intact. A Swan-Ganz catheter ends in the\n right pulmonary artery. Intra-aortic balloon pump was removed. Heart size is\n still top normal. Left pleural effusion with adjacent atelectasis increased,\n still small. Lung volumes are lower.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082131, "text": ", J. 8:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with STEMI on vent\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PFI REPORT\n Left pleural effusion increased, with increasing adjacent atelectasis. Lung\n volumes are lower.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081770, "text": " 11:18 AM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: eval for pneumothorax or any other change\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man intubated, with new sudden hypoxia.\n REASON FOR THIS EXAMINATION:\n eval for pneumothorax or any other change\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE AP PORTABLE VIEW OF THE CHEST\n\n REASON FOR EXAM: hypoxia postop.\n\n Comparison is made with prior study performed 3 hours before. There are no\n acute interval choices.\n\n ET tube is seen in standard position. NG tube tip is in the stomach with side\n port at the level of the ET junction. Swan-Ganz catheter tip is in the right\n pulmonary artery. Intra-aortic balloon pump is in standard position. Left\n lower lobe collapse is persistent. Left pleural effusion is changed.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081730, "text": " 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change.\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock, intubated.\n REASON FOR THIS EXAMINATION:\n eval for change.\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 1:53 PM\n Intraaortic balloon pump in good position. Left small pleural effusion and LLL\n collapse is unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 75-year-old male with cardiogenic shock, intubated. Evaluate for\n change.\n\n COMPARISON: Multiple prior studies, the most recent were on .\n\n PORTABLE AP CHEST RADIOGRAPH: ET tube tip terminates 56 mm above the carina.\n Swan-Ganz catheter tip is located in the left pulmonary artery. Intraaortic\n balloon pump is in appropriate position, located 24 mm below the aortic arch.\n Unchanged small left pleural effusion and left basilar collapse. Heart size\n appears unchanged. NG tube follows appropriate course, with the side-hole\n present in the level of the GE junction.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1081731, "text": ", S. 7:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change.\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with cardiogenic shock, intubated.\n REASON FOR THIS EXAMINATION:\n eval for change.\n ______________________________________________________________________________\n PFI REPORT\n Intraaortic balloon pump in good position. Left small pleural effusion and LLL\n collapse is unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1082625, "text": " 10:54 AM\n CHEST (PA & LAT) Clip # \n Reason: eval for left lung nodule seen on portable cxr\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p STEMI and cardiogenic shock\n REASON FOR THIS EXAMINATION:\n eval for left lung nodule seen on portable cxr\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Left lung nodules seen on a previous chest radiograph. Please\n compare.\n\n COMPARISON: Comparison is made to a chest radiograph done earlier on the same\n day.\n\n FINDINGS: Frontal and lateral chest radiographs show bibasilar consolidation\n consistent with atelectasis, most pronounced at the retrocardiac area. The\n circular area of opacity described on the previous radiograph is not apparent\n and in retrospect, was likely an area of resolving atelectasis, though repeat\n frontal and lateral chest radiographs when the patient is able to take a\n better breath is recommended at a later date. Evidence of previous cardiac\n surgery is redemonstrated. Cardiomediastinal silhouette is stable as is the\n visualized osseous and soft tissue structures.\n\n" }, { "category": "Radiology", "chartdate": "2176-05-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082261, "text": " 4:49 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: ? interval change\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p STEMI c/b cardiogenic shock who was extubated this\n afternoon but is now hypoxic and tachypnic.\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n WET READ: DXAe FRI 7:36 PM\n ET tube has been removed. Left pleural effusion has resolved. R swan ganz\n catheter remains in place. No acute process\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW\n\n HISTORY: Cardiogenic shock with hypoxia and tachypnea.\n\n REFERENCE EXAM: at 9:00 a.m.\n\n FINDINGS: Standard endotracheal tube has been removed. The Swan-Ganz\n catheter tip is in the right main pulmonary artery. A large portion of the\n right lung cannot be adequately assessed due to overlying hardware. There is\n patchy alveolar infiltrate versus volume loss at the left base. Mediastinal\n clips and sternal wires are again seen. The NG tube has been removed.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-05-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1082007, "text": " 2:29 PM\n PORTABLE ABDOMEN; -76 BY SAME PHYSICIAN # \n Reason: NG tube position\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man with STEMI, cardiogenic shock\n REASON FOR THIS EXAMINATION:\n NG tube position\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, ONE VIEW.\n\n COMPARISON: .\n\n HISTORY: NG tube placement.\n\n FINDINGS: NG tube is seen terminating in the stomach. Scattered air within\n bowel loops are identified. The osseous structures are unchanged.\n\n IMPRESSION: NG tube within the stomach.\n\n\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 578434, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Alteration in Nutrition\n Assessment:\n Action:\n Response:\n Plan:\n Nausea / vomiting\n Assessment:\n Action:\n Response:\n Plan:\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\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": "2176-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 578436, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n Alteration in Nutrition\n Assessment:\n Due to episodes of vomiting and intermittent dizziness has not had much\n of an appetite and has not eaten today. Tolerating liquid.\n Action:\n Offering small amounts of food\n Response:\n Not feeling like eating at this time\n Plan:\n Now that pt has had good BM appetite may improve. Cont to offer food\n especially while OOB to chair\n Nausea / vomiting\n Assessment:\n With episode of coughing this am,vomited mod amount. Has not had good\n BM since admission, still gets dizzy with turns especially to right\n side\n Action:\n Given zofran,and fleets enema\n Response:\n No more vomiting, able to tolerate pills, good BM post enema\n Plan:\n Give zofran as needed, monitor bowels and cont with colace and senna,\n turn slowly\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hemodynamically stable. lisinopril and lopressor both started\n yesterday. HR 70-88 NSR, BP 120-148/60-70\n Action:\n Lisinopril increased to 10mg daily, OOB to chair.\n Response:\n Remains hemodynamically stable, easier get OOB from yesterday\n Plan:\n Titrate lisinopril and lopressor as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Cont to have shoulder pain s/p surgery.\n Action:\n Tylenol and ice pack and sling\n Response:\n Pain decreased with above interventions\n Plan:\n Cont with Tylenol and ice packs,sling.\n" }, { "category": "Nursing", "chartdate": "2176-05-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 578438, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. No off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Alteration in Nutrition\n Assessment:\n Due to episodes of vomiting and intermittent dizziness has not had much\n of an appetite and has not eaten today. Tolerating liquid.\n Action:\n Offering small amounts of food\n Response:\n Not feeling like eating at this time\n Plan:\n Now that pt has had good BM appetite may improve. Cont to offer food\n especially while OOB to chair\n Nausea / vomiting\n Assessment:\n With episode of coughing this am,vomited mod amount. Has not had good\n BM since admission, still gets dizzy with turns especially to right\n side\n Action:\n Given zofran,and fleets enema\n Response:\n No more vomiting, able to tolerate pills, good BM post enema\n Plan:\n Give zofran as needed, monitor bowels and cont with colace and senna,\n turn slowly\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hemodynamically stable. lisinopril and lopressor both started\n yesterday. HR 70-88 NSR, BP 120-148/60-70\n Action:\n Lisinopril increased to 10mg daily, OOB to chair.\n Response:\n Remains hemodynamically stable, easier get OOB from yesterday\n Plan:\n Titrate lisinopril and lopressor as tolerated.\n Pain control (acute pain, chronic pain)\n Assessment:\n Cont to have shoulder pain s/p surgery.\n Action:\n Tylenol and ice pack and sling\n Response:\n Pain decreased with above interventions\n Plan:\n Cont with Tylenol and ice packs,sling.\n Impaired Skin Integrity\n Assessment:\n Has yeasty looking rash in groin. Pink/red not open. Mid back has area\n that appears to be the site of a previous burn maybe with heating pad\n which the pt has used for pain control in the past. Area is unbroken\n Action:\n Cleansed with aloe vesta and miconazole powder applied\n Response:\n Looks less better than yesterday, does not appear as inflamed as\n yesterday\n Plan:\n Cont with miconazole powder\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Breathing became more labored, crackles throughout with wheezes\n Action:\n Team notified and examined pt, chest xray taken and atroven MDI\n Response:\n Improved, now with bibasilar crackles. Started incentive spirometry\n Plan:\n Cont with incentive spirometer and monitor resp and volume status.\n GU: unable to void with foley out , once foley placed put out 500cc.\n urine output greatly reduced and urine amber with sediment\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n" }, { "category": "Nursing", "chartdate": "2176-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578121, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-05-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578122, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Shock, cardiogenic\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577738, "text": "Shock, cardiogenic\n Assessment:\n Stable BPs on IABP 1:2 and Dopamine gtt at 3mcg/k./min\n Action:\n Dopa maintained at 3mcg. IABP switched to 1:4 at 01:00\n Response:\n HD stable on IABP 1:4, Gd augmentation and systolic/diastolic\n unloading. Heparin gtt therapeutic PTT\n Plan:\n ? DC IABP today. Wean Dopa as tol, follow hemodyanamics, uop, distal\n perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats >95% on 70% FI02 and 8 PEEP\n Action:\n ABGs monitored, sxn\nd for sm/mod amts tan/bld tinged secretions.\n Response:\n Stable sats.\n Plan:\n Wean vent as tol, continue VAP bundle per protocol. Levoflox due today\n for empiric ASP PNA coverage\n Altered mental status (not Delirium)\n Assessment:\n Very restless/agitated on low dose fent/versed gtts resulting in HR up\n to 100s and SBPs 160s w/ MAPs 100s. Moving all extremities off bed.\n Not following commands/tracking. Grimacing at times\n Action:\n Pt re-oriented/re-directed. ABG drawn showing adequate oxygenation.\n Bolus sedation and gtt increased for comfort. R leg immobilizer placed\n Response:\n Short term effect w/ bolus sedation, continues w/ freq periods of\n restlessness, lifting R leg (IABP) off bed. Not following commands.\n Rarely overbreathing vent 1-3 breaths.\n Plan:\n Wean sedation/daily wake ups once IABP out as pt currently easily\n agitated and restless. Reorient PRN. Pain management for recent L\n rotator cuff surgery\n Alteration in Nutrition\n Assessment:\n TF residuals 90-120cc, abd soft distended, no stool\n Action:\n No change in TF rate 2/2 residuals. Colace given.\n Response:\n Mod amts residuals\n Plan:\n Increase TF as tol, FS QID\n tx as indicated. Continue bowel regimen. ?\n LBM\n Thrombocytopenia, acute\n Assessment:\n PLT . Lg clot suctioned for mouth. Some bloody secretions from ETT\n Action:\n Team aware of clot. protonix, famotidine continue to be held \n potential causes of thrombocytopenia.\n Response:\n No evidence of bleeding. AM HCT 27.8 (31)\n Plan:\n monitor plt and assess for signs of bleeding.\n" }, { "category": "Physician ", "chartdate": "2176-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577804, "text": "Chief Complaint: -Hypoxic with O2 sat 88% 11am, CXR with slightly\n worsened effusion otherwise no change. FiO2 70% and PEEP 8\n -ECHO no PFO, did not look specifically for for RV strain, but with the\n images they did get no evidence\n -Dopamine was turned off, but pt with MAP in 40's. Restarted Dopa @ 3\n -A-line placed\n - HIT antibody negative\n - I/O neg 1.1L @2300\n Fick: 1:2 3pm 5.4/2.9/833 --> 1:4 4am 7/3.7/793\n ABG: 7.39/39/85 70% 8 PEEP at 2300 --> changed to 1:4 given improved\n resp status.\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Dopamine - 3 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Fentanyl - 05:00 AM\n Midazolam (Versed) - 05:00 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 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 68 (58 - 81) bpm\n BP: 127/62(96) {87/32(60) - 155/63(109)} mmHg\n RR: 16 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n PAP: (52 mmHg) / (22 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 59 - 69\n Total In:\n 1,838 mL\n 433 mL\n PO:\n TF:\n 612 mL\n 155 mL\n IVF:\n 1,097 mL\n 278 mL\n Blood products:\n Total out:\n 2,946 mL\n 200 mL\n Urine:\n 2,886 mL\n 200 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,108 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 28 cmH2O\n SpO2: 99%\n ABG: 7.37/42/84./22/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 120\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 114 K/uL\n 9.6 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n WBC\n 6.4\n 8.0\n Hct\n 31\n 27.8\n 30.6\n 28.4\n Plt\n 111\n 114\n Cr\n 1.3\n 1.5\n 1.3\n TCO2\n 22\n 22\n 24\n 22\n 24\n 24\n 25\n Glucose\n 118\n 114\n 108\n Other labs: PT / PTT / INR:14.8/58.7/1.3, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n ALTERATION IN NUTRITION\n THROMBOCYTOPENIA, ACUTE\n NAUSEA / VOMITING\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n SHOCK, CARDIOGENIC\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n MYOCARDIAL INFARCTION, ACUTE (AMI, STEMI, NSTEMI)\n .H/O CORONARY ARTERY DISEASE (CAD, ISCHEMIC HEART DISEASE)\n .H/O ULCERATIVE COLITIS\n .H/O CORONARY ARTERY BYPASS GRAFT (CABG)\n PAIN CONTROL (ACUTE PAIN, CHRONIC PAIN)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 PM\n Arterial Line - 01:30 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": "2176-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577806, "text": "24 Hour Events:\n -Hypoxic with O2 sat 88% 11am, CXR with slightly worsened effusion\n otherwise no change. FiO2 70% and PEEP 8\n -ECHO no PFO, did not look specifically for for RV strain, but with the\n images they did get no evidence\n -Dopamine was turned off, but pt with MAP in 40's. Restarted Dopa @ 3\n -A-line placed\n - HIT antibody negative\n - I/O neg 1.1L @2300\n Fick: 1:2 3pm 5.4/2.9/833 --> 1:4 4am 7/3.7/793\n ABG: 7.39/39/85 70% 8 PEEP at 2300 --> changed to 1:4 given improved\n resp\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Dopamine - 3 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Fentanyl - 05:00 AM\n Midazolam (Versed) - 05:00 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 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 68 (58 - 81) bpm\n BP: 127/62(96) {87/32(60) - 155/63(109)} mmHg\n RR: 16 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n PAP: (52 mmHg) / (22 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 59 - 69\n Total In:\n 1,838 mL\n 433 mL\n PO:\n TF:\n 612 mL\n 155 mL\n IVF:\n 1,097 mL\n 278 mL\n Blood products:\n Total out:\n 2,946 mL\n 200 mL\n Urine:\n 2,886 mL\n 200 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,108 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 28 cmH2O\n SpO2: 99%\n ABG: 7.37/42/84./22/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 120\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT/ND, BS+\n Ext: 1+ edema to 6cm above ankle, dopplerable pulses bilaterally\n Labs / Radiology\n 114 K/uL\n 9.6 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n WBC\n 6.4\n 8.0\n Hct\n 31\n 27.8\n 30.6\n 28.4\n Plt\n 111\n 114\n Cr\n 1.3\n 1.5\n 1.3\n TCO2\n 22\n 22\n 24\n 22\n 24\n 24\n 25\n Glucose\n 118\n 114\n 108\n Other labs: PT / PTT / INR:14.8/58.7/1.3, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n # Cardiogenic Shock/STEMI. Latest Co/CI/SVR=7.3/3.9/722. Remains very\n labile O/N but less highs/lows than yesterday. Likely a component of\n autonomic dysregulation.\n - Plan to cont IABP on 1:1\n - Continue dopamine for pressure support\n - Repeat Fick calculations with change in pressors\n - Continue ASA 325, Plavix 75, heparin gtt for IABP, simva 80.\n - Try to wean FiO2 again today.\n .\n # PUMP: Still volume up. Did not receive lasix yesterday.\n - 20 mg this AM. Goal I/O -500 cc if BP allows\n - Continue afterload reduction with IABP, consider ACE if Cre allows.\n .\n # RHYTHM: Mostly NSR with rate 50s-60s, sporadic PVCs. Hold BB.\n .\n # Anemia: PLT stabilized but Hct dropping. Will follow today and\n consider transfusion if continues to drop.\n - Continue to avoid drugs that may cause thrombocytopenia\n .\n # Vomiting: resolved\n .\n # Resp Failure/Aspiration:\n - Try to wean FiO2 again today to 40%\n - frequent suctioning\n - continue COPD meds\n - Continue levaquin instead of Vanc/Zosyn\n .\n # ARF. Cre improved O/N.\n - monitor daily lytes, renally dose meds\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # GERD. conitnue to avoue H2b or PPI for now due to thrombocytopenia.\n # FEN: Tolerating TFs.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n IABP line - 02:40 PM\n Arterial Line - 01:30 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": "2176-05-02 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 577815, "text": "24 Hour Events:\n -Hypoxic with O2 sat 88% 11am, CXR with slightly worsened effusion\n otherwise no change. FiO2 70% and PEEP 8\n -ECHO showed no PFO, did not look specifically for for RV strain, but\n with the images they did get no evidence\n -Dopamine was turned off, but pt with MAP in 40's. Restarted Dopa @ 3\n -A-line placed\n - HIT antibody negative\n - I/O neg 1.1L @2300\n Fick: 1:2 3pm 5.4/2.9/833 --> 1:4 4am 7/3.7/793\n ABG: 7.39/39/85 70% 8 PEEP at 2300 --> changed to 1:4 given improved\n resp\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 04:04 PM\n Vancomycin - 09:30 PM\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Heparin Sodium - 1,100 units/hour\n Dopamine - 3 mcg/Kg/min\n Midazolam (Versed) - 1 mg/hour\n Fentanyl (Concentrate) - 25 mcg/hour\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Fentanyl - 05:00 AM\n Midazolam (Versed) - 05:00 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 07:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.1\nC (97\n HR: 68 (58 - 81) bpm\n BP: 127/62(96) {87/32(60) - 155/63(109)} mmHg\n RR: 16 (14 - 22) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 12 (8 - 18)mmHg\n PAP: (52 mmHg) / (22 mmHg)\n CO/CI (Fick): (7 L/min) / (3.7 L/min/m2)\n Mixed Venous O2% Sat: 59 - 69\n Total In:\n 1,838 mL\n 433 mL\n PO:\n TF:\n 612 mL\n 155 mL\n IVF:\n 1,097 mL\n 278 mL\n Blood products:\n Total out:\n 2,946 mL\n 200 mL\n Urine:\n 2,886 mL\n 200 mL\n NG:\n 60 mL\n Stool:\n Drains:\n Balance:\n -1,108 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 31 cmH2O\n Plateau: 28 cmH2O\n SpO2: 99%\n ABG: 7.37/42/84./22/0\n Ve: 9.1 L/min\n PaO2 / FiO2: 120\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n 114 K/uL\n 9.6 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 108 mEq/L\n 139 mEq/L\n 28.4 %\n 8.0 K/uL\n [image002.jpg]\n 12:32 PM\n 04:24 PM\n 11:33 PM\n 04:04 AM\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n WBC\n 6.4\n 8.0\n Hct\n 31\n 27.8\n 30.6\n 28.4\n Plt\n 111\n 114\n Cr\n 1.3\n 1.5\n 1.3\n TCO2\n 22\n 22\n 24\n 22\n 24\n 24\n 25\n Glucose\n 118\n 114\n 108\n Other labs: PT / PTT / INR:14.8/58.7/1.3, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.0 mg/dL, Mg++:1.9 mg/dL, PO4:3.0 mg/dL\n Assessment and Plan\n # Cardiogenic Shock/STEMI: Has required IABP-- Latest\n Co/CI/SVR=7.3/3.9/722. BP labilility improved-- Likely a component of\n autonomic dysregulation.\n - Plan to DC IABP\n - Continue to wean dopamine\n - Continue ASA 325, Plavix 75, DC heparin gtt for IABP, simva 80.\n - Try to wean FiO2 again today.\n .\n # PUMP: Still volume up.Put out well to 40 IV lasix.\n - Goal I/O -1000 cc today\n .\n # RHYTHM: Mostly NSR with rate 50s-60s, sporadic PVCs. Hold BB.\n .\n # Anemia: HCT and PLTslightly improved. Will follow today and consider\n transfusion if continues to drop.\n - Continue to avoid drugs that may cause thrombocytopenia\n - Transfusion for Hct<21 or >3pt Hct drop\n .\n # Abd Distension: Active bowel sounds though nearly no stool output\n past few days. Possible to could represent obstruction versus ileus\n versus reduced gastric motlity secondary to limited feeding.\n - KUB to r/o obstruction\n -Holding TF high residulas\n - Consider reglan to improve motility if no obstruction on KUB\n .\n # Resp Failure/Aspiration:\n - CXR to assess tube placement\n - Cont to wean FiO2\n - frequent suctioning\n - continue nebs\n - Continue levaquin for asp PNA\nDC tomorrow for 10 day course\n .\n # ARF. Cre improved O/N.\n - monitor daily lytes, renally dose meds\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n # GERD. conitnue to avoid H2b or PPI for now due to thrombocytopenia.\n - begin sucralfate for stress ulcer PPX\n # FEN: Tolerating TFs.\n # PPX: sucralfate, start Hep SC when Heparin IV stopped, bowel regimen\n # Code: FULL\n # Dispo: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 50 minutes of critical care time.\n Additional comments:\n Hypoxemia, respiratory failure, hypotension, IABP\n ------ Protected Section Addendum Entered By: ,MD\n on: 09:09 ------\n" }, { "category": "Respiratory ", "chartdate": "2176-05-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 577790, "text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 64.4 None\n Ideal tidal volume: 257.6 / 386.4 / 515.2 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: No\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 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: 25 cmH2O\n Cuff volume: 5 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments: Had been some bloody secretions early in shift\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Supra-sternal retractions\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: Maintain PEEP at current level and reduce FiO2 as\n tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt to be weaned off balloon pump today. Oxygenation has been somewhat\n challenging but Po2 are steady around 80 on the shift.\n" }, { "category": "General", "chartdate": "2176-05-02 00:00:00.000", "description": "ICU Event Note", "row_id": 577887, "text": "Clinician: Nurse\n Pt IABP was pulled by CCU cardiology fellow at 1515 and predssure held\n x one hour. Good hemostasis no hematoma.\n Pt was sedated at that time as he was uncooperative and restless. At 5\n pm fellow and Rn in room when pt awoke and thrashed and his groin\n started oozing. Again fellow held pressure x 45 minutes and hemostasis\n achieved, No Hematoma noted. Pt now Very sedate and we will tolerate\n MAPS of 65 and dopa may have to be restarted as Pt is to lay flat and\n not move for 6 hours. We are holding any meds that would raise his BP\n too high. Goal map 65-70. distal pulses are good since IABP removal.\n Groin is no longer oozing.\n" }, { "category": "Physician ", "chartdate": "2176-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578030, "text": "24 Hour Events:\n - Fluid balance neg 1.6L\n - Stim Showed: 11.3 (<15) and increased to 18.2 (diff <9), started\n hydrocortisone 50mg q6\n - DA weaned off\n - IABP removed\n - KUB read as \"nonspecific bowel pattern\"\n - Starting reglan and dulcolax\n - Haldol PRN for agitation\n - No change in vent settings\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Fentanyl - 05:15 PM\n Midazolam (Versed) - 05:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 99 (56 - 99) bpm\n BP: 136/56(296) {103/40(73) - 145/56(296)} mmHg\n RR: 18 (15 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 18 (6 - 19)mmHg\n PAP: (40 mmHg) / (29 mmHg)\n CO/CI (Fick): (7.1 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 830 mL\n 302 mL\n PO:\n TF:\n 215 mL\n 163 mL\n IVF:\n 615 mL\n 139 mL\n Blood products:\n Total out:\n 2,439 mL\n 275 mL\n Urine:\n 2,439 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,609 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 34.4 cmH2O/mL\n SpO2: 98%\n ABG: 7.45/35/112/23/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 160\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n 150 K/uL\n 9.5 g/dL\n 101 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n 04:18 PM\n 04:42 PM\n 09:24 PM\n 04:33 AM\n WBC\n 8.0\n 6.0\n 7.8\n Hct\n 30.6\n 28.4\n 25.8\n 27.9\n Plt\n 114\n 127\n 150\n Cr\n 1.5\n 1.3\n 1.2\n 1.3\n TCO2\n 22\n 24\n 24\n 25\n 25\n Glucose\n 114\n 108\n 104\n 101\n Other labs: PT / PTT / INR:13.1/26.5/1.1, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .\n # Cardiogenic Shock/STEMI. Off DA, off IABP. Pressures have ranged\n 81/40 - 126/69 with Fick #s: 7.1/3.8/550 at 9PM.\n - stable continue to moniter\n - Continue ASA 325, Plavix 75, simva 80.\n .\n # PUMP: Received 20 mg lasix yesterday, is -1600mL and clinically\n volume status is improving significantly with decreased pedal edema\n today.\n - Goal -500 today, with 20 mg lasix this PM if needed\n .\n # RHYTHM: Mostly NSR with more volatile HR 50s-90s, sporadic PVCs.\n - Hold BB.\n .\n # Anemia: Improving. PLT continuing to rise, up to 150 today\nvery\n likely plt drop related to IABP; HCT rising slightly, 25.8 -> 27.9.\n overnight. Will continue to monitor.\n - cont to trend Hct, PM hct today\n .\n # Sedation: on versed and fentanyl for pain\n - switch to propofol for easier weaning\n - haldol prn for agitation\n .\n # Resp Failure/Aspiration: No weaning attempts yesterday given focus on\n weaning pressors and IABP; Remains on 70% FiO2, PEEP 8.\n - wean Fi02 today as tolerated to 40%, check ABG\n - Will attempt to wean aggressively today with reduced sedation given\n significant clinical improvement.\n - frequent suctioning\n - continue COPD meds, now with standing albuterol and ipratropium q4h\n - Day Abx course (levaquin) for suspected aspiration\n renally\n adjust to QD\n .\n # Adrenal insuffiency in critical illness- pt technically qualifies for\n relative adrenal \n - Failed stim suggesting adrenal insufficiency which certainly\n could be affecting BP. Started hydrocortisone 50 mg q6, will follow.\n - will moniter stable over 24h\n # Abdomen remains distended this AM: likely constipation, no concerning\n signs on KUB.\n - Aggressive bowel regimen: senna, colace, reglan, dulcolax\n - Continue to monitor by physical exam\n .\n # ARF. Cre continuing to improve, stable at 1.3.\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n - restart Asacol when pt able to tolerate POs\n .\n # depression. celexa.\n ICU Care\n Nutrition: TF\n Nutren Pulmonary (Full) - 08:00 PM 25 mL/hour\n Glycemic Control: ISS\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT: Heparin SC\n Stress ulcer: sucrafalate\n VAP: HOB elevated 30 degrees\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n ------ Protected Section ------\n Cardiology Teaching Physician Note\n On this day I saw, examined and was physically present with the\n resident / fellow for the key portions of the services provided. I\n agree with the above note and plans.\n I would add the following remarks:\n History\n nothing to add\n Physical Examination\n nothing to add\n Medical Decision Making\n nothing to add\n Total time spent on patient care: 60 minutes of critical care time.\n Additional comments:\n intubated, hypotensive, respiraroty failure, MI\n ------ Protected Section Addendum Entered By: ,MD\n on: 11:30 ------\n" }, { "category": "Physician ", "chartdate": "2176-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578400, "text": "Chief Complaint: cardiogenic shock/STEMI s/p L shoulder surgery\n Hour Events:\n ARTERIAL LINE - STOP 09:19 AM\n CORDIS/INTRODUCER - STOP 12:45 PM\n - Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n - Iron labs unrevealing for low Hct: fe=53, ferritin=176, transferrin =\n 228, TIBC=296\n -I/O: 8pm -400cc. Did not put out for 6 hrs after foley removed despite\n 20 mg Lasix at 930 PM. Re-inserted foley at 10:30, put out additioal\n 700cc.\n -Cr increased from 1.2 to 1.5\n - complaining of anterior L knee pain with movement; not swollen,\n bruised or tender to light pressure. no calf pain. likely r/t forceful\n restraining during periods of agitation while he was sedated. treating\n with ice packs and , monitor.\n - this AM: felt\ngassy\n then N/V x1; passed very small BM last night\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:30 AM\n Furosemide (Lasix) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.1\n HR: 73 (70 - 94) bpm\n BP: 129/58(75) {113/57(70) - 155/77(107)} mmHg\n RR: 27 (13 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n Total In:\n 1,182 mL\n 240 mL\n PO:\n 1,000 mL\n 240 mL\n TF:\n IVF:\n 182 mL\n Blood products:\n Total out:\n 2,170 mL\n 395 mL\n Urine:\n 2,170 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -988 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GEN: awake, alert, oriented, NAD\n Eyes/conjunctiva: PERRL\n CV: RRR, no m/r/g appreciate, JVP flat\n Chest: CTAB, No c/r/w\n Abd: Soft, NT, mildly distended, +BS\n Ext: No edema, radial pulses 2+ bilaterally, DP 1+ bilaterally\n MSK: Anterior L knee pain to deep palpation\n Labs / Radiology\n 280 K/uL\n 10.5 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 31.6 %\n 9.9 K/uL\n [image002.jpg]\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n 07:38 PM\n 05:32 AM\n WBC\n 6.0\n 7.8\n 9.1\n 9.9\n Hct\n 25.8\n 27.9\n 27.7\n 31.6\n Plt\n 127\n 150\n 205\n 280\n Cr\n 1.3\n 1.2\n 1.5\n TCO2\n 25\n 25\n 22\n 27\n 28\n Glucose\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:72.8 %, Lymph:20.7 %, Mono:3.4 %, Eos:2.6 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG (LIMA to\n LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia here with\n STEMI s/p acromioplasty\n # Cardiogenic shock and STEMI:\n - BPs continue to stabilize, hemodynamically stable with no episodes of\n hypotension.\n - continue ASA 325, plavix 600, SQ heparin, simvastatin 80, metoprolol\n 12.5 mg PO daily\n - Increase lisinopril to 10 mg PO daily\n # Cards Pump: Met diuresis goal of -1L yesterday to 20 mg lasix x2 but\n failed to put out urine without foley\n - Cre bump 1.2 - 1.5\n - Clinically euvolemic, resp status continuing to improve on O2 by NC.\n - Goal even today.\n # RHYTHM: NSR with rate 80s.\n # Resp Failure: Significantly improved, now 95-97% on 2L NC.\n - finished abx course for aspiration, remains afebrile\n #Anemia: Slightly improved from yesterday, Hct 31.1. No iron\n deficiency, no rectal blood loss, no hemolysis. Will trend.\n # Acid/Base: Acidemia has resolved, but Alkalemic yesterday pH\n 7.48/36/143, suggestive of respiratory alkalosis.\n - ABG today to trend acid/base status\n # ARF: baseline Cr 1.3 - now 1.5. Likely r/t aggressive diuresis\n - hold diuresis for now, trend creatinine and lytes, renally dose meds\n # s/p shoulder surgery - pain control w fentanyl bolus prn.\n - will schedule f/u with Dr. for \n - per ortho: ROM as tolerated, WB < 5 lbs, sling until \n # Ulcerative colitis: all guaiacs negative. continue asacol 1600 \n # depression: celexa\n # hx of GERD: use H2 blocker instead of PPI since plavix\n FEN: tolerating POs; replete electrolytes as needed\n ACCESS: PIVs\n PROPHYLAXIS:\n -DVT ppx: SC heparin\n -Pain management with fentanyl PRN\n -Bowel regimen with senna/colace, with reglan, dulcolax as needed\n CODE: full, discussed\n DISPO: to floor today pending full 24 hours hemodynamically stable\n CONTACT: wife is HCP verified. Cell-- :\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2176-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578402, "text": "Chief Complaint: cardiogenic shock/STEMI s/p L shoulder surgery\n Hour Events:\n ARTERIAL LINE - STOP 09:19 AM\n CORDIS/INTRODUCER - STOP 12:45 PM\n - Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n - Iron labs unrevealing for low Hct: fe=53, ferritin=176, transferrin =\n 228, TIBC=296\n -I/O: 8pm -400cc. Did not put out for 6 hrs after foley removed despite\n 20 mg Lasix at 930 PM. Re-inserted foley at 10:30, put out additioal\n 700cc.\n -Cr increased from 1.2 to 1.5\n - complaining of anterior L knee pain with movement; not swollen,\n bruised or tender to light pressure. no calf pain. likely r/t forceful\n restraining during periods of agitation while he was sedated. treating\n with ice packs and , monitor.\n - this AM: felt\ngassy\n then N/V x1; passed very small BM last night\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:30 AM\n Furosemide (Lasix) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.1\n HR: 73 (70 - 94) bpm\n BP: 129/58(75) {113/57(70) - 155/77(107)} mmHg\n RR: 27 (13 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n Total In:\n 1,182 mL\n 240 mL\n PO:\n 1,000 mL\n 240 mL\n TF:\n IVF:\n 182 mL\n Blood products:\n Total out:\n 2,170 mL\n 395 mL\n Urine:\n 2,170 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -988 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GEN: awake, alert, oriented, NAD\n Eyes/conjunctiva: PERRL\n CV: RRR, no m/r/g appreciate, JVP flat\n Chest: CTAB, No c/r/w\n Abd: Soft, NT, mildly distended, +BS\n Ext: No edema, radial pulses 2+ bilaterally, DP 1+ bilaterally\n MSK: Anterior L knee pain to deep palpation\n Labs / Radiology\n 280 K/uL\n 10.5 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 31.6 %\n 9.9 K/uL\n [image002.jpg]\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n 07:38 PM\n 05:32 AM\n WBC\n 6.0\n 7.8\n 9.1\n 9.9\n Hct\n 25.8\n 27.9\n 27.7\n 31.6\n Plt\n 127\n 150\n 205\n 280\n Cr\n 1.3\n 1.2\n 1.5\n TCO2\n 25\n 25\n 22\n 27\n 28\n Glucose\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:72.8 %, Lymph:20.7 %, Mono:3.4 %, Eos:2.6 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG (LIMA to\n LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia here with\n STEMI s/p acromioplasty\n # Cardiogenic shock and STEMI:\n - BPs continue to stabilize, hemodynamically stable with no episodes of\n hypotension.\n - continue ASA 325, plavix 600, SQ heparin, simvastatin 80, metoprolol\n 12.5 mg PO daily\n - Increase lisinopril to 10 mg PO daily\n # Cards Pump: Met diuresis goal of -1L yesterday to 20 mg lasix x2 but\n failed to put out urine without foley\n - Cre bump 1.2 - 1.5\n - Clinically euvolemic, resp status continuing to improve on O2 by NC.\n - Goal even today.\n # RHYTHM: NSR with rate 80s.\n # Resp Failure: Significantly improved, now 95-97% on 2L NC.\n - finished abx course for aspiration, remains afebrile\n #Anemia: Slightly improved from yesterday, Hct 31.1. No iron\n deficiency, no rectal blood loss, no hemolysis. Will trend.\n #N/V: remains constipated and likely needs aggressive bowel regimen\n - Fleet enema today, Zofran PRN; follow clinically\n # Acid/Base: Acidemia has resolved, but Alkalemic yesterday pH\n 7.48/36/143, suggestive of respiratory alkalosis.\n - ABG today to trend acid/base status\n # ARF: baseline Cr 1.3 - now 1.5. Likely r/t aggressive diuresis\n - hold diuresis for now, trend creatinine and lytes, renally dose meds\n # s/p shoulder surgery - pain control w fentanyl bolus prn.\n - will schedule f/u with Dr. for \n - per ortho: ROM as tolerated, WB < 5 lbs, sling until \n # Ulcerative colitis: all guaiacs negative. continue asacol 1600 \n # depression: celexa\n # hx of GERD: use H2 blocker instead of PPI since plavix\n FEN: tolerating POs; replete electrolytes as needed\n ACCESS: PIVs\n PROPHYLAXIS:\n -DVT ppx: SC heparin\n -Pain management with fentanyl PRN\n -Bowel regimen with senna/colace, with reglan, dulcolax as needed\n CODE: full, discussed\n DISPO: to floor today pending full 24 hours hemodynamically stable\n CONTACT: wife is HCP verified. Cell-- :\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2176-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577733, "text": "Shock, cardiogenic\n Assessment:\n Stable BPs on IABP 1:2 and Dopamine gtt at 3mcg/k./min\n Action:\n Dopa maintained at 3mcg. IABP switched to 1:4 at 01:00\n Response:\n HD stable on IABP 1:4, Gd augmentation and systolic/diastolic\n unloading. Heparin gtt therapeutic PTT\n Plan:\n ? DC IABP today. Wean Dopa as tol.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats >95% on 70% FI02 and 8 PEEP\n Action:\n ABGs monitored, sxn\nd for sm/mod amts tan/bld tinged secretions.\n Response:\n Stable sats.\n Plan:\n Wean vent as tol, continue VAP bundle per protocol. Levoflox due today\n for empiric ASP PNA coverage\n Altered mental status (not Delirium)\n Assessment:\n Very restless/agitated on low dose fent/versed gtts resulting in HR up\n to 100s and SBPs 160s w/ MAPs 100s. Moving all extremities off bed.\n Not following commands/tracking. Grimacing at times\n Action:\n Pt re-oriented/re-directed. ABG drawn showing adequate oxygenation.\n Bolus sedation and gtt increased for comfort. R leg immobilizer placed\n Response:\n Short term effect w/ bolus sedation, continues w/ freq periods of\n restlessness, lifting R leg (IABP) off bed. Not following commands.\n Rarely overbreathing vent 1-3 breaths.\n Plan:\n Wean sedation as tol, attempt daily wake ups, Reorient PRN. Pain\n management for recent L rotator cuff surgery\n Alteration in Nutrition\n Assessment:\n TF residuals 90-120cc, abd soft distended, no stool\n Action:\n No change in TF rate 2/2 residuals. Colace given.\n Response:\n Mod amts residuals\n Plan:\n Increase TF as tol, FS QID\n tx as indicated. Continue bowel regimen. ?\n LBM\n" }, { "category": "Physician ", "chartdate": "2176-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578024, "text": "24 Hour Events:\n - Fluid balance neg 1.6L\n - Stim Showed: 11.3 (<15) and increased to 18.2 (diff <9), started\n hydrocortisone 50mg q6\n - DA weaned off\n - IABP removed\n - KUB read as \"nonspecific bowel pattern\"\n - Starting reglan and dulcolax\n - Haldol PRN for agitation\n - No change in vent settings\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Fentanyl - 05:15 PM\n Midazolam (Versed) - 05:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 99 (56 - 99) bpm\n BP: 136/56(296) {103/40(73) - 145/56(296)} mmHg\n RR: 18 (15 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 18 (6 - 19)mmHg\n PAP: (40 mmHg) / (29 mmHg)\n CO/CI (Fick): (7.1 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 830 mL\n 302 mL\n PO:\n TF:\n 215 mL\n 163 mL\n IVF:\n 615 mL\n 139 mL\n Blood products:\n Total out:\n 2,439 mL\n 275 mL\n Urine:\n 2,439 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,609 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 34.4 cmH2O/mL\n SpO2: 98%\n ABG: 7.45/35/112/23/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 160\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n 150 K/uL\n 9.5 g/dL\n 101 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n 04:18 PM\n 04:42 PM\n 09:24 PM\n 04:33 AM\n WBC\n 8.0\n 6.0\n 7.8\n Hct\n 30.6\n 28.4\n 25.8\n 27.9\n Plt\n 114\n 127\n 150\n Cr\n 1.5\n 1.3\n 1.2\n 1.3\n TCO2\n 22\n 24\n 24\n 25\n 25\n Glucose\n 114\n 108\n 104\n 101\n Other labs: PT / PTT / INR:13.1/26.5/1.1, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n .\n # Cardiogenic Shock/STEMI. Off DA, off IABP. Pressures have ranged\n 81/40 - 126/69 with Fick #s: 7.1/3.8/550 at 9PM.\n - stable continue to moniter\n - Continue ASA 325, Plavix 75, simva 80.\n .\n # PUMP: Received 20 mg lasix yesterday, is -1600mL and clinically\n volume status is improving significantly with decreased pedal edema\n today.\n - Goal -500 today, with 20 mg lasix this PM if needed\n .\n # RHYTHM: Mostly NSR with more volatile HR 50s-90s, sporadic PVCs.\n - Hold BB.\n .\n # Anemia: Improving. PLT continuing to rise, up to 150 today\nvery\n likely plt drop related to IABP; HCT rising slightly, 25.8 -> 27.9.\n overnight. Will continue to monitor.\n - cont to trend Hct, PM hct today\n .\n # Sedation: on versed and fentanyl for pain\n - switch to propofol for easier weaning\n - haldol prn for agitation\n .\n # Resp Failure/Aspiration: No weaning attempts yesterday given focus on\n weaning pressors and IABP; Remains on 70% FiO2, PEEP 8.\n - wean Fi02 today as tolerated to 40%, check ABG\n - Will attempt to wean aggressively today with reduced sedation given\n significant clinical improvement.\n - frequent suctioning\n - continue COPD meds, now with standing albuterol and ipratropium q4h\n - Day Abx course (levaquin) for suspected aspiration\n renally\n adjust to QD\n .\n # Adrenal insuffiency in critical illness- pt technically qualifies for\n relative adrenal \n - Failed stim suggesting adrenal insufficiency which certainly\n could be affecting BP. Started hydrocortisone 50 mg q6, will follow.\n - will moniter stable over 24h\n # Abdomen remains distended this AM: likely constipation, no concerning\n signs on KUB.\n - Aggressive bowel regimen: senna, colace, reglan, dulcolax\n - Continue to monitor by physical exam\n .\n # ARF. Cre continuing to improve, stable at 1.3.\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n - restart Asacol when pt able to tolerate POs\n .\n # depression. celexa.\n ICU Care\n Nutrition: TF\n Nutren Pulmonary (Full) - 08:00 PM 25 mL/hour\n Glycemic Control: ISS\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT: Heparin SC\n Stress ulcer: sucrafalate\n VAP: HOB elevated 30 degrees\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Nursing", "chartdate": "2176-05-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 578320, "text": "75 y/o M transferred from OSH s/p perioperative STEMI. Cardiac Cath:3\n BMS to distal SVG to OM. Cardiac cath c/b hypotension requiring\n pressors-dopamine/levophed & IABP placement. Further c/b\n vomiting/aspiration requiring emergent intubation. Levo weaned off\n 09:00 . TTE : EF 45-50% c/ inf wall HK. Now off IABP, pressors,\n extubated. Mask ventilation required on several hours after\n extubation for episode pul ed, responded to lasix, IV NTG.\n Pain control (acute pain, chronic pain)\n Assessment:\n Having no pain in left shoulder while lying bed. After getting up to\n chair c/o pain\n Action:\n Given 650mg Tylenol and ice pack applied to area. Sling placed on arm\n Response:\n Pain after Tylenol went to and with ice packs staying around a\n which pt says is acceptable.\n Plan:\n Offer Tylenol q6. ice packs as needed. Assess pain level at least q4.\n Alteration in Nutrition\n Assessment:\n Had episode of vomiting early this morning. Received zofran with\n relief. Couple episodes of fleeting moments of nausea. Poor appetite.\n Has been having very very small amounts of loose to semi formed stool.\n Action:\n Receiving reglan q6. given senna this evening, encouraging po intake\n especially while OOB to chair.\n Response:\n No improvement in appetite. No vomiting.\n Plan:\n Cont to encourage po intake. benefit from nutrition consult.\n Myocardial infarction, acute (AMI, STEMI, NSTEMI)\n Assessment:\n Hemodynamically stable with HR 70-90 NSR, BP 113-155/57-73\n Action:\n Started lisinopril 5mg this morning.\n Response:\n BP maintained with no need for NTG for HTN\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2176-05-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 577782, "text": "Shock, cardiogenic\n Assessment:\n Stable BPs on IABP 1:2 and Dopamine gtt at 3mcg/k./min\n Action:\n Dopa maintained at 3mcg. IABP switched to 1:4 at 01:00\n Response:\n HD stable on IABP 1:4, Gd augmentation and systolic/diastolic\n unloading. CO/CI/SVR 7/3.7/793 (5.4/2.9/833), MV02 69% (60%) on IABP\n 1:4 and Dopa 3mcg. Heparin gtt therapeutic, PTT 58.7\n Plan:\n DC IABP today. Wean Dopa as tol, follow hemodynamics, uop,\n distal perfusion\n Respiratory failure, acute (not ARDS/)\n Assessment:\n O2 sats >95% on 70% FI02 and 8 PEEP\n Action:\n ABGs monitored, sxn\nd for sm/mod amts tan/bld tinged secretions.\n Response:\n Stable sats.\n Plan:\n Wean vent as tol, continue VAP bundle per protocol. Levoflox\n due today for empiric ASP PNA coverage\n Altered mental status (not Delirium)\n Assessment:\n Very restless/agitated on low dose fent/versed gtts resulting in HR up\n to 100s and SBPs 160s w/ MAPs 100s. Moving all extremities off bed.\n Not following commands/tracking. Grimacing at times\n Action:\n Pt re-oriented/re-directed. ABG drawn showing adequate oxygenation.\n Bolus sedation and gtt increased for comfort. R leg immobilizer placed\n Response:\n Short effect w/ bolus sedation, continues w/ freq periods of\n restlessness, lifting R leg (IABP) off bed. Not following commands.\n Rarely overbreathing vent 1-2 breaths.\n Plan:\n Wean sedation/daily wake ups once IABP out as pt currently\n easily agitated and restless. Reorient PRN. ***? Haldol for agitation\n instead of increasing fent/versed gtts.\n Pain management for recent L rotator cuff surgery\n Alteration in Nutrition\n Assessment:\n TF residuals 90-120cc, abd soft distended, no stool\n Action:\n TF rate not advanced residuals. Colace given.\n Response:\n 150cc residual at 03:30\n TF held for 1.5 hr and reduced to 15cc/hr at\n 05:00\n Plan:\n Increase TF as tol, FS QID\n tx as indicated. Continue bowel\n regimen. ? LBM\n Thrombocytopenia, acute\n Assessment:\n PLT 114 (111). Lg clot suctioned from mouth. Some bloody secretions\n from ETT\n Action:\n Team aware of clot. protonix, famotidine continue to be held \n potential causes of thrombocytopenia.\n Response:\n AM HCT 28.4 (30.6)\n Plan:\n monitor plt and assess for signs of bleeding.\n" }, { "category": "Physician ", "chartdate": "2176-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578002, "text": "24 Hour Events:\n - Fluid balance neg 1.6L\n - Stim Showed: 11.3 (<15) and increased to 18.2 (diff <9), started\n hydrocortisone 50mg q6\n - DA weaned off\n - IABP removed\n - KUB read as \"nonspecific bowel pattern\"\n - Starting reglan and dulcolax\n - Haldol PRN for agitation\n - No change in vent settings\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\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2176-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578003, "text": "24 Hour Events:\n - Fluid balance neg 1.6L\n - Stim Showed: 11.3 (<15) and increased to 18.2 (diff <9), started\n hydrocortisone 50mg q6\n - DA weaned off\n - IABP removed\n - KUB read as \"nonspecific bowel pattern\"\n - Starting reglan and dulcolax\n - Haldol PRN for agitation\n - No change in vent settings\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\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Respiratory support\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n [image002.jpg]\n WBC\n Hct\n Plt\n Cr\n TropT\n TCO2\n Glucose\n Imaging:\n Microbiology:\n ECG:\n Assessment and Plan\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Communication: Comments:\n Code status:\n Disposition:\n ------ Protected Section------\n ------ Protected Section Error Entered By: , MD\n on: 07:55 ------\n" }, { "category": "Respiratory ", "chartdate": "2176-05-04 00:00:00.000", "description": "Generic Note", "row_id": 578170, "text": "TITLE:\n Respiratory Care: Pt initially on NIV @ beginning of shift, comf and\n cooperative; awake and became restless and uncooperative with NIV,\n ripped off mask >> changed to HFN, subsequently 6 lpm NC maintaining\n sp02 92%, seen for MDI\ns as ordered with spacer, will monitor closely\n and restart NIV if needed.\n" }, { "category": "Physician ", "chartdate": "2176-05-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578393, "text": "Chief Complaint: cardiogenic shock/STEMI s/p L shoulder surgery\n Hour Events:\n ARTERIAL LINE - STOP 09:19 AM\n CORDIS/INTRODUCER - STOP 12:45 PM\n - Hemodynamically stable yesterday, OOB to chair with assistance and in\n NAD\n - advanced diet to regular\n - Per Ortho re L shoulder: sling for 14d post-op, make f/u appt with\n Dr. at 14d post-op (to do on monday), ROM as tolerated,\n weight-bearing < 5 lbs.\n - Iron labs unrevealing for low Hct: fe=53, ferritin=176, transferrin =\n 228, TIBC=296\n -I/O: 8pm -400cc. Did not put out for 6 hrs after foley removed despite\n 20 mg Lasix at 930 PM. Re-inserted foley at 10:30, put out additioal\n 700cc.\n -Cr increased from 1.2 to 1.5\n - complaining of anterior L knee pain with movement; not swollen,\n bruised or tender to light pressure. no calf pain. likely r/t forceful\n restraining during periods of agitation while he was sedated. treating\n with ice packs and , monitor.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Ranitidine (Prophylaxis) - 10:30 AM\n Furosemide (Lasix) - 09:44 PM\n Heparin Sodium (Prophylaxis) - 11:00 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 06:50 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 36.2\nC (97.1\n HR: 73 (70 - 94) bpm\n BP: 129/58(75) {113/57(70) - 155/77(107)} mmHg\n RR: 27 (13 - 34) insp/min\n SpO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n Total In:\n 1,182 mL\n 240 mL\n PO:\n 1,000 mL\n 240 mL\n TF:\n IVF:\n 182 mL\n Blood products:\n Total out:\n 2,170 mL\n 395 mL\n Urine:\n 2,170 mL\n 395 mL\n NG:\n Stool:\n Drains:\n Balance:\n -988 mL\n -155 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 95%\n ABG: ///26/\n Physical Examination\n GEN: awake, alert, oriented, NAD\n Eyes/conjunctiva: PERRL\n CV: RRR, no m/r/g appreciate, JVP flat\n Chest: CTAB, No c/r/w\n Abd: Soft, NT/ND, +BS\n Ext: No edema, radial pulses 2+ bilaterally, DP 1+ bilaterally\n MSK: Anterior L knee pain to deep palpation\n Labs / Radiology\n 280 K/uL\n 10.5 g/dL\n 97 mg/dL\n 1.5 mg/dL\n 26 mEq/L\n 3.7 mEq/L\n 27 mg/dL\n 102 mEq/L\n 141 mEq/L\n 31.6 %\n 9.9 K/uL\n [image002.jpg]\n 09:24 PM\n 04:33 AM\n 11:09 AM\n 12:04 PM\n 04:51 PM\n 07:59 PM\n 10:19 PM\n 06:28 AM\n 07:38 PM\n 05:32 AM\n WBC\n 6.0\n 7.8\n 9.1\n 9.9\n Hct\n 25.8\n 27.9\n 27.7\n 31.6\n Plt\n 127\n 150\n 205\n 280\n Cr\n 1.3\n 1.2\n 1.5\n TCO2\n 25\n 25\n 22\n 27\n 28\n Glucose\n 101\n 97\n Other labs: PT / PTT / INR:14.2/27.2/1.2, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:72.8 %, Lymph:20.7 %, Mono:3.4 %, Eos:2.6 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.6 mg/dL, Mg++:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n ASSESSMENT AND PLAN: 75yo man with hx of CAD s/p CABG (LIMA to\n LAD, SVG to PDA, OM and Diagonal), PVD, HTN, hyperlipidemia here with\n STEMI s/p acromioplasty\n # Cardiogenic shock and STEMI:\n - BPs continue to stabilize, hemodynamically stable with no episodes of\n hypotension.\n - continue ASA 325, plavix 600, SQ heparin, simvastatin 80, metoprolol\n 12.5 mg PO daily\n - Increase lisinopril to 10 mg PO daily\n # Cards Pump: Met diuresis goal of -1L yesterday to 20 mg lasix x2 but\n failed to put out urine without foley\n - Cre bump 1.2 - 1.5\n - Clinically euvolemic, resp status continuing to improve on O2 by NC.\n - Goal even today.\n # RHYTHM: NSR with rate 80s.\n # Resp Failure: Significantly improved, now 95-97% on 2L NC.\n - finished abx course for aspiration, remains afebrile\n #Anemia: Slightly improved from yesterday, Hct 31.1. No iron\n deficiency, no rectal blood loss, no hemolysis. Will trend.\n # Acid/Base: Acidemia has resolved, but Alkalemic yesterday pH\n 7.48/36/143, suggestive of respiratory alkalosis.\n - ABG today to trend acid/base status\n # ARF: baseline Cr 1.3 - now 1.5. Likely r/t aggressive diuresis\n - hold diuresis for now, trend creatinine and lytes, renally dose meds\n # s/p shoulder surgery - pain control w fentanyl bolus prn.\n - will schedule f/u with Dr. for \n - per ortho: ROM as tolerated, WB < 5 lbs, sling until \n # Ulcerative colitis: all guaiacs negative. continue asacol 1600 \n # depression: celexa\n # hx of GERD: use H2 blocker instead of PPI since plavix\n FEN: tolerating POs; replete electrolytes as needed\n ACCESS: PIVs\n PROPHYLAXIS:\n -DVT ppx: SC heparin\n -Pain management with fentanyl PRN\n -Bowel regimen with senna/colace, with reglan, dulcolax as needed\n CODE: full, discussed\n DISPO: to floor today pending full 24 hours hemodynamically stable\n CONTACT: wife is HCP verified. Cell-- :\n \n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n 20 Gauge - 02:39 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2176-05-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 578006, "text": "24 Hour Events:\n - Fluid balance neg 1.6L\n - Stim Showed: 11.3 (<15) and increased to 18.2 (diff <9), started\n hydrocortisone 50mg q6\n - DA weaned off\n - IABP removed\n - KUB read as \"nonspecific bowel pattern\"\n - Starting reglan and dulcolax\n - Haldol PRN for agitation\n - No change in vent settings\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:00 AM\n Infusions:\n Midazolam (Versed) - 5 mg/hour\n Other ICU medications:\n Fentanyl - 05:15 PM\n Midazolam (Versed) - 05:20 PM\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 36.6\nC (97.9\n Tcurrent: 36.6\nC (97.9\n HR: 99 (56 - 99) bpm\n BP: 136/56(296) {103/40(73) - 145/56(296)} mmHg\n RR: 18 (15 - 34) insp/min\n SpO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 86.9 kg (admission): 76.4 kg\n Height: 66 Inch\n CVP: 18 (6 - 19)mmHg\n PAP: (40 mmHg) / (29 mmHg)\n CO/CI (Fick): (7.1 L/min) / (3.8 L/min/m2)\n Mixed Venous O2% Sat: 67 - 71\n Total In:\n 830 mL\n 302 mL\n PO:\n TF:\n 215 mL\n 163 mL\n IVF:\n 615 mL\n 139 mL\n Blood products:\n Total out:\n 2,439 mL\n 275 mL\n Urine:\n 2,439 mL\n 275 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,609 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n RR (Set): 16\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 70%\n RSBI Deferred: FiO2 > 60%\n PIP: 28 cmH2O\n Plateau: 24 cmH2O\n Compliance: 34.4 cmH2O/mL\n SpO2: 98%\n ABG: 7.45/35/112/23/0\n Ve: 9.5 L/min\n PaO2 / FiO2: 160\n Physical Examination\n GEN: intubated, sedate, responds to pain\n Eyes/conjunctiva: PERRL\n CV: RRR over IABP sounds. No m/r/g appreciated. JVP flat.\n Chest: No c/r/w over IABP sounds.\n Abd: Soft, NT, mildly distended and tympanitic, BS+\n Ext: trace edema, dopplerable pulses bilaterally\n Labs / Radiology\n 150 K/uL\n 9.5 g/dL\n 101 mg/dL\n 1.3 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 21 mg/dL\n 106 mEq/L\n 139 mEq/L\n 27.9 %\n 7.8 K/uL\n [image002.jpg]\n 10:42 AM\n 03:19 PM\n 03:42 PM\n 10:49 PM\n 04:01 AM\n 04:11 AM\n 04:18 PM\n 04:42 PM\n 09:24 PM\n 04:33 AM\n WBC\n 8.0\n 6.0\n 7.8\n Hct\n 30.6\n 28.4\n 25.8\n 27.9\n Plt\n 114\n 127\n 150\n Cr\n 1.5\n 1.3\n 1.2\n 1.3\n TCO2\n 22\n 24\n 24\n 25\n 25\n Glucose\n 114\n 108\n 104\n 101\n Other labs: PT / PTT / INR:13.1/26.5/1.1, CK / CKMB /\n Troponin-T:3175/148/15.28, ALT / AST:20/71, Alk Phos / T Bili:71/1.0,\n Differential-Neuts:66.1 %, Lymph:20.5 %, Mono:6.6 %, Eos:5.9 %,\n Fibrinogen:625 mg/dL, Lactic Acid:0.9 mmol/L, Albumin:2.7 g/dL, LDH:840\n IU/L, Ca++:8.3 mg/dL, Mg++:2.2 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n # Cardiogenic Shock/STEMI. Off DA, off IABP. Pressures have ranged\n 81/40 - 126/69 with Fick #s: 7.1/3.8/550 at 9PM.\n - Failed stim suggesting adrenal insufficiency which certainly\n could be affecting BP. Started hydrocortisone 50 mg q6, will follow.\n - Continue ASA 325, Plavix 75, simva 80.\n .\n # PUMP: Received 20 mg lasix yesterday, is -1600mL and clinically\n volume status is improving significantly with decreased pedal edema\n today.\n - Goal -500 today, with 20 mg lasix this PM if needed\n .\n # RHYTHM: Mostly NSR with more volatile HR 50s-90s, sporadic PVCs. Hold\n BB.\n .\n # Anemia: Improving. PLT continuing to rise, up to 150 today\nvery\n likely plt drop related to IABP; HCT rising slightly, 25.8 -> 27.9.\n overnight. Will continue to monitor.\n .\n # Sedation: Received Haldol x1 for agitation.\n .\n # Resp Failure/Aspiration: No weaning attempts yesterday given focus on\n weaning pressors and IABP; Remains on 70% FiO2, PEEP 8.\n - Will attempt to wean aggressively today with reduced sedation given\n significant clinical improvement.\n - frequent suctioning\n - continue COPD meds, now with standing albuterol and ipratropium q4h\n - Day Abx course (levaquin) for suspected aspiration\n .\n # Abdomen remains distended this AM: likely constipation, no concerning\n signs on KUB.\n - Aggressive bowel regimen: senna, colace, reglan, dulcolax\n - Continue to monitor by physical exam\n .\n # ARF. Cre continuing to improve, now 1.3.\n .\n # s/p shoulder surgery\n - continue pain control with fentanyl bolus prn\n .\n # UC. per GI, d/c asacol for now.\n - guaiac stools to make sure UC is not flaring. if flares, LD\n prednisone.\n .\n # depression. celexa.\n ICU Care\n Nutrition: TF\n Nutren Pulmonary (Full) - 08:00 PM 25 mL/hour\n Glycemic Control: ISS\n Lines:\n Cordis/Introducer - 02:40 PM\n PA Catheter - 02:40 PM\n Arterial Line - 01:30 PM\n Prophylaxis:\n DVT: Heparin SC\n Stress ulcer: sucrafalate\n VAP: HOB elevated 30 degrees\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: CCU for now\n" }, { "category": "Radiology", "chartdate": "2176-05-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082461, "text": " 9:01 AM\n CHEST (PORTABLE AP) Clip # \n Reason: interval chage, pulm edema\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man who came in with cardiogenic shock/stemi. presents with\n increased work of breathing\n REASON FOR THIS EXAMINATION:\n interval chage, pulm edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Increased workup breathing.\n\n Portable AP chest radiograph was compared to .\n\n Cardiomediastinal silhouette is stable. There is slight interval improvement\n in interstitial opacities consistent with interval resolution of pulmonary\n edema which is still present, mild. There are no new areas of consolidation.\n The bibasal retrocardiac atelectasis is unchanged compared to at\n 5 p.m. but improved since morning radiograph. There is no\n interval development of pleural effusion or pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2176-05-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1082581, "text": " 7:02 AM\n CHEST (PORTABLE AP) Clip # \n Reason: aspiration pneumonia vs. flash pulmonary edema\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 75 year old man s/p cardiogenic shock, with worsening rales\n REASON FOR THIS EXAMINATION:\n aspiration pneumonia vs. flash pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 7:57 A.M., \n\n HISTORY: Cardiogenic shock with worsening rales and possible aspiration\n pneumonia.\n\n IMPRESSION: AP chest compared to :\n\n Heart size is normal, mediastinal and pulmonary vasculature minimally engorged\n but unchanged. Peribronchial opacification in the right lower lobe, stable\n since could be atelectasis or recent aspiration, but there are no\n other pulmonary findings to suggest edema.\n\n A 16-mm wide nodular opacity projecting over the left lung base and cardiac\n silhouette is new or newly apparent since all the recent chest radiographs,\n after show relative opacification in the left lower lobe due to\n atelectasis, I cannot document how long this nodule has been present. It\n warrants evaluation with at least conventional chest radiographs.\n\n Findings discussed by telephone with housestaff caregiver at the time of\n dictation..\n\n" }, { "category": "Radiology", "chartdate": "2176-05-02 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1081942, "text": " 10:14 AM\n PORTABLE ABDOMEN Clip # \n Reason: eval for bowel obstruction\n Admitting Diagnosis: ST-SEGMENT ELEVATION MYOCARIAL INFARCTION\\CARDIAC CATH\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE ABDOMEN, ONE VIEW.\n\n COMPARISON: .\n\n HISTORY: Evaluate for obstruction.\n\n FINDINGS: NG tube is seen terminating within the duodenum. Scattered\n air-filled loops of small and large bowel are identified. There is no\n evidence of dilated loops of bowel or pneumatosis. The osseous structures are\n unchanged.\n\n IMPRESSION: Nonspecific bowel gas pattern.\n\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2162-02-19 00:00:00.000", "description": "Report", "row_id": 1552102, "text": "Admission Note\nOriginally admitted to 5 post syncopal epside at home. Transferred from @0830 with noted hypotension 80/50 and low UOP x24hrs of 160cc after multiple 250cc IVBs totaling 2liters without effect.\nNuerologically intact on arrival with verbal frustrations and agitation regarding c/o bladder pain r/t foley cath.\nLinens found to be saturated with urine and foley cath leaking. Pt states I told them I was gonna pull that thing out if they didn't take it out. Cath appeared dislodged into the urethral with balloon still inflated. Foley cath dc'd. Inserted new 18fr foley cath with pt continuing c/o pain. Small amount of bloody urine noted and pt verbalizing slight relief from pain. Baseline BP 100/50's. Team informed and pt thought to be transferred unnecessarily pending improved UOP to be called out back to floor.\n\n" }, { "category": "Nursing/other", "chartdate": "2162-02-19 00:00:00.000", "description": "Report", "row_id": 1552103, "text": "Shift summary\nPending call out to floor. see transfer note for full assesment data. Pt appears comfortable, denies c/o pain and less agitated. Agrees to ask for help when attempting to get out of bed. BP stable, not orthostatic. UOP continues low and blood tinged, voiding without difficulty. L AC peripheral IV dc'd d/t infiltration and redness to site. R ac peripheral IV wit good blood return, easily draw for serum sampling.\n" }, { "category": "Nursing/other", "chartdate": "2162-02-20 00:00:00.000", "description": "Report", "row_id": 1552104, "text": "npn 7p-7a (see also careview flownotes for objective data)\n\ndx: pulmonary htn; hep C cirrhosis; obesity; IDDM; previous ETOH; previous IVDA; thrombocytopenia;\n\nadmitted/transferred to MICU-A for hypotension and syncopal episode;\npt c/o this 12 hours d/t hemodynamically stable, though no floor beds available;\n\n7p-7a:\nvss this night; very verbal regarding voicing her opinions and efforts to direct her cares--re blood draws, b/p cuff, getting OOB to commode on own, etc; tried to allow self direction w/in safety; foley out yesterday at her insistance; voided x3 this 12 hours, pink, s/p trauma to bladder/urethra re foley cath;\n\nROS:\nneuro:\na/o x3; moves all extremites equally, PERLA; gets OOB on own, no this night;\n\nc-v:\nhrt rate 90's, to low 100's when OOB to commode; 2 pt drop in hct, 27 down to 25 this a.m., MD notified and stated awareness; pt planned to be transferred out to regular floor, if transfusion is ordered, will not be transfused before transfer, MD aware; no blood transfusion ordered at time of writing this note;\n\nresp:\nRA sat 98-99; occasional non-prod cough heard by nurse , esp after OOB to commode;\n\ng-i:\nhad jello and crackers overnight, tolerated well;\n\ng-u:\nas above, foley out yesterday with trauma, voiding pink urine; continues to have scant amount bleeding peri-area--likely d/t foley issues as discussed above;\n\naccess:\nRt a.c. PIV being used for blood draws; this a.m. blood return slow, expected speciment to be hemolyzed with elevated K+, and results did come back as expected, MD notified and aware; (pt refusing venous phlebotomy draw);\n\nsocial:\npt's brother called last eve; pt talking on phone last eve;\n\nPLAN:\nhypotension resolved at this time;\ncovering MD thought possibly d/t dehydration, that because of pt's pulm htn, she may need higher fluid needs;\n\ntransfer note written; MD writing transfer orders at this time (05:15); now has bed available on CC7; Resident writing MD transfer orders; transfer will likely happen close to change of shift;\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2162-02-20 00:00:00.000", "description": "Report", "row_id": 1552105, "text": "06:45 npn addendum re transfer preparation:\n\npt needs to be seen by GI before transfer d/t slowly dropping hct and + guiac PR.\n" }, { "category": "Radiology", "chartdate": "2162-02-17 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 851185, "text": " 10:12 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: FALL. ?LOC.R/O BLEED\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with fall 3 days ago, ?LOC, with INR 2 and plt 60.\n REASON FOR THIS EXAMINATION:\n r/o bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PHRa WED 10:35 PM\n No bleed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall three days ago with questionable loss of consciousness. On\n anticoagulation. Rule out bleed.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: None.\n\n FINDINGS: There is no intracranial hemorrhage, abnormal extra-axial fluid\n collection, mass effect or midline shift. The ventricles are normal, and the\n cisterns are patent. The -white matter attenuation is normal. The\n visualized paranasal sinuses and mastoid air cells are clear. No fracture is\n detected.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-02-17 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 851181, "text": " 9:17 PM\n CHEST (PA & LAT) Clip # \n Reason: r/o CHF\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with asthma, pulm HTN presents with shortness of breath and\n syncope.\n REASON FOR THIS EXAMINATION:\n r/o CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Shortness of breath and syncope. History of asthma and pulmonary\n hypertension.\n\n COMPARISON: .\n\n AP AND LATERAL CHEST: The heart size is unchanged. The pulmonary vascularity\n is within normal limits. There is no pleural effusion or pneumothorax. The\n visualized osseous structures are unremarkable.\n\n IMPRESSION: No significant change since . No acute pulmonary\n disease.\n\n\n" }, { "category": "Radiology", "chartdate": "2162-02-19 00:00:00.000", "description": "DUPLEX DOPP ABD/PEL", "row_id": 851399, "text": " 3:39 PM\n DUPLEX DOPP ABD/PEL Clip # \n Reason: please do doppler to assess portal flow\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with hep c cirrhosis, R CHF, increased INR\n REASON FOR THIS EXAMINATION:\n please do doppler to assess portal flow\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hepatitis C, cirrhosis, right heart failure, increased INR.\n\n Abdominal ultrasound: The liver is diffusely coarsened in echotexture\n consistent with cirrhosis. There is a tiny amount of ascites. Spleen is not\n enlarged at 8.6 cm. The gallbladder is decompressed. There is no intra or\n extrahepatic biliary dilatation, and the common bile duct measures 4 mm.\n\n Liver Doppler: There is reversal of flow within the portal vein as well as\n the splenic vein. Normal flow and waveforms are identified within the left\n and right hepatic arteries. The IVC as well as the hepatic veins are dilated.\n\n IMPRESSION:\n\n 1) Enlarged hepatic veins and inferior vena cava consistent with right heart\n failure.\n\n 2) Coarsened liver echotexture, as well as hepatofugal flow identified within\n the portal and splenic veins. These findings are consistent with cirrhosis\n and portal hypertension. There is only a tiny amount of ascites.\n\n\n\n\n\n\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2162-02-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 852434, "text": " 6:44 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for acute changes.\n Admitting Diagnosis: SYNCOPE;TELEMETRY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 45 year old woman with acute mental status change.\n REASON FOR THIS EXAMINATION:\n please evaluate for acute changes.\n CONTRAINDICATIONS for IV CONTRAST:\n ARF\n ______________________________________________________________________________\n WET READ: EEZ SAT 6:53 PM\n no acute hemorrhage\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Acute mental status changes. Evaluate for acute change.\n\n TECHNIQUE: Noncontrast head CT.\n\n COMPARISON: Head CT scan from .\n\n NONCONTRAST HEAD CT: There is no acute intra- or extra-axial hemorrhage,\n hydrocephalus, shift of normally midline structures, or evidence of acute\n major vascular territorial infarction. Osseous and extracranial soft tissue\n structures are unremarkable.\n\n IMPRESSION: No acute intracranial hemorrhage or change from .\n\n" }, { "category": "ECG", "chartdate": "2162-02-17 00:00:00.000", "description": "Report", "row_id": 179434, "text": "Baseline artifact. Supraventricular rhythm at the upper limits of normal rate.\nThe P wave morphology suggest a low septal origin. Since the previous tracing\nof the atrial mechanism has changed from sinus. Other features are\nprobably unchanged. Clinical correlation is suggested.\n\n" } ]

[ { "category": "Physician ", "chartdate": "2184-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568553, "text": "Chief Complaint:\n 24 Hour Events:\n - DNR/DNI overnight, family wants to make patient CMO this morning\n - no plans for surgery or escalation of intervention\n FEVER - 101.7\nF - 02:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 07:40 PM\n Ambisome - 10:20 PM\n Ceftazidime - 03:30 AM\n Metronidazole - 06:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:44 PM\n Heparin Sodium (Prophylaxis) - 07:44 PM\n Morphine Sulfate - 09:35 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.7\nC (98\n HR: 92 (90 - 110) bpm\n BP: 111/54(67) {77/43(50) - 143/72(86)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,362 mL\n 897 mL\n PO:\n TF:\n IVF:\n 2,362 mL\n 897 mL\n Blood products:\n Total out:\n 2,965 mL\n 645 mL\n Urine:\n 2,965 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -603 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment.\n - neuro checks q2 hrs\n - elevated HOB\n - avoid hypotension to maintain CPP\n - cont mannitol 50 g q6; holding for osm >320, Na >150; monitor renal\n failure\n - hold steroids for now given likely infection\n - cont ambisome and flucytosine\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - Neurosurgery made aware that patients status has deteriorated this AM\n and that family does not want to pursue operative management or\n intubation\n .\n 2. Cryptococcal meninigitis:\n - cont ambisome and flucytosine\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection.\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n - replace bicarb via IV/amps\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n - cont flagyl\n .\n 6. HIV/AIDS:\n - Refusing HAART meds\n - Dapsone for PCP \n .\n 7. Hypothyroidism:\n - cont. levothyroxine\n FEN: NPO\n Prophylaxis: pneumoboots/heparin sq, PPI, bowel regimen\n Access: PICC\n Code status: DNR/DNI\n Dispo: ICU care for now, family plans to come today to assess goals of\n care today.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568551, "text": "Chief Complaint:\n 24 Hour Events:\n - DNR/DNI overnight, family wants to make patient CMO this morning\n - no plans for surgery or escalation of intervention\n FEVER - 101.7\nF - 02:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 07:40 PM\n Ambisome - 10:20 PM\n Ceftazidime - 03:30 AM\n Metronidazole - 06:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:44 PM\n Heparin Sodium (Prophylaxis) - 07:44 PM\n Morphine Sulfate - 09:35 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.7\nC (98\n HR: 92 (90 - 110) bpm\n BP: 111/54(67) {77/43(50) - 143/72(86)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,362 mL\n 897 mL\n PO:\n TF:\n IVF:\n 2,362 mL\n 897 mL\n Blood products:\n Total out:\n 2,965 mL\n 645 mL\n Urine:\n 2,965 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -603 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O MENINGITIS, BACTERIAL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568970, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.0\nF - 10:00 AM\n Continued CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.3\nC (101\n HR: 112 (101 - 138) bpm\n BP: 88/40(50) {88/40(50) - 92/54(62)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 336 mL\n 128 mL\n PO:\n TF:\n IVF:\n 336 mL\n 128 mL\n Blood products:\n Total out:\n 400 mL\n 0 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -64 mL\n 128 mL\n Respiratory support\n SpO2: 93%\n ABG: ////\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568971, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.0\nF - 10:00 AM\n Continued CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.3\nC (101\n HR: 112 (101 - 138) bpm\n BP: 88/40(50) {88/40(50) - 92/54(62)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 336 mL\n 128 mL\n PO:\n TF:\n IVF:\n 336 mL\n 128 mL\n Blood products:\n Total out:\n 400 mL\n 0 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -64 mL\n 128 mL\n Respiratory support\n SpO2: 93%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568972, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.0\nF - 10:00 AM\n Continued CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.3\nC (101\n HR: 112 (101 - 138) bpm\n BP: 88/40(50) {88/40(50) - 92/54(62)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 336 mL\n 128 mL\n PO:\n TF:\n IVF:\n 336 mL\n 128 mL\n Blood products:\n Total out:\n 400 mL\n 0 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -64 mL\n 128 mL\n Respiratory support\n SpO2: 93%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment. Patient made CMO\n .\n 2. Cryptococcal meninigitis: Continued on ambisome and flucytosine.\n D/C when CMO\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection. Upon MICU admit, patient continued on\n vanco/ceftax/flagyl. D/C when CMO\n .\n 4. Hypokalemia and metabolic acidosis: CMO\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n .\n 6. HIV/AIDS: Was continued on Dapsone for PCP .\n - Refusing HAART meds\n .\n 7. Hypothyroidism\n FEN: NPO\n Prophylaxis: pneumoboots\n Access: PICC\n Code status: CMO. DNR/DNI\n Dispo: CMO. Palliative care unable to place patient over weekend.\n Will continued morphine gtt.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Radiology", "chartdate": "2184-02-16 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1070563, "text": " 8:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: hernia w/incarcaration, abscess. Likely does not need PO con\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with swelling, redness, pus from abdominal incision s/p VP\n shunt placement, -F/C/S, -abd pain,\n REASON FOR THIS EXAMINATION:\n hernia w/incarcaration, abscess. Likely does not need PO contrast.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: GWp MON 10:34 PM\n VP shunt not in peritoneal cavity with low density collection about distal tip\n\n Liver lesion is hemangioma Vs mets recommend MR \n\n\n Bilat infrahilar soft tissue prominence incompletely characterized -\n lymphadenopathy Vs neoplasm Recommend non-urgent chest CT\n WET READ VERSION #1 GWp MON 10:19 PM\n VP shunt not in peritoneal cavity with low density collection about distal tip\n\n Liver lesion is hemangioma Vs mets recommend MR \n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with swelling, redness, and pus from the\n abdominal incision status post VP shunt placement. Abdominal pain, hernia\n with an incarceration abscess.\n\n COMPARISON: None available.\n\n TECHNIQUE: Multiple MDCT axial images were obtained from the lung bases to\n the proximal thighs after the uneventful administration of 130 cc of Optiray\n intravenously. Enteric contrast was not administered. Sagittal and coronal\n reformations were derived.\n\n FINDINGS:\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:\n\n In the visualized thorax, there is bibasilar atelectasis. There is soft\n tissue prominence within the infrahilar regions (series 2, image 1) which may\n represent lymphadenopathy associated with HIV. There is no pleural effusion\n or pneumothorax. The visualized heart is of normal size. There is no\n pericardial effusion.\n\n In the abdomen, there is a 4.9 x 7.1 cm rounded hypdensity in segments VI and\n VII of the liver demonstrating peripheral nodular enhancement compatible with\n a hemangioma. The gallbladder, spleen, adrenals, pancreas, and abdominal\n loops of small and large bowel are unremarkable. The kidneys symmetrically\n take up and excrete contrast without hydrnephrosis. There are multiple oval\n hypodensities in each kidney measuring to 1.6 x 2.2 cm on the left and 1.3 x\n (Over)\n\n 8:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: hernia w/incarcaration, abscess. Likely does not need PO con\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 1.7 cm on the right, likely benign cysts. There is no free air, free fluid,\n or pathologic lymphadenopathy. The abdominal aorta is normal in caliber and\n course, but atherosclerotic calcifications are seen. The takeoff of the\n celiac axis and SMA appear patent. There is a small umbilical hernia\n containing fat. Additionally, multiple subcutaneous nodules are present within\n the anterior abdominal wall, and correlation with history of subcutaneous\n injections is recommended.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST:\n\n Pelvic loops of bowel are unremarkable. The bladder and distal ureters are\n unremarkable. The adnexa are unremarkable. There is no pelvic free air or\n free fluid. Bilateral inguinal lymph nodes are prominent, measuring up to 13\n mm wide.\n\n MUSCULOSKELETAL: In the right anterior abdominal wall external to the\n abdominal musculature, the ventriculoperitoneal shunt catheter terminates\n outside of the intraperitoneal cavity. Where it terminates, there is a large\n 6.5 x 10.0 x 7.8- cm fluid attenuating collection. There is associated skin\n thickening.\n\n There is no suspicious osteolytic or osteoblastic lesion. Degenerative\n changes are seen at numerous levels in the spine.\n\n IMPRESSION:\n\n 1. VP shunt terminates outside of the intraperitoneal cavity, within the\n right anterior abdominal subcutaneous tissues. Where it terminates, there is a\n large fluid collection with overlying skin thickening consistent with a\n CSFoma. Infection of this collection cannot be determined on the basis of\n this examination, and clinical correlation is recommended.\n\n 2. Large segment VI and VII hypodensity with peripheral enhancing nodularity\n compatible with a hemangioma.\n\n 3. Prominent soft tissue density within both infrahilar regions, incompletely\n characterized on this study. Findings may represent lymphadenopathy associated\n with HIV.\n\n 4. Multiple subcutaneous nodules within the anterior abdominal wall.\n Correlation with history of subcutaneous injections is recommended.\n\n COMMENT: These results were posted to the ED Dashboard at time of\n interpretation.\n (Over)\n\n 8:38 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: hernia w/incarcaration, abscess. Likely does not need PO con\n Field of view: 42 Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-02-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1070580, "text": " 1:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pna?\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with recent VP shunt placement, now febrile\n REASON FOR THIS EXAMINATION:\n pna?\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with recent VP shunt placement\n with no febrile.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The right PICC line tip is in proximal SVC. Cardiomediastinal silhouette is\n unremarkable. Lungs are essentially clear with no evidence of new areas of\n consolidation worrisome for pneumonia. The VP shunt is projecting over the\n right hemithorax, unchanged. No pleural effusion or pneumothorax is seen.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-02-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1070747, "text": " 6:22 PM\n PORTABLE ABDOMEN Clip # \n Reason: please evaluate placement of distal catheter of VP shunt\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with distal catheter tip revision\n REASON FOR THIS EXAMINATION:\n please evaluate placement of distal catheter of VP shunt\n ______________________________________________________________________________\n WET READ: AKSb TUE 9:00 PM\n Distal catheter in mid abdomen overlying L4 vertebral body. More proximal\n catheter extends from RUQ. Scoliosis. Contrast in bladder and colon from\n recent CT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 60-year-old female with distal catheter tip\n revision. Evaluate placement of distal catheter of VP shunt.\n\n EXAMINATION: Single supine abdominal radiograph.\n\n COMPARISON: Comparison to abdominal radiographs from and CT from\n .\n\n FINDINGS: The projected tip of the VP shunt overlies the right lateral aspect\n of the L4 vertebral body. Note is made of retained contrast throughout the\n colon compatible with recent contrast administration from CT examination. Note\n is also made of contrast pooled within the bladder. The proximal segment of\n the catheter extends out of the field of view through the right upper\n quadrant. Bowel gas pattern is unremarkable, without evidence of ileus or\n obstruction. Visualized soft tissues are normal. Note is made of sigmoid\n scoliosis and degenerative changes with endplate sclerosis, most prominent at\n the level of L3-L4.\n\n IMPRESSION: VP shunt with distal tip overlying the right lateral aspect of\n the L4 vertebral body.\n\n\n" }, { "category": "Radiology", "chartdate": "2184-02-20 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1071269, "text": " 11:10 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval for signs of increased ICP or interval change\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with HIV and cryptococcal meningitis s/p VP shunt. Now with\n blurry vision. Please eval for signs of increased ICP\n REASON FOR THIS EXAMINATION:\n please eval for signs of increased ICP or interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old female with HIV, cryptococcal meningitis, status post\n VP shunt. Evaluate for evidence of increased intracranial pressure.\n\n COMPARISON: .\n\n NON-CONTRAST HEAD CT: There is no hemorrhage, hydrocephalus, shift of\n normally midline structure, or evidence of major vascular territorial infarct.\n The -white matter differentiation is preserved. Right frontal\n ventriculostomy catheter terminates in the frontal of the left lateral.\n Hypodensities in the left cerebellar hemisphere, right temporal lobe, and left\n caudate head are unchanged, representing prior sites of cryptococcal\n involvement. There is continued opacification of the right sphenoid sinuse and\n increased secretions in the nasopharynx.\n\n IMPRESSION: No hemorrhage or change in size or configuration of ventricles.\n\n" }, { "category": "Radiology", "chartdate": "2184-02-19 00:00:00.000", "description": "FLUORO GUID FOR SPINE DIAG/THERAPEUTIC INJ", "row_id": 1071156, "text": " 4:30 PM\n LUMBAR PUNCTURE Clip # \n Reason: Please perform lumbar puncture for gram stain, culture, \n Admitting Diagnosis: ABDOMINAL PAIN\n ********************************* CPT Codes ********************************\n * LUMBAR SPINAL PUNCTURE FLUORO GUID FOR SPINE DIAG/THE *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with HIV/AIDS, being treated for cryptococcal meningitis s/p\n VP shunt. Presented with fevers and malfunctioning VP shunt now s/p revision.\n Need LP and neurology chief resident could not do on floor last month. Required\n flouro guided LP.\n REASON FOR THIS EXAMINATION:\n Please perform lumbar puncture for gram stain, culture, fungal stain and\n culture and cell count, glucose and protein.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Female patient with history of cryptococcal meningitis and now with\n fever. Multiple attempts for lumbar puncture on the floor by the referring\n clinician were unsuccessful. Patient is referred for fluoroscopic guided\n lumbar puncture.\n\n TECHNIQUE: Informed consent was obtained after explaining the risks,\n indications, and alternative management.\n\n The patient was brought to the fluoroscopic suite and placed on the\n fluoroscopic table in prone position. Access to the lumbar subarachnoid space\n was obtained with a 22 gauge spinal needle under local anesthesia using 1%\n lidocaine and with aseptic precautions. Openning pressure was measure to be 13\n mmHg. Approximately 13 cc of CSF fluid were removed and sent to pathology and\n microbiology as per request of referring physician. patient tolerated the\n procedure well without any complications. Patient was sent to the floor with\n post procedure orders.\n\n Access was obtained at the level of L4-5.\n\n IMPRESSION:\n\n 1. Successful lumbar puncture via the L4/5 level.\n 2. Opening pressure = 13mmHg.\n 3. CSF specimens sent to pathology and microbiology as per request of\n referring physician.\n\n\n\n" }, { "category": "Nursing", "chartdate": "2184-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568704, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt had meeting with team and decided to make pt comfort measures only\n this AM.\n Action:\n Started morphine drip at noon for comfort. Pt was moaning at 2Pm,\n family felt pt was uncomfortable, moaning with turns, otherwise non\n responsive. Titrated up morphine to 4mg per hour and pt responded to\n that, no further moaning, pt snoring at times sedated, appears\n comfortable. Palliative care MD came by, they spoke with family,\n answered questions, and felt comfort was attained and measures\n appropriate.\n Response:\n PT appears comfortable, sedate. Family appreciate care and are staying\n with pt.\n Plan:\n Continue comfort measures.\n" }, { "category": "Nursing", "chartdate": "2184-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568620, "text": "60 yo women recently dx with cryptococcal meningitis, tx w/amtibx\n also had V-P shunt placed for increased ICP. \n represented to with fevers and bulge in abdomen. CT abd with s/q\n fluid collection and catheter tip leading into fluid collection\n suggesting migration of catheter tip. Went to OR on for revision\n and repositioning of tip of catheter. Fever of 101/9 and blood cs\n with coag neg staph Rx vanco/ceftaz. Subsequent blood cx negative. LP\n by IR was negative, + for crypto, but negative otherwise. C. diff +,\n got 10 days of flagyl. Also being treated for RTA with HCO3. Right\n sided temporal headache and LUE weakness - CT scan had fluid collection\n around side of VP-shunt. Resident spoke with daughter regarding change\n in status, she was made DNR/DNI\n family in today and pt made comfort\n measures only.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Minimally responsive, pt appears comfortable throughout morning; family\n coping appropritely\n Action:\n Per family request, pt made CMO, all meds d/c\nd; Morphine drip started\n at 2mg /hr\n Response:\n Pt comfortable, family at bedside\n Plan:\n Continue to provide support to family, comfort measures for patient,\n assess pain lvel on Morphine drip, Awaiting palliative care consult for\n further plan.\n" }, { "category": "Nursing", "chartdate": "2184-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568869, "text": "60 yo women recently dx with cryptococcal meningitis, tx w/amtibx\n also had V-P shunt placed for increased ICP. \n represented to with fevers and bulge in abdomen. CT abd with s/q\n fluid collection and catheter tip leading into fluid collection\n suggesting migration of catheter tip. Went to OR on for revision\n and repositioning of tip of catheter. Fever of 101/9 and blood cs\n with coag neg staph Rx vanco/ceftaz. Subsequent blood cx negative. LP\n by IR was negative, + for crypto, but negative otherwise. C. diff +,\n got 10 days of flagyl. Right sided temporal headache and LUE weakness\n - CT scan had fluid collection around side of VP-shunt. Pt now\n DNR/DNI\npt made comfort measures only on and Morphine drip\n started. Family at bedside\n coping well.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remains hemodynamically stable; unresponsive to minimally responsive\n Appears very comfortable on Morphine drip at 4mg/hr\n Action:\n Cont Morphine IV, providing comfort measures including q2hr turning,\n oral care, eye drops, skin care\n Response:\n Status unchanged\n Plan:\n Continue morphine and comfort measures, provide support to family at\n bedside, palliative care is following, case manager consulted regarding\n possible transfer to facility nearer to pt\ns family in if\n she remains stable over the weekend; transfer to floor, private room.\n" }, { "category": "Physician ", "chartdate": "2184-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568552, "text": "Chief Complaint:\n 24 Hour Events:\n - DNR/DNI overnight, family wants to make patient CMO this morning\n - no plans for surgery or escalation of intervention\n FEVER - 101.7\nF - 02:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 07:40 PM\n Ambisome - 10:20 PM\n Ceftazidime - 03:30 AM\n Metronidazole - 06:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:44 PM\n Heparin Sodium (Prophylaxis) - 07:44 PM\n Morphine Sulfate - 09:35 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.7\nC (98\n HR: 92 (90 - 110) bpm\n BP: 111/54(67) {77/43(50) - 143/72(86)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,362 mL\n 897 mL\n PO:\n TF:\n IVF:\n 2,362 mL\n 897 mL\n Blood products:\n Total out:\n 2,965 mL\n 645 mL\n Urine:\n 2,965 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -603 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n IMPAIRED PHYSICAL MOBILITY\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O MENINGITIS, BACTERIAL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-04 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 568598, "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 60 yo women with AIDS, with crypto meningitis, c/b cerebritis,\n hemiparalysis. family opting for CMO\n 24 Hour Events:\n FEVER - 101.7\nF - 02:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:44 PM\n Heparin Sodium (Prophylaxis) - 07:44 PM\n Morphine Sulfate - 09:35 PM\n Other medications:\n ampho\n flucytosine\n dapsone\n synthroid\n mannitol\n PPI\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 35.5\nC (95.9\n HR: 94 (89 - 110) bpm\n BP: 96/52(62) {77/43(50) - 143/72(86)} mmHg\n RR: 17 (15 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,362 mL\n 1,270 mL\n PO:\n TF:\n IVF:\n 2,362 mL\n 1,270 mL\n Blood products:\n Total out:\n 2,965 mL\n 970 mL\n Urine:\n 2,965 mL\n 970 mL\n NG:\n Stool:\n Drains:\n Balance:\n -603 mL\n 300 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n General Appearance: No acute distress\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed,\n Paralyzed, Tone: Not assessed, left hemiparesis\n Labs / Radiology\n 8.6 g/dL\n 196 K/uL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Fluid analysis / Other labs: OSM 310\n Assessment and Plan\n Cryptococcal meningitis c/b cerebritis, CSF fluid collection.\n brain edema: osm 316, and creatining increasing so will stop mannitol\n family likely to make CMO later today\n will get palliative care consult\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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 :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2184-03-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568865, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-03-05 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568868, "text": "60 yo women recently dx with cryptococcal meningitis, tx w/amtibx\n also had V-P shunt placed for increased ICP. \n represented to with fevers and bulge in abdomen. CT abd with s/q\n fluid collection and catheter tip leading into fluid collection\n suggesting migration of catheter tip. Went to OR on for revision\n and repositioning of tip of catheter. Fever of 101/9 and blood cs\n with coag neg staph Rx vanco/ceftaz. Subsequent blood cx negative. LP\n by IR was negative, + for crypto, but negative otherwise. C. diff +,\n got 10 days of flagyl. Right sided temporal headache and LUE weakness\n - CT scan had fluid collection around side of VP-shunt. Pt now\n DNR/DNI\npt made comfort measures only on and Morphine drip\n started. Family at bedside\n coping well.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remains hemodynamically stable; unresponsive to minimally responsive\n Appears very comfortable on Morphine drip at 4mg/hr\n Action:\n Cont Morphine IV, providing comfort measures including q2hr turning,\n oral care, eye drops, skin care\n Response:\n Status unchanged\n Plan:\n Continue morphine and comfort measures, provide support to family at\n bedside, palliative care is following, case manager consulted regarding\n possible transfer to facility nearer to pt\ns family in if\n she remains stable over the weekend; transfer to floor, private room.\n" }, { "category": "Nursing", "chartdate": "2184-03-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568945, "text": "60 yo women recently dx with cryptococcal meningitis, tx w/amtibx\n also had V-P shunt placed for increased ICP. \n represented to with fevers and bulge in abdomen. CT abd with s/q\n fluid collection and catheter tip leading into fluid collection\n suggesting migration of catheter tip. Went to OR on for revision\n and repositioning of tip of catheter. Fever of 101/9 and blood cs\n with coag neg staph Rx vanco/ceftaz. Subsequent blood cx negative. LP\n by IR was negative, + for crypto, but negative otherwise. C. diff +,\n got 10 days of flagyl. Right sided temporal headache and LUE weakness\n - CT scan had fluid collection morphine drip to 10 mg/hr at 0400 due\n to patient moaning after turning . Family at bedside\n coping well.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remains hemodynamically stable; unresponsive to minimally responsive\n Appears very comfortable on Morphine drip at 10 mg/hr\n Action:\n Cont Morphine IV, providing comfort measures including q2hr turning,\n oral care, eye drops, skin care\n Response:\n Status unchanged\n Plan:\n Continue morphine and comfort measures, provide support to family at\n bedside, palliative care is following, case manager consulted regarding\n possible transfer to facility nearer to pt\ns family in if\n she remains stable over the weekend; transfer to floor, private room.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Comfort measures only\n Height:\n Admission weight:\n 95 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Precautions:\n PMH: Anemia, Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: s/p VP shunt on for management of cyrptococcal\n meningitis. HIV postive not being tx'd with anti virals. C diff colitis\n tx'd with flagyl, Depression, hypothyrodism\n Surgery / Procedure and date: s/p VP shunt.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:88\n D:40\n Temperature:\n 101\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 16 insp/min\n Heart Rate:\n 112 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 93% %\n O2 flow:\n FiO2 set:\n 24h total in:\n 95 mL\n 24h total out:\n 0 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 09:58 AM\n Potassium:\n 4.0 mEq/L\n 09:58 AM\n Chloride:\n 109 mEq/L\n 02:14 AM\n CO2:\n 18 mEq/L\n 02:14 AM\n BUN:\n 19 mg/dL\n 02:14 AM\n Creatinine:\n 1.6 mg/dL\n 02:14 AM\n Glucose:\n 114 mg/dL\n 02:14 AM\n Hematocrit:\n 25.9 %\n 02:14 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: ccu\n Transferred to: cc612\n Date & time of Transfer: 12:00 AM\n" }, { "category": "Nursing", "chartdate": "2184-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568543, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status, she is\n currently DNR/DNI with ? comfort measures when family arrives later\n today ().\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Please see neuro exam via flow sheet. She appears to respond to\n movement with groaning, also noted with movement appearing to dry\n heave. No movement noted spontaneously on L side except LL limb moves\n upward to painful stimuli. Has no corneal reflex on L side and seems\n to try to prevent rn from opening R eye, but able to do so and has (+)\n corneal reflex on R side. Decrease in bp to mid 70\ns with no change in\n hr (90\ns), also at same time decrease in uo to 20cc/hr.\n Action:\n Neuro checked q 4 hours with no change, respositioned q 2\n 3 from side\n to side. Very flaccid with movement. Rec\nd 250cc NS bolus. Conts on\n mannitol with na/osm checked prior to rec\ning med.\n Response:\n Increase in bp to 100-110\ns, also increase in uo with ivf bolus.\n Groans slightly with movement and dry heaves but settles back quickly.\n Plan:\n To discuss with family today comfort measures.\n" }, { "category": "Rehab Services", "chartdate": "2184-03-04 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 568670, "text": "Patient made CMO today by family, no further acute PT necessary, please\n re-consult if change in status.\n" }, { "category": "Nursing", "chartdate": "2184-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568721, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Morphine drip continues at 4mg/hour with pt. appearing to be\n comfortable. Family (daughter and friend) at bedside throughout\n night and also stating pt. appears to be comfortable.\n Action:\n Mouthcare prn. Repositioned side to side. Eye drops and eye ointment\n as ordered.\n Response:\n Vital signs stable when taken. Afeb.\n Plan:\n Continue comfort measures. Palliative care involved and following pt.\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568445, "text": "TITLE:\n .H/O meningitis, bacterial\n Assessment:\n Pt received unresponsive except to painful stimuli-when stimulated will\n moan. No other form of communication observed. PERRLA/brisk, +corneals.\n Pt withdraws extremities to nailbed pressure R>L, at times LUE doesn\n w/d. One episode of tremors in RUE noted. With activity pt moans and\n will briefly open eyes.\n Action:\n Mannitol given, along with abx as ordered. Morphine given PRN, and\n repositioned for comfort.\n Response:\n Morphine appearing to provide adequate pain control per VS.\n Plan:\n Pt was already a DNR, now a DNI as well after MICU team spoke with pt\n daughter. is to continue current meds/neuro exams and make CMO\n tomorrow after other family members arrive.\n" }, { "category": "Physician ", "chartdate": "2184-03-05 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 568817, "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 60 yo women with cryptococcal PNA, made CMO\n 24 Hour Events:\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 4 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 11:56 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.9\nC (102\n HR: 117 (84 - 138) bpm\n BP: 91/54(62) {68/39(47) - 129/82(94)} mmHg\n RR: 25 (10 - 31) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 164 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 164 mL\n Blood products:\n Total out:\n 1,720 mL\n 250 mL\n Urine:\n 1,720 mL\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n -287 mL\n -86 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Rhonchorous: ), good air movement\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 8.6 g/dL\n 196 K/uL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n To get palliative care consult to discuss disposition options.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition :Transfer to floor\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2184-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568818, "text": "Chief Complaint:\n 24 Hour Events:\n - made \n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 4 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 134 (84 - 134) bpm\n BP: 129/82(94) {68/39(47) - 129/82(94)} mmHg\n RR: 28 (10 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 104 mL\n Blood products:\n Total out:\n 1,720 mL\n 225 mL\n Urine:\n 1,720 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -287 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment. Patient made \n .\n 2. Cryptococcal meninigitis: Continued on ambisome and flucytosine.\n D/C when \n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection. Upon MICU admit, patient continued on\n vanco/ceftax/flagyl. D/C when \n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n .\n 6. HIV/AIDS: Was continued on Dapsone for PCP .\n - Refusing HAART meds\n .\n 7. Hypothyroidism\n FEN: NPO\n Prophylaxis: pneumoboots\n Access: PICC\n Code status: . DNR/DNI\n Dispo: , discuss options with palliative care.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "General", "chartdate": "2184-03-05 00:00:00.000", "description": "ICU Event Note", "row_id": 568822, "text": "Clinician: Resident\n Family expressed that the patient did not want aggressive care such as\n surgery. It was explained that if patient did not want surgery, the\n patient should not be intubated as it would only be a temporary measure\n until surgery could be peformed. Patient was made DNR/DNI on at\n 2:48 PM. Dr. also visited the family and reinforced that it was\n unlikely patient would return to baseline even with surgery. The\n family was considering transitioning the goals to comfort care however\n wanted to wait for more famiily members to arrive. Patients care goals\n were officialy transitioned to comfort care on at 11:30AM.\n Patient was started on morphine gtt for comfort. Palliative care has\n been consulted. I will ask them to review disposition options, such as\n inpatient hospice centers near where the family is.\n Total time spent: 30 minutes\n" }, { "category": "Nutrition", "chartdate": "2184-03-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 568825, "text": "Comments:\n Noted patient made CMO. Will sign off, please consult if plan of care\n changes.\n 12:22 PM\n" }, { "category": "Physician ", "chartdate": "2184-03-02 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 568204, "text": "Chief Complaint: Concern for herniation\n HPI:\n Pt is a 60 yo F with PMHx sig. for HIV (CD4 cout 163 in ) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () to decrease ICP and treated with amphoterici/flucytosine\n transitioned to fluconazole for week course. She represented on\n with fevers and a \"bulge\" at her abdomial insertion site. An\n abdominal CAT scan revealed \"VP shunt terminates outside of the\n intraperitoneal cavity, within the right anterior abdominal\n subcutaneous tissues. Where it terminates, there is a large fluid\n collection with overlying skin thickening consistent with a CSFoma.\"\n She went to the OR on for VP shunt revision and repositioning\n of the distal end of the catheter by Dr. . She also had a fever\n to 101.9 on and had blood cultures from that grew\n coag-neg Staph; she received 2-3 days of vanc/ceftaz pending speciation\n and CSF studies from LP from that was only positive for\n cryptococcus. Subsequent bcxs have been negative. She is also\n positive for C. diff and complete 10 day course of flagyl ending .\n Pt has been pending placement. Psych is following for depression,\n feels this is c/w adjustment disorder; pt has been refusing\n antidepressants. Pt has also been refusing HAART but will take dapsone\n for PCP . In addition, she has been persistently hypokalemia and\n was being treated for RTA with sodium bicarb.\n .\n This morning, pt complained of a r-sided headache and was noted to have\n LUE weakness. CT head showed new new right frontoparietal lesion\n concerning for stroke. Neurology did not feel this was c/w shock, felt\n is was more likely a fluid collection or empyema. Neurosurgery has\n also been consulted. Pt also had an MRI.\n Patient admitted from: \n History obtained from Medical records\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 08:03 PM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 PM\n Other medications:\n Past medical history:\n Family history:\n Social History:\n PMH: Mostly taken from the records\n 1. HIV: Diagnosed in . Sexually transmitted. Followed by Dr. \n in . Not consistently on anti-retrovirals due to intolerance\n and non-response. VL 24,900 and CD4 163.\n 2. Hypothyroidism\n 3. Fibromyalgia\n 4. Rheumatoid arthritis\n 5. Vertigo\n 6. CVA x3 - initially reported as most recently 2mos ago with\n dysarthria and facial droop\n 7. DMII: Diet-controlled\n 8. s/p appendectomy\n 9. s/p hysterectomy for cervical cancer\n 10. HTN and hyperlipidemia treated w/ tricor per ID records\n 11. OSA: Has not worn CPAP for over 1 year\n . Per pt childhood polio\n 13. T&A\n 14. Cataract surgery\n . B12 deficiency receiving monthly B12 injections\n .\n Medications: at home per rehab notes\n novolog scale\n dapsone 100mg q6pm\n fluconazole 400mg for 8 weeks then decrease to 200mg daily\n hydrocortisone 25mg PR\n levothyroxine 25mcg daily\n nystatin triamcinolone creame \n artificial tears bilaterally\n then difficult to tell other medications, looks as though omeprazole,\n KCL, senna, docusate, proctozone were recently discontinued\n .\n Medications: inpatient\n Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN\n Ipratropium Bromide Neb 1 NEB IH Q6H:PRN\n Aspirin 300 mg PR DAILY\n Dapsone 100 mg PO DAILY\n Fluconazole 400 mg PO Q24H\n HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN\n Heparin 5000 UNIT SC TID\n Levothyroxine Sodium 25 mcg PO DAILY\n Pantoprazole 40 mg PO Q24H\n Ondansetron 4 mg IV Q8H:PRN nausea\n Calcium Carbonate 500 mg PO QID:PRN\n Sodium Bicarbonate 650 mg PO TID\n Senna 1 TAB PO BID:PRN\n Bisacodyl 10 mg PO/PR DAILY:PRN\n Artificial Tear Ointment 1 Appl BOTH EYES HS\n Artificial Tears Preserv. Free 1-2 DROP BOTH EYES TID\n N/C\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other: Pt has been in the hospital/rehab in the past 3 months.\n Previously, she lived alone. Pt denied tob, etoh history.\n Review of systems:\n Constitutional: No(t) Fatigue, No(t) Fever\n Eyes: Blurry vision\n Ear, Nose, Throat: Dry mouth\n Cardiovascular: No(t) Chest pain, No(t) Palpitations, No(t) Edema\n Respiratory: No(t) Cough, No(t) Dyspnea, No(t) Tachypnea, No(t) Wheeze\n Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t) Emesis,\n No(t) Diarrhea, No(t) Constipation\n Neurologic: Headache, L sided weakness\n Psychiatric / Sleep: No(t) Suicidal, passive suicidality\n Flowsheet Data as of 10:15 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 39.3\nC (102.8\n HR: 125 (90 - 130) bpm\n BP: 129/86(92) {123/64(69) - 150/86(96)} mmHg\n RR: 26 (17 - 29) insp/min\n SpO2: 90%\n Total In:\n 60 mL\n PO:\n TF:\n IVF:\n 60 mL\n Blood products:\n Total out:\n 0 mL\n 300 mL\n Urine:\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n -240 mL\n Respiratory\n SpO2: 90%\n ABG: ///21/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): self,\n hospital, Sunday , Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE\n , Tone: Increased, upgoing babinski's bilaterally, clonus esp. in\n RUE, BLEs\n Labs / Radiology\n 370 K/uL\n 9.7 g/dL\n 106 mg/dL\n 1.2 mg/dL\n 17 mg/dL\n 21 mEq/L\n 107 mEq/L\n 3.1 mEq/L\n 140 mEq/L\n 27.4 %\n 11.8 K/uL\n [image002.jpg]\n \n 2:33 A4/14/ 04:59 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 11.8\n Hct\n 27.4\n Plt\n 370\n Cr\n 1.2\n Glucose\n 106\n Other labs: Ca++:9.6 mg/dL, Mg++:2.0 mg/dL, PO4:3.7 mg/dL\n Imaging: CT head:\n 1. Interval development of vasogenic edema in the right frontal lobe\n with\n associated midline shift and effacement of the perimesencephalic\n cistern on\n the right. MRI of the brain with and without contrast is recommended\n for\n additional evaluation.\n 2. Low-density lesions within the right temporal lobe, left cerebellar\n hemisphere and left caudate head, which are stable consistent with\n patient's history of cryptococcal involvement.\n 3. No acute intracranial hemorrhage.\n MRI head:\n 1. Rapidly progressive (over 2 weeks) region of presumed vasogenic\n edema\n centered within the right frontal lobe with more focal low T1 intensity\n lesions within it, resulting in mild-to-moderate leftward subfalcine\n herniation. Given its rapid progression as well as location adjacent to\n the\n ventricular drain, underlying cerebritis/abscess formation is felt to\n be most likely etiology (causes included typical bacterial infection,\n cryptococcal\n infection, fungal infection, TB, or other opportunistic infections).\n Less likely, the differential diagnosis would include acute\n demyelinating\n leukoencephalitis, or a cortically based venous thrombosis. Underlying\n neoplasm such as Kaposi's or lymphoma would be highly atypical for this\n presentation given time course.\n 2. Small punctate regions of right frontal lobe restricted\n diffusion/acute\n infarction surrounding the vasogenic edema likely related to adjacent\n mass\n effect/vasospasm.\n 3. Slight interval increase in size to the low T1 previously described\n cystic-type lesions within the right temporal lobe and left cerebellum\n which\n display no surrounding T1 signal abnormality and are likley sequela of\n prior infection.\n Microbiology: Blood Culture, Routine (Final ):\n STAPHYLOCOCCUS, COAGULASE NEGATIVE.\n ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON REQUEST.\n .\n 4:49 pm CSF;SPINAL FLUID TUBE 2.\n GRAM STAIN (Final ):\n NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.\n 4+ (>10 per 1000X FIELD): YEAST(S).\n CONSISTENT WITH CRYPTOCOCCUS SPECIES.\n This is a concentrated smear made by cytospin method, please\n refer to\n hematology for a quantitative white blood cell count.\n FLUID CULTURE (Final ): NO GROWTH.\n FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.\n .\n CRYPTOCOCCAL ANTIGEN (Final ):\n POSITIVE FOR CRYPTOCOCCAL ANTIGEN.\n Assessment and Plan\n A/P: 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who\n was recently hospitalized with cryptococcal meningitis requiring a VP\n shunt () who was readmitted with malfunctioning shunt and now has a\n fluid collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point.\n - neuro checks q2 hrs\n - elevated HOB\n - avoid hypotension to maintain CPP\n - mannitol 75 g loading dose followed by 50 g q6; holding for osm >320,\n Na >150; monitor renal failure\n - hold steroids for now given likely infection\n - if pt decompensates over night, will intubated to hyperventilation\n for pCO2 goal of 30 and will STAT page Neurosurg for emergent\n decompressive craniectomy.\n - will intensify cryptococcal infection with ambisome and flucytosine\n - will cover for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - will d/w Neurosurg re: sampling shunt v. LP by IR\n - US-guided aspiration of abdominal fluid collection though previous\n cultures have been negative, which is more reassuring\n .\n 2. Cryptococcal meninigitis:\n - change fluconazole to ambisome and flucytosine\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection.\n - will cover for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - US-guided aspiration of abdominal fluid collection though previous\n cultures have been negative, which is more reassuring\n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n - urine studies\n - replete K\n - replace bicarb via IV/amps\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n - Restart flagyl\n .\n 6. HIV/AIDS:\n - Refusing HAART meds\n - Dapsone for PCP \n .\n 7. Hypothyroidism:\n - cont. levothyroxine\n ICU Care\n Nutrition:\n Comments: NPO for now\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer:\n VAP:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n" }, { "category": "Nursing", "chartdate": "2184-03-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568912, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n pt appears comfortable, breathing shallow at 26/min\n Action:\n turned and repositioned q 2 hrs. oral care and eye care given.\n Response:\n pt still looks comfortable.\n Plan:\n Family at bedside, no change in morphine gtt this shift.\n" }, { "category": "General", "chartdate": "2184-03-02 00:00:00.000", "description": "Generic Note", "row_id": 568198, "text": "TITLE: MICU overnight attending note.\n Evaluated patient at bedside. Remains tachycardic with preserved BP.\n Neurologically awake, attends to voice, speech mumbled\n unable to\n clearly discern words other than\n and\n Left hemiparesis.\n Moving right hand freely, grasping, squeezing. Abd soft.\n Cryptococcal meningitis, hydrocephalous requiring VP shunt, now with\n sepsis and neurological decline since admission. CNS fluid collection\n may represent sterile CSF related to the VP shunt, or infected CSF\n collection (Crypto vs bacterial). Continue to monitor neurological\n status. Continue mannitol. Contact Neurosurgical service in the event\n of further neurological decline.\n Total time providing critical care= 35 minutes.\n" }, { "category": "Physician ", "chartdate": "2184-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568790, "text": "Chief Complaint:\n 24 Hour Events:\n - made CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 4 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 134 (84 - 134) bpm\n BP: 129/82(94) {68/39(47) - 129/82(94)} mmHg\n RR: 28 (10 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 104 mL\n Blood products:\n Total out:\n 1,720 mL\n 225 mL\n Urine:\n 1,720 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -287 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n IMPAIRED PHYSICAL MOBILITY\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O MENINGITIS, BACTERIAL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568791, "text": "Chief Complaint:\n 24 Hour Events:\n - made CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 4 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 134 (84 - 134) bpm\n BP: 129/82(94) {68/39(47) - 129/82(94)} mmHg\n RR: 28 (10 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 104 mL\n Blood products:\n Total out:\n 1,720 mL\n 225 mL\n Urine:\n 1,720 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -287 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n COMFORT CARE (CMO, COMFORT MEASURES)\n IMPAIRED PHYSICAL MOBILITY\n .H/O CVA (STROKE, CEREBRAL INFARCTION), OTHER\n .H/O MENINGITIS, BACTERIAL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-05 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568792, "text": "Chief Complaint:\n 24 Hour Events:\n - made \n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 4 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 07:25 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 37.2\nC (98.9\n Tcurrent: 37.2\nC (98.9\n HR: 134 (84 - 134) bpm\n BP: 129/82(94) {68/39(47) - 129/82(94)} mmHg\n RR: 28 (10 - 28) insp/min\n SpO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 1,433 mL\n 104 mL\n PO:\n TF:\n IVF:\n 1,433 mL\n 104 mL\n Blood products:\n Total out:\n 1,720 mL\n 225 mL\n Urine:\n 1,720 mL\n 225 mL\n NG:\n Stool:\n Drains:\n Balance:\n -287 mL\n -121 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 94%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment. Patient made \n .\n 2. Cryptococcal meninigitis: Continued on ambisome and flucytosine.\n D/C when \n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection. Upon MICU admit, patient continued on\n vanco/ceftax/flagyl. D/C when \n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n .\n 6. HIV/AIDS: Was continued on Dapsone for PCP .\n - Refusing HAART meds\n .\n 7. Hypothyroidism:\n FEN: NPO\n Prophylaxis: pneumoboots\n Access: PICC\n Code status: . DNR/DNI\n Dispo: , callout to floor\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2184-03-06 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 568987, "text": "60 yo women recently dx with cryptococcal meningitis, tx w/amtibx\n also had V-P shunt placed for increased ICP. \n represented to with fevers and bulge in abdomen. CT abd with s/q\n fluid collection and catheter tip leading into fluid collection\n suggesting migration of catheter tip. Went to OR on for revision\n and repositioning of tip of catheter. Fever of 101/9 and blood cs\n with coag neg staph Rx vanco/ceftaz. Subsequent blood cx negative. LP\n by IR was negative, + for crypto, but negative otherwise. C. diff +,\n got 10 days of flagyl. Right sided temporal headache and LUE weakness\n - CT scan had fluid collection morphine drip to 10 mg/hr at 0400 due\n to patient moaning after turning . Family at bedside\n coping well.\n Comfort care (CMO, Comfort Measures)\n Assessment:\n Pt remains hemodynamically stable; unresponsive to minimally responsive\n Appears very comfortable on Morphine drip at 10 mg/hr\n Action:\n Cont Morphine IV, providing comfort measures including q2hr turning,\n oral care, eye drops, skin care\n Response:\n Status unchanged. T 102.2\n given Tylenol 650mg PR at 0830am.\n Plan:\n Continue morphine and comfort measures, provide support to family at\n bedside, palliative care is following, case manager consulted regarding\n possible transfer to facility nearer to pt\ns family in if\n she remains stable over the weekend; transfer to floor, private room.\n Tylenol for fever/comfort.\n Demographics\n Attending MD:\n R.\n Admit diagnosis:\n ABDOMINAL PAIN\n Code status:\n Comfort measures only\n Height:\n Admission weight:\n 95 kg\n Daily weight:\n Allergies/Reactions:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Precautions: Contact\n PMH: Anemia, Diabetes - Oral \n CV-PMH: Hypertension\n Additional history: s/p VP shunt on for management of cyrptococcal\n meningitis. HIV postive not being tx'd with anti virals. C diff colitis\n tx'd with flagyl, Depression, hypothyrodism\n Surgery / Procedure and date: s/p VP shunt.\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:83\n D:36\n Temperature:\n 102.2\n Arterial BP:\n S:\n D:\n Respiratory rate:\n 15 insp/min\n Heart Rate:\n 110 bpm\n Heart rhythm:\n ST (Sinus Tachycardia)\n O2 delivery device:\n None\n O2 saturation:\n 91% %\n O2 flow:\n 0 L/min\n FiO2 set:\n 24h total in:\n 171 mL\n 24h total out:\n 280 mL\n Pertinent Lab Results:\n Sodium:\n 140 mEq/L\n 09:58 AM\n Potassium:\n 4.0 mEq/L\n 09:58 AM\n Chloride:\n 109 mEq/L\n 02:14 AM\n CO2:\n 18 mEq/L\n 02:14 AM\n BUN:\n 19 mg/dL\n 02:14 AM\n Creatinine:\n 1.6 mg/dL\n 02:14 AM\n Glucose:\n 114 mg/dL\n 02:14 AM\n Hematocrit:\n 25.9 %\n 02:14 AM\n Additional pertinent labs:\n Lines / Tubes / Drains:\n Foley catheter , PICC line\n Valuables / Signature\n Patient valuables: None\n Other valuables: white plastic rosary\n Clothes: Sent home with: family\n Wallet / Money:\n No money / wallet\n Cash / Credit cards sent home with: family\n Jewelry:\n Transferred from: CCU f624\n Transferred to: CC612\n Date & time of Transfer: 10:00 AM\n" }, { "category": "Physician ", "chartdate": "2184-03-06 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568989, "text": "Chief Complaint:\n 24 Hour Events:\n FEVER - 102.0\nF - 10:00 AM\n Continued CMO\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ambisome - 10:20 PM\n Metronidazole - 06:30 AM\n Vancomycin - 09:00 AM\n Ceftazidime - 10:00 AM\n Infusions:\n Morphine Sulfate - 10 mg/hour\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 07:40 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.9\nC (102\n Tcurrent: 38.3\nC (101\n HR: 112 (101 - 138) bpm\n BP: 88/40(50) {88/40(50) - 92/54(62)} mmHg\n RR: 16 (12 - 25) insp/min\n SpO2: 93%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 336 mL\n 128 mL\n PO:\n TF:\n IVF:\n 336 mL\n 128 mL\n Blood products:\n Total out:\n 400 mL\n 0 mL\n Urine:\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n -64 mL\n 128 mL\n Respiratory support\n SpO2: 93%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 109 mEq/L\n 140 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment. Patient made CMO\n .\n 2. Cryptococcal meninigitis: Continued on ambisome and flucytosine.\n D/C when CMO\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection. Upon MICU admit, patient continued on\n vanco/ceftax/flagyl. D/C when CMO\n .\n 4. Hypokalemia and metabolic acidosis: CMO\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n .\n 6. HIV/AIDS: Was continued on Dapsone for PCP .\n - Refusing HAART meds\n .\n 7. Hypothyroidism\n FEN: NPO\n Prophylaxis: pneumoboots\n Access: PICC\n Code status: CMO. DNR/DNI\n Dispo: CMO. Palliative care unable to place patient over weekend.\n Will continued morphine gtt for patient comfort.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Comfort measures only\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2184-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568500, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status, she is\n currently DNR/DNI with ? comfort measures when family arrives later\n today ().\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Please see neuro exam via flow sheet. She appears to respond to\n movement with groaning, also noted with movement appearing to dry\n heave. No movement noted spontaneously on L side except LL limb moves\n upward to painful stimuli. Has no corneal reflex on L side and seems\n to try to prevent rn from opening R eye, but able to do so and has (+)\n corneal reflex on R side. Decrease in bp to mid 70\ns with no change in\n hr (90\ns), also at same time decrease in uo to 20cc/hr.\n Action:\n Neuro checked q 4 hours with no change, respositioned q 2\n 3 from side\n to side. Very flaccid with movement. Rec\nd 250cc NS bolus. Conts on\n mannitol with na/osm checked prior to rec\ning med.\n Response:\n Increase in bp to 100-110\ns, also increase in uo with ivf bolus.\n Groans slightly with movement and dry heaves but settles back quickly.\n Plan:\n To discuss with family today comfort measures.\n" }, { "category": "Radiology", "chartdate": "2184-03-02 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1073162, "text": " 11:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for any infarct or VP shunt abnormality.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with HIV and being treated for cryptococcal meningitis and\n s/p VP shunt. Now with left sided weakness. Please eval for any infarct or VP\n shunt abnormality.\n REASON FOR THIS EXAMINATION:\n Please eval for any infarct or VP shunt abnormality.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PFI: There is approximately 6 mm of midline shift to the left with increased\n vasogenic edema in the right frontal lobe. There is a small focus of possible\n low-attenuation the cortex (series 2, image 24) that may represent a focus of\n infarct. Followup MRI with and without contrast is recommended for additional\n evaluation.\n\n TECHNIQUE: Axial CT images of the brain were obtained without the\n administration of contrast.\n\n COMPARISON: CT of the brain from .\n\n FINDINGS: There is a new area of low attenuation in the right frontal lobe\n consistent with vasogenic edema which results in mass effect on the anterior\n lateral right ventricle and causes approximately 6 mm of midline shift to the\n left. There is low attenuation in the right frontal lobe (series 2, image 24)\n that appears to extend to the cortex and may represent an area of ischemia.\n There is mild effacement of the right perimesencephalic cistern. There is\n diffuse effacement of the sulci on the right in the right cerebral hemisphere.\n The right frontal ventriculostomy terminates in the anterior lateral left\n ventricle. Hypodensities in the left cerebellum, right temporal lobe and left\n caudate head are unchanged representing prior sites of cryptococcal\n involvement.\n\n IMPRESSION:\n 1. Interval development of vasogenic edema in the right frontal lobe with\n associated midline shift and effacement of the perimesencephalic cistern on\n the right. MRI of the brain with and without contrast is recommended for\n additional evaluation.\n\n 2. Low-density lesions within the right temporal lobe, left cerebellar\n hemisphere and left caudate head, which are stable consistent with patient's\n history of cryptococcal involvement.\n\n 3. No acute intracranial hemorrhage.\n\n Dr. was informed of these results by Dr. at 1:15 p.m. on\n .\n\n (Over)\n\n 11:33 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please eval for any infarct or VP shunt abnormality.\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2184-03-02 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1073206, "text": " 1:59 PM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: neuro recs for stat MR of head, assess frontal parietal area\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with HIV and cryptococcal meningitis, now with L arm\n weakness. Neuro recs for stat MR of head.\n REASON FOR THIS EXAMINATION:\n neuro recs for stat MR of head, assess frontal parietal area.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKPe TUE 7:47 PM\n Large region of vasogenic edema centered within the right parietal lobe with\n more focal punctate low T1 intensity lesions within it with similar-appearing\n mass effect and midline shift as noted on recently performed CT. Left\n cerebellar and right temporal lobe lesions are slightly increased in size from\n prior MRI, but likely stable from most recent head CT. No restricted\n diffusion is noted within the more focal low-intensity T1 lesions within the\n vasogenic edema. No post-contrast images or T2/FLAIR images were obtained due\n to patient termination of the exam. Differential is broad in this\n immunocompromised patient with underlying cerebritis/focal abscesses are\n highest on the list given its rapid appearance. Cortical venous thrombosis\n with underlying edema, neoplasm, or acute demyelinating leukoencephalitis are\n also on the differential but felt less likely given patient's clinical\n presentation.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: HIV and recently treated and known cryptococcal meningitis,\n presenting with new right frontal lesion and left arm weakness.\n\n Comparison is made to MRI and and \n head CTs.\n\n TECHNIQUE: Sagittal and axial T1 pre-contrast images were obtained in\n conjunction with diffusion-weighted sequences. No post-gadolinium images, T2\n images, or FLAIR images were obtained due to patient termination of the exam\n due to discomfort.\n\n LIMITED MRI OF THE BRAIN: As noted on recently performed CT, there is large\n region of vasogenic edema centered within the right frontal lobe with some\n more focal ovoid low T1 lesions within it measuring 11-15 mm in longest\n dimension. No restricted diffusion is noted within these more focal\n components, although there are small punctate regions of restricted diffusion\n surrounding the edema which are new from prior exam. More well-defined oval\n low T1 lesions within the right temporal lobe measuring 17 mm currently and\n within the left cerebellar hemisphere measuring 24 mm, currently has slightly\n increased in size from MRI but display no significant surrounding\n edema. Left caudate lesion is stable.\n\n Positioning of right frontal approach endoventricle drain as well as mass\n effect on the falx is not significantly changed from most recent CT with 11 mm\n of leftward subfalcine herniation.\n (Over)\n\n 1:59 PM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: neuro recs for stat MR of head, assess frontal parietal area\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n IMPRESSION:\n 1. Rapidly progressive (over 2 weeks) region of presumed vasogenic edema\n centered within the right frontal lobe with more focal low T1 intensity\n lesions within it, resulting in mild-to-moderate leftward subfalcine\n herniation. Given its rapid progression as well as location adjacent to the\n ventricular drain, underlying cerebritis/abscess formation is felt to be most\n likely etiology (causes included typical bacterial infection, cryptococcal\n infection, fungal infection, TB, or other opportunistic infections).\n\n Less likely, the differential diagnosis would include acute demyelinating\n leukoencephalitis, or a cortically based venous thrombosis. Underlying\n neoplasm such as Kaposi's or lymphoma would be highly atypical for this\n presentation given time course.\n\n 2. Small punctate regions of right frontal lobe restricted diffusion/acute\n infarction surrounding the vasogenic edema likely related to adjacent mass\n effect/vasospasm.\n\n 3. Slight interval increase in size to the low T1 previously described\n cystic-type lesions within the right temporal lobe and left cerebellum which\n display no surrounding T1 signal abnormality and are likley sequela of prior\n infection.\n\n The findings were discussed in person with infectious disease consult team\n shortly after exam acquisition. If patient will tolerate, repeat attempt at\n completing full imaging the brain can be performed to better characterize the\n lesion.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2184-03-02 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 1073207, "text": ", R. MED FA2 1:59 PM\n MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # \n Reason: neuro recs for stat MR of head, assess frontal parietal area\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with HIV and cryptococcal meningitis, now with L arm\n weakness. Neuro recs for stat MR of head.\n REASON FOR THIS EXAMINATION:\n neuro recs for stat MR of head, assess frontal parietal area.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Large region of vasogenic edema centered within the right parietal lobe with\n more focal punctate low T1 intensity lesions within it with similar-appearing\n mass effect and midline shift as noted on recently performed CT. Left\n cerebellar and right temporal lobe lesions are slightly increased in size from\n prior MRI, but likely stable from most recent head CT. No restricted\n diffusion is noted within the more focal low-intensity T1 lesions within the\n vasogenic edema. No post-contrast images or T2/FLAIR images were obtained due\n to patient termination of the exam. Differential is broad in this\n immunocompromised patient with underlying cerebritis/focal abscesses are\n highest on the list given its rapid appearance. Cortical venous thrombosis\n with underlying edema, neoplasm, or acute demyelinating leukoencephalitis are\n also on the differential but felt less likely given patient's clinical\n presentation.\n\n" }, { "category": "Radiology", "chartdate": "2184-03-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1073345, "text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval\n Admitting Diagnosis: ABDOMINAL PAIN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 60 year old woman with hx ICH\n REASON FOR THIS EXAMINATION:\n eval interval\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 8:28 A.M. \n\n HISTORY: Cerebral hemorrhage.\n\n IMPRESSION: AP chest compared to and :\n\n Lungs are low in volume but clear. Heart size is normal. Abnormal contour\n projecting over the upper heart and right hilus could be a projection of the\n left atrium. Conventional radiographs recommended when feasible. No pleural\n effusion. Indentation and displacement of the trachea to the right most\n commonly due to an enlarged thyroid. Clinical correlation advised.\n\n Right PIC line tip projects over the low SVC. No pneumothorax or pleural\n effusion.\n\n" }, { "category": "Nursing", "chartdate": "2184-03-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568617, "text": "Comfort care (CMO, Comfort Measures)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2184-03-04 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568628, "text": "Chief Complaint:\n 24 Hour Events:\n - DNR/DNI overnight, family wants to make patient CMO this morning\n - no plans for surgery or escalation of intervention\n FEVER - 101.7\nF - 02:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Vancomycin - 07:40 PM\n Ambisome - 10:20 PM\n Ceftazidime - 03:30 AM\n Metronidazole - 06:30 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 07:44 PM\n Heparin Sodium (Prophylaxis) - 07:44 PM\n Morphine Sulfate - 09:35 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 07:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 38.7\nC (101.7\n Tcurrent: 36.7\nC (98\n HR: 92 (90 - 110) bpm\n BP: 111/54(67) {77/43(50) - 143/72(86)} mmHg\n RR: 16 (15 - 24) insp/min\n SpO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,362 mL\n 897 mL\n PO:\n TF:\n IVF:\n 2,362 mL\n 897 mL\n Blood products:\n Total out:\n 2,965 mL\n 645 mL\n Urine:\n 2,965 mL\n 645 mL\n NG:\n Stool:\n Drains:\n Balance:\n -603 mL\n 252 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 97%\n ABG: ///18/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Cardiovascular: normal PMI, normal S1/S2\n Respiratory / Chest: Clear breath sounds, Diminished at bases\n Abdominal: Soft, Non-tender, Bowel sounds present\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 196 K/uL\n 8.6 g/dL\n 114 mg/dL\n 1.6 mg/dL\n 18 mEq/L\n 4.6 mEq/L\n 19 mg/dL\n 109 mEq/L\n 138 mEq/L\n 25.9 %\n 11.1 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n 02:14 AM\n WBC\n 11.8\n 14.8\n 11.1\n Hct\n 27.4\n 27.6\n 25.9\n Plt\n 370\n 283\n 196\n Cr\n 1.2\n 1.2\n 1.4\n 1.6\n Glucose\n 106\n 159\n 163\n 114\n Other labs: PT / PTT / INR:16.2/45.2/1.4, Differential-Neuts:83.9 %,\n Band:0.0 %, Lymph:6.7 %, Mono:4.2 %, Eos:4.8 %, Ca++:8.6 mg/dL,\n Mg++:1.8 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who was\n recently hospitalized with cryptococcal meningitis requiring a VP shunt\n () who was readmitted with malfunctioning shunt and now has a fluid\n collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment.\n - neuro checks q2 hrs\n - elevated HOB\n - avoid hypotension to maintain CPP\n - can discontinue mannitol as renal function is worsening and serum osm\n was 316 this morning. (was 50 g q6 with goal osm >320, Na >150)\n - hold steroids for now given likely infection\n - cont ambisome and flucytosine\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - Neurosurgery made aware that patients status has deteriorated and\n that family does not want to pursue operative management or intubation\n .\n 2. Cryptococcal meninigitis:\n - cont ambisome and flucytosine\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection.\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n - replace bicarb via IV/amps\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n - cont flagyl\n .\n 6. HIV/AIDS:\n - Refusing HAART meds\n - will discontinue Dapsone for PCP for now as patient not taking\n PO\n .\n 7. Hypothyroidism:\n - cont. levothyroxine\n FEN: NPO\n Prophylaxis: pneumoboots/heparin sq, PPI, bowel regimen\n Access: PICC\n Code status: DNR/DNI, may be made CMO today at which point abx will\n likely be discontinued.\n Dispo: ICU care for now, family plans to come today to assess goals of\n care today.\n ICU Care\n Nutrition: NPO\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT: heparin SC, pneumoboots\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: DNR/DNI\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2184-03-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568308, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:30 PM\n URINE CULTURE - At 09:15 PM\n BLOOD CULTURED - At 09:16 PM\n FEVER - 102.8\nF - 09:00 PM\n Admitted\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 03:50 AM\n Metronidazole - 04:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.2\nC (100.8\n HR: 114 (90 - 130) bpm\n BP: 124/74(85) {103/58(69) - 159/86(96)} mmHg\n RR: 21 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 732 mL\n 878 mL\n PO:\n TF:\n IVF:\n 732 mL\n 878 mL\n Blood products:\n Total out:\n 680 mL\n 980 mL\n Urine:\n 680 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 52 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Labs / Radiology\n 283 K/uL\n 9.8 g/dL\n 163 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 138 mEq/L\n 27.6 %\n 14.8 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n WBC\n 11.8\n 14.8\n Hct\n 27.4\n 27.6\n Plt\n 370\n 283\n Cr\n 1.2\n 1.2\n 1.4\n Glucose\n 106\n 159\n 163\n Other labs: PT / PTT / INR:14.7/32.5/1.3, Differential-Neuts:83.0 %,\n Band:0.0 %, Lymph:5.0 %, Mono:10.0 %, Eos:0.0 %, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568309, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:30 PM\n URINE CULTURE - At 09:15 PM\n BLOOD CULTURED - At 09:16 PM\n FEVER - 102.8\nF - 09:00 PM\n Admitted\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 03:50 AM\n Metronidazole - 04:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.2\nC (100.8\n HR: 114 (90 - 130) bpm\n BP: 124/74(85) {103/58(69) - 159/86(96)} mmHg\n RR: 21 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 732 mL\n 878 mL\n PO:\n TF:\n IVF:\n 732 mL\n 878 mL\n Blood products:\n Total out:\n 680 mL\n 980 mL\n Urine:\n 680 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 52 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): self,\n hospital, Sunday , Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE\n , Tone: Increased, upgoing babinski's bilaterally, clonus esp. in\n RUE, BLEs\n Labs / Radiology\n 283 K/uL\n 9.8 g/dL\n 163 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 138 mEq/L\n 27.6 %\n 14.8 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n WBC\n 11.8\n 14.8\n Hct\n 27.4\n 27.6\n Plt\n 370\n 283\n Cr\n 1.2\n 1.2\n 1.4\n Glucose\n 106\n 159\n 163\n Other labs: PT / PTT / INR:14.7/32.5/1.3, Differential-Neuts:83.0 %,\n Band:0.0 %, Lymph:5.0 %, Mono:10.0 %, Eos:0.0 %, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568311, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:30 PM\n URINE CULTURE - At 09:15 PM\n BLOOD CULTURED - At 09:16 PM\n FEVER - 102.8\nF - 09:00 PM\n Admitted\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 03:50 AM\n Metronidazole - 04:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.2\nC (100.8\n HR: 114 (90 - 130) bpm\n BP: 124/74(85) {103/58(69) - 159/86(96)} mmHg\n RR: 21 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 732 mL\n 878 mL\n PO:\n TF:\n IVF:\n 732 mL\n 878 mL\n Blood products:\n Total out:\n 680 mL\n 980 mL\n Urine:\n 680 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 52 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Attentive, Responds to: Not assessed, Oriented (to): self,\n hospital, Sunday , Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE\n , Tone: Increased, upgoing babinski's bilaterally, clonus esp. in\n RUE, BLEs\n Labs / Radiology\n 283 K/uL\n 9.8 g/dL\n 163 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 138 mEq/L\n 27.6 %\n 14.8 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n WBC\n 11.8\n 14.8\n Hct\n 27.4\n 27.6\n Plt\n 370\n 283\n Cr\n 1.2\n 1.2\n 1.4\n Glucose\n 106\n 159\n 163\n Other labs: PT / PTT / INR:14.7/32.5/1.3, Differential-Neuts:83.0 %,\n Band:0.0 %, Lymph:5.0 %, Mono:10.0 %, Eos:0.0 %, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n A/P: 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who\n was recently hospitalized with cryptococcal meningitis requiring a VP\n shunt () who was readmitted with malfunctioning shunt and now has a\n fluid collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point.\n - neuro checks q2 hrs\n - elevated HOB\n - avoid hypotension to maintain CPP\n - cont mannitol 50 g q6; holding for osm >320, Na >150; monitor renal\n failure\n - hold steroids for now given likely infection\n - if pt decompensates will intubate to hyperventilation for pCO2 goal\n of 30 and will STAT page Neurosurg for emergent decompressive\n craniectomy.\n - will intensify cryptococcal infection with ambisome and flucytosine\n - will cover for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - will d/w Neurosurg re: sampling shunt v. LP by IR\n - US-guided aspiration of abdominal fluid collection though previous\n cultures have been negative, which is more reassuring\n .\n 2. Cryptococcal meninigitis:\n - cont ambisome and flucytosine\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection.\n - will cover for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - US-guided aspiration of abdominal fluid collection though previous\n cultures have been negative, which is more reassuring\n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n - urine studies\n - replete K\n - replace bicarb via IV/amps\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n - cont flagyl\n .\n 6. HIV/AIDS:\n - Refusing HAART meds\n - Dapsone for PCP \n .\n 7. Hypothyroidism:\n - cont. levothyroxine\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-03 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 568315, "text": "Chief Complaint: Acute stroke\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60 yo women with AIDS, cryptococcal meningitis, c/b need for V-P shunt,\n readmitted for shunt migration, and now with likely intracerebral\n infection and left hemiparesis.\n Overnight patient stable. Left sided hemiparesis unchanged, and right\n sided movement unchanged.\n 24 Hour Events:\n PICC LINE - START 03:30 PM\n URINE CULTURE - At 09:15 PM\n BLOOD CULTURED - At 09:16 PM\n FEVER - 102.8\nF - 09:00 PM\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 03:50 AM\n Metronidazole - 04:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 PM\n Other medications:\n vanco\n asa\n hep s/q\n dapsone\n levoxyl\n ceftaz\n mannitol\n ambisome\n flycytosine\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 09:11 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.2\nC (100.8\n HR: 109 (90 - 130) bpm\n BP: 136/65(81) {103/58(69) - 159/86(96)} mmHg\n RR: 22 (17 - 29) insp/min\n SpO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 732 mL\n 897 mL\n PO:\n TF:\n IVF:\n 732 mL\n 897 mL\n Blood products:\n Total out:\n 680 mL\n 980 mL\n Urine:\n 680 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 52 mL\n -83 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 99%\n ABG: ///20/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: No(t) Pupils dilated, right pupil>left\n Head, Ears, Nose, Throat: No(t) Normocephalic\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:\n Present)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present, Distended\n Extremities: Right: Trace, Left: Trace\n Skin: Not assessed\n Neurologic: No(t) Attentive, No(t) Follows simple commands, Responds\n to: Tactile stimuli, Movement: Not assessed, Tone: Not assessed,\n minimally response, non verbal\n Labs / Radiology\n 9.8 g/dL\n 283 K/uL\n 163 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 138 mEq/L\n 27.6 %\n 14.8 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n WBC\n 11.8\n 14.8\n Hct\n 27.4\n 27.6\n Plt\n 370\n 283\n Cr\n 1.2\n 1.2\n 1.4\n Glucose\n 106\n 159\n 163\n Other labs: PT / PTT / INR:14.7/32.5/1.3, Differential-Neuts:83.0 %,\n Band:0.0 %, Lymph:5.0 %, Mono:10.0 %, Eos:0.0 %, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Fluid analysis / Other labs: osm 290\n Assessment and Plan\n Cryptococcal cerebritis: Worsening mental status this morning. Not\n communicative. Will alert NSG and discuss with family if they would\n want craniectomy.\n If wanting agressive care, would probably intubate and hyperventilate.\n Continue ambisome and flucytosine for cryptos as well as vanco/ceftaz\n for possible bacterial superinfection.\n C. diff: on flagyl\n AIDS: has been refusing HAART medication.\n overal prognosis seems poor.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition :ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2184-03-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568172, "text": ".H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O meningitis, bacterial\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2184-03-02 00:00:00.000", "description": "Physician Attending Admission Note - MICU", "row_id": 568177, "text": "Chief Complaint: increased ICP pressure\n I saw and examined the patient, and was physically present with the ICU\n Resident for key portions of the services provided. I agree with his /\n her note above, including assessment and plan.\n HPI:\n 60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\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 HIV CD4 163 in not on HAART\n hypothyroid\n RA\n CVA x 3\n noncontributory for CNS infection\n Occupation:\n Drugs: denies\n Tobacco:\n Alcohol: denies\n Other: three children\n Review of systems:\n Constitutional: No(t) Fever\n Cardiovascular: No(t) Chest pain\n Respiratory: No(t) Dyspnea\n Gastrointestinal: No(t) Abdominal pain\n Genitourinary: Foley\n Musculoskeletal: No(t) Myalgias\n Endocrine: No(t) Hyperglycemia\n Psychiatric / Sleep: Delirious\n Signs or concerns for abuse : No\n Pain: No pain / appears comfortable\n Flowsheet Data as of 06:24 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since 12 AM\n Tmax: 36.3\nC (97.4\n Tcurrent: 36.3\nC (97.4\n HR: 100 (90 - 100) bpm\n BP: 140/84(96) {140/81(94) - 140/84(96)} mmHg\n RR: 21 (17 - 21) insp/min\n SpO2: 98%\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 SpO2: 98%\n ABG: ////\n Physical Examination\n Eyes / Conjunctiva: Right pupil>Left.\n Cardiovascular: (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Breath Sounds: Clear : )\n Abdominal: abdominal collection\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed, left facial droop (old). unable move left side.right\n clonus, ankle clonus\n Labs / Radiology\n 370 K/uL\n 27.4 %\n 9.7 g/dL\n 1.2\n 17\n 21\n 107\n 3.1\n 140\n 11.8 K/uL\n [image002.jpg]\n 04:59 PM\n WBC\n 11.8\n Hct\n 27.4\n Plt\n 370\n Assessment and Plan\n Cerebral brain fluid collection. Likely infectious. Restart ambisome\n and flucytosine as per ID. Starting Vanco/ceftaz/flagyl in case this\n is retrograde infection through V-P shunt.\n Will treat increased ICP and edema with mannitol, aim serum osm 320,\n Na<150. 50mg q6h, with a bolus of 75g.\n C. diff on flagyl.\n HIV: has refused HAART medications. On dapsone for PCP prophylaxis\n RTA: Can give NaHCO3 IV boluses.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines / Intubation:\n PICC Line - 03:30 PM\n Comments:\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: PPI\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 45 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568278, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pupil on R 4mm and pupil on L 2-3mm. Both pupils briskly reactive to\n light. R eye with upward gaze- Dr. made aware. L side completely\n immobile - pt. with sensation to all of L side. RUE lifts and holds.\n RLE moves on bed. Pt. follows commands consistently. Speech slurred\n and difficult to understand. Appears to be oriented x3.\n Action:\n Q2hr neuro checks.\n Response:\n No change in neuro exam except possibly more pronounced upward gaze of\n R eye.\n Plan:\n Continue to monitor neuro exam closely.\n .H/O meningitis, bacterial\n Assessment:\n Febrile to 102.9. HR 120s and BP stable.\n Action:\n Urine and blood cxs sent. Mannitol IV started q6hrs. Please note that\n RN has to call pharmacy for each dose due to parameters with osmolality\n levels.\n Response:\n Low grade temps after Tylenol prn.\n Plan:\n Continue abx regimen. Monitor temps. Follow blood cx results.\n Daughter in visiting pt. She will be back to visit later\n today. She is the spokesperson.\n" }, { "category": "General", "chartdate": "2184-03-04 00:00:00.000", "description": "ICU Event Note", "row_id": 568463, "text": "Clinician: Resident\n Spoke with patient's daughter in person on night of and she\n expressed her wishes for her mother to be DNR/DNI overnight with\n further plans to aggressively pursue comfort measures in morning once\n some family members were able to come in and see the patient.\n" }, { "category": "Nursing", "chartdate": "2184-03-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568195, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pt not able to move L arm or leg, .sensation is decreased on left side.\n PERRL. Oriented x\ns 3. Speech is slow.\n Action:\n Head CT and MRI show fluid collection\n Response:\n No change is neuro status.\n Plan:\n Cont to monitor neuro status\n .H/O meningitis, bacterial\n Assessment:\n Afebrile. WBC ^\nd this am. Fluid collection around side of VP shunt.\n Action:\n Restarted on antibiotics. Seen by ID.\n Response:\n No change in neuro status.\n Plan:\n Pt to start on mannitol tonite Cont to monitor neuro status. Check\n lytes. ? OR if status worsens.\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568252, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status.\n .H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Pupil on R 4mm and pupil on L 2-3mm. Both pupils briskly reactive to\n light. R eye with upward gaze- Dr. made aware. L side completely\n immobile - pt. with sensation to all of L side. RUE lifts and holds.\n RLE moves on bed. Pt. follows commands consistently. Speech slurred\n and difficult to understand. Appears to be oriented x3.\n Action:\n Q2hr neuro checks.\n Response:\n No change in neuro exam except possibly more pronounced upward gaze of\n R eye.\n Plan:\n Continue to monitor neuro exam closely.\n .H/O meningitis, bacterial\n Assessment:\n Febrile to 102.9. HR 120s and BP stable.\n Action:\n Urine and blood cxs sent. Mannitol IV started q6hrs. Please note that\n RN has to call pharmacy for each dose due to parameters with osmolality\n levels.\n Response:\n Low grade temps after Tylenol prn.\n Plan:\n Continue abx regimen. Monitor temps. Follow blood cx results.\n Daughter in visiting pt. She will be back to visit later\n today. She is the spokesperson.\n" }, { "category": "Physician ", "chartdate": "2184-03-03 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 568335, "text": "Chief Complaint:\n 24 Hour Events:\n PICC LINE - START 03:30 PM\n URINE CULTURE - At 09:15 PM\n BLOOD CULTURED - At 09:16 PM\n FEVER - 102.8\nF - 09:00 PM\n Admitted\n Allergies:\n Sulfa (Sulfonamide Antibiotics)\n Anaphylaxis;\n Last dose of Antibiotics:\n Ceftazidime - 03:50 AM\n Metronidazole - 04:58 AM\n Infusions:\n Other ICU medications:\n Pantoprazole (Protonix) - 10:02 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 07:49 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since 12 AM\n Tmax: 39.3\nC (102.8\n Tcurrent: 38.2\nC (100.8\n HR: 114 (90 - 130) bpm\n BP: 124/74(85) {103/58(69) - 159/86(96)} mmHg\n RR: 21 (17 - 29) insp/min\n SpO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Total In:\n 732 mL\n 878 mL\n PO:\n TF:\n IVF:\n 732 mL\n 878 mL\n Blood products:\n Total out:\n 680 mL\n 980 mL\n Urine:\n 680 mL\n 980 mL\n NG:\n Stool:\n Drains:\n Balance:\n 52 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: None\n SpO2: 98%\n ABG: ///20/\n Physical Examination\n Eyes / Conjunctiva: R pupil 1 mm larger than L, both reactive; EOMI\n Head, Ears, Nose, Throat: VP shunt track nontender\n Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse:\n Present), (Right DP pulse: Present), (Left DP pulse: Present)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : ,\n Diminished: at bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Extremities: Right: Absent, Left: Absent\n Skin: Not assessed\n Neurologic: Markedly decreased responsiveness and level of arousal\n today, Movement: LUE 0/5, RUE 3+/5, LLE 0/5, RLE , Tone: Increased,\n upgoing babinski's bilaterally, clonus esp. in RUE, BLEs\n Labs / Radiology\n 283 K/uL\n 9.8 g/dL\n 163 mg/dL\n 1.4 mg/dL\n 20 mEq/L\n 3.9 mEq/L\n 16 mg/dL\n 108 mEq/L\n 138 mEq/L\n 27.6 %\n 14.8 K/uL\n [image002.jpg]\n 04:59 PM\n 01:06 AM\n 05:09 AM\n WBC\n 11.8\n 14.8\n Hct\n 27.4\n 27.6\n Plt\n 370\n 283\n Cr\n 1.2\n 1.2\n 1.4\n Glucose\n 106\n 159\n 163\n Other labs: PT / PTT / INR:14.7/32.5/1.3, Differential-Neuts:83.0 %,\n Band:0.0 %, Lymph:5.0 %, Mono:10.0 %, Eos:0.0 %, Ca++:9.2 mg/dL,\n Mg++:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n A/P: 60 yo F with PMHx sig. for HIV (CD4 cout 139 this admission) who\n was recently hospitalized with cryptococcal meningitis requiring a VP\n shunt () who was readmitted with malfunctioning shunt and now has a\n fluid collection in her brain with concern for impending herniation.\n .\n 1. Cerebral fluid collection: After discussion with Neurosurgery,\n Neurology, and ID, this is most likely an infectious fluid collection\n or possibly a sterile fluid collection given lack of fever and\n leukocytosis. This is not felt to be a stroke. The main concern is\n herniation at this point. Neuro exam markedly worse this AM over acute\n period. Family made aware and have decided that they do not want\n aggressive intervention regarding surgical treatment.\n - neuro checks q2 hrs\n - elevated HOB\n - avoid hypotension to maintain CPP\n - cont mannitol 50 g q6; holding for osm >320, Na >150; monitor renal\n failure\n - hold steroids for now given likely infection\n - cont ambisome and flucytosine\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n - Neurosurgery made aware that patients status has deteriorated this AM\n and that family does not want to pursue operative management or\n intubation\n .\n 2. Cryptococcal meninigitis:\n - cont ambisome and flucytosine\n .\n 3. Abdominal fluid collection: Previous cultures from negative\n for bacterial infection.\n - cont coverage for retrograde infection from abdomen wtih\n vanc/ceftax/flagyl\n .\n 4. Hypokalemia and metabolic acidosis: Pt has been presumptively\n treated for RTA with po sodium bicarb.\n - replace bicarb via IV/amps\n .\n 5. C. diff: Pt already completed 10 day course of flagyl.\n - cont flagyl\n .\n 6. HIV/AIDS:\n - Refusing HAART meds\n - Dapsone for PCP \n .\n 7. Hypothyroidism:\n - cont. levothyroxine\n FEN: NPO\n Prophylaxis: pneumoboots/heparin sq, PPI, bowel regimen\n Access: PICC\n Code status: DNR/DNI\n Dispo: ICU care for now, family plans to come today to assess goals of\n care today.\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 03:30 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": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568361, "text": ".H/O meningitis, bacterial\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568431, "text": ".H/O meningitis, bacterial\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568246, "text": ".H/O CVA (Stroke, Cerebral infarction), Other\n Assessment:\n Action:\n Response:\n Plan:\n .H/O meningitis, bacterial\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568432, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status.\n .H/O meningitis, bacterial\n Assessment:\n Pt awake this am. speech is difficult to understand unable to move L\n side.. Recognizes her family when visiting. Conts on Mannitol. TM 10.17\n Action:\n As day progressed, pt became less responsive c/o generalized\n discomfort. Family concerned about pt being in pain. Given Mso4 2mg IV\n .\n Response:\n Good control of pain with MSO4. Family spoke with Medical team and\n neuro surgeon. Pt is DNR, once other family members have arrived.\n Plan:\n MSO4 prn for discomfort. Emotional support of family. Cont with\n mannitol for now. Cont antibiotics.\n" }, { "category": "Nursing", "chartdate": "2184-03-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 568433, "text": "60 yo women recently dx with cryptococcal meningitis, tx with ampho and\n flycytosine () also had V-P shunt placed for increased ICP.\n represented to with fevers and bulge in abdomen. CT abd\n with s/q fluid collection and catheter tip leading into fluid\n collection suggesting migration of catheter tip. Went to OR on \n for revision and repositioning of tip of catheter. Fever of 101/9 and\n blood cs with coag neg staph. Did get a few days of vanco/ceftaz.\n Subsequent blood cx negative. LP by IR was negative, + for crypto, but\n negative otherwise. C. diff +, got 10 days of flagyl. Also being\n treated for RTA with HCO3. Right sided temporal headache today and LUE\n weakness. CT scan had fluid collection around side of VP-shunt.\n Resident spoke with daughter regarding change in status.\n .H/O meningitis, bacterial\n Assessment:\n Pt awake this am. speech is difficult to understand unable to move L\n side.. Recognizes her family when visiting. Conts on Mannitol. TM 10.17\n Action:\n As day progressed, pt became less responsive c/o generalized\n discomfort. Family concerned about pt being in pain. Given Mso4 2mg IV\n .\n Response:\n Good control of pain with MSO4. Family spoke with Medical team and\n neuro surgeon. Pt is DNR, once other family members have arrived.\n Plan:\n MSO4 prn for discomfort. Emotional support of family. Cont with\n mannitol for now. Cont antibiotics.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2124-12-16 00:00:00.000", "description": "Report", "row_id": 1890627, "text": "Neonatology Attending\n\nDOL 5 CGA 34 6/7 weeks\n\nStable in RA. R 40s-60s. No A/B.\n\nOn 120 cc/kg/d BM/PE 20 mostly po. Voiding. Stooling. Wt 2035 grams (down 25).\n\nHearing screen passed.\n\nStable temp in off isolette.\n\nMother discharged yesterday. desire transfer to when bed available.\n\nA: Doing well\n\nP: Continue monitoring\n Increase to 140 cc/kg/d\n Transfer to when bed available.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-16 00:00:00.000", "description": "Report", "row_id": 1890628, "text": "Neonatology Attending\nExam AF soft, flat, clear bs, no murmur, benign abd, + breakdown of skin on buttocks, active\n\nDesitin ordered\n" }, { "category": "Nursing/other", "chartdate": "2124-12-16 00:00:00.000", "description": "Report", "row_id": 1890629, "text": "1.TF increased to 140cc/k/d of BM or PE20, po/pg q4h. abd\nstable, voiding and passing stool A: tolerating\nfeedings,learning to po P; cont to encourage po when awake\nand alert, follow wts.\n3.temps stable in off isolette, active and alert with cares,\nlearning to bottle feed P: cont to support growth and\ndevelopment.\n4. no contact with family yet today, expected to visit this\npm. Continue to inform and support.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-17 00:00:00.000", "description": "Report", "row_id": 1890630, "text": "NICU NPN 1900-0700\n\n\n#1 FEN O: TF REMAIN AT 140CC/K/D. WEIGHT 2050G, UP 15G.\nTOLERATING GAVAGE/PO FEEDS OF BM/PE 20 WELL, LEARNING TO\nBOTTLE. ABDOMEN IS SOFT, VOIDING AND STOOLING, NO SPITS,\nMIN. NGT ASPIRATES. A: LEARNING TO PO. P: CONTINUE TO OFFER\nPO'S.\n\n#3 G&D O TEMPS ARE STABLE, IN OFF , PLAN TO\nMOVE TO CRIB TONIGHT. RIANNA IS ALERT AND ACTIVE WITH CARES,\nSLEEPS WELL IN BETWEEN CARES, FONTANELLS ARE SOFT AND FLAT.\nA: AGA P: CONTINUE TO SUPPORT DEVELOPMENT.\n\n#4 PARENTING O: NO CONTACT THUS FAR THIS SHIFT.\n\nDIAPER AREA, EXCORIATED. NNP AWARE, AND CRITICAID ORDERED.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-17 00:00:00.000", "description": "Report", "row_id": 1890631, "text": "Neonatology Attending Note\nDay 6\n\nRA. Cl and =. RR30-60s. No A&Bs. No murmur. HR 140-160s. Pink, sl jaundiced. Wt 2050, up 15 g. TF 140 cc/k/day PE/BM20. Tol well. Nl voiding and stooling. In off .\n\nIncrease to TF 150 cc/k/day. Transition to open crib. No other changes.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-17 00:00:00.000", "description": "Report", "row_id": 1890632, "text": "NPN 0700-1900\n\n\n1. O: Pt receiving 150cc/kg of PE/BM 20 po/pngt alt. Took\nwhole bottle. Remaining feed via ngt. Min aspirates. No\nspits. Abd soft. Voiding and stooling g-. Criticaid applied\nto Buttock. A: Tol feeds. P: Cont to monitor wt, abd, and\ntol of feeds.\n\n3. o: Temp stable in off . Alert and active with\ncare. Sucks on pacifier. A/P: Cont to cluster care. Cont to\nmonitor temp.\n\n4. No contact from this hsift thus far.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-17 00:00:00.000", "description": "Report", "row_id": 1890633, "text": "Neonatology Attending Note\n\n transfer could not be arranged due to bed unavailability. agreed to transfer to . Medical course reviewed with Dr. .\n\nPlease see bedside chart/dictated summary for further details.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-17 00:00:00.000", "description": "Report", "row_id": 1890634, "text": "Discharge Note\nSee previous note. Report given to RN at . Consent obtained by RN. Cont to monitor pt at . Cont to encourage feeding. to visit tomorrow.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-13 00:00:00.000", "description": "Report", "row_id": 1890616, "text": "nurisng progress note 0700-1900\n\n\n#1fen\no: tf 100cc/kg of pe20, 35cc q4hours po fed. abd benign.\nvoiding and stooling guiac neg. ag24-24.5cm. aspirates\n.3-3cc of undigested formula. moderate spits with feeds.\na:spits after each feed. p: continue feeds q4hours as\ntolerated.\n#2 resp\no: o2sats in r/a >95%. lsc and equal. no retractions. rr\n30-60's. a: stable. p: continue to monitor for s/s resp\ndistress.\n#3 g&d\no: air controlled isolette with stable temperatures. alert\nand awake with cares. fontanelles soft and flat. maew.\nsucking on pacifier. a: aga P; continue to monitor and\nsupport as needed/\n#4 parenting\no: have not heard or seen today. a: unable to fully\nassess due to no contact with . p: continue to\nsupport and follow as needed. pt care needes teaching when\n available.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-13 00:00:00.000", "description": "Report", "row_id": 1890617, "text": "NICU Fellow Physical Exam\nSleeping comfortably\nHEENT: AFLF, mmm, Op clear, no nasal flare\nCV: RRR, no murmur\nLungs: cta bilat\nAbd: soft, no loops, +bs\nExt: mae\nNeuro: appropriate for age\nSkin: mildy erythem diaper area\n" }, { "category": "Nursing/other", "chartdate": "2124-12-14 00:00:00.000", "description": "Report", "row_id": 1890618, "text": "NPN 1900-0700\n\n\n1 FEN\nCurrent wt 2.055kg, down 40 grams. TF remain at\n100cc/kg/day of PE 20. Bottle feeding 20-25cc. Abd exam\nbenign. Small spit x's 1. Dstick wnl. Voiding and\nstooling.\n\n2 Resp\nMaintaining sats greater than 94% in RA. Noted to have\ndesat with po feeding, requiring BBO2. RR 40-60's. Lung\nsounds cl/=. Mild subcostal retractions noted.\n\n3 G&D\nTemp stable in air controlled isolette. Awake and active\nwith cares. Sleeps well between cares. State screen sent.\n\n\n4 Parenting\nMom and Dad up for cares. Dad bottle fed infant and\nheld during gavage.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-14 00:00:00.000", "description": "Report", "row_id": 1890619, "text": "nursing progress note\n\n\n#1 fen\no: tf 100cc/kg minimum po feed, 120cc/kg gavage feeds. po\nfeeding qfeed this shift 100cc/kg+. abd. benign. bs+ voiding\nand stooling guiac neg. qs. ag 23.5-24.5cm. no spits,\naspirates 1.2-2cc partially digested milk. a: tolerating\nfeeds well. p: continue with feeds q4hours as tolerated.\n\n#2 resp\no: r/a sats >95%. lsc and equal. minimal to no retractions.\na: stable p: continue to monitor for s/s resp distress and\nsupport as needed.\n\n#3 g&d\no: off isolette with stable temperatures. awake and alert\nwith cares. fontanelles soft and flat. sucking on pacifier.\nhands to mouth and face. a: stable p: continue to monitor\nfor any changes in assessment and support as needed.\n\n#4 parenting\no: family meeting today. having minimal questions.\nplan suggested for move to hospital when pt more\nstable due to convenience to home. a: in depth pt\ncare teaching needed. p: continue to support and continue\nongoing pt care needs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-14 00:00:00.000", "description": "Report", "row_id": 1890620, "text": "Neonatology\nDoing well in RA. No spells.\n\nWeight down slightly. Feeds at 120 cc/k/d and doing well.\n\nContinue as at present.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-12 00:00:00.000", "description": "Report", "row_id": 1890610, "text": "Neonatology\nDOing well. Remains in RA. No apnea.\n\nFeeds going well. Taking 70 cc/k/d without difficulty. Will increase minimum to 80 cc/k/d. Abdomen benign.\n\nWt 2095 own 15. Abdomen bneign.\n\nNot jaundiced.\n\nCLinically stable on abx. 48 h r/o.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-12 00:00:00.000", "description": "Report", "row_id": 1890611, "text": "1. TF increased to 80cc/k/d of PE 20, 28cc q4h, took 30cc po\nwell, abd soft, stable, voiding and passing mec stools A:\ntolerating and taking feedings well P: increase fluids to\n100cc/k/d at 24hrs.\n2. Rianna remains in RA, BBS clear and equal, sats>95,\nRR30-60 A: stable respiratory P: cont to monitor/assess.\n3. temps stable double wrapped in open crib, taking po well,\nactive and alert with cares A: appropriate developmental\nbehaviors P: continue to promote growth and development.\n4. no contact with family yet today P: family meeting soon.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-12 00:00:00.000", "description": "Report", "row_id": 1890612, "text": "NICU Fellow Physical Exam\nGen: sleeping\nHEENT: AFLF, mmm, op clear, no nasal flare\nCV: RRR no murmur\nLUngs: clear, no rtx\nAbd: soft, no loops, +BS\next: mae\nSkin: minimal jaundice\nneuro: appropriate\n" }, { "category": "Nursing/other", "chartdate": "2124-12-13 00:00:00.000", "description": "Report", "row_id": 1890613, "text": "Co-Worker Note: Nights\n\n\n1. FEN: O: BW= 2110g. Wt. tonight unchanged at 2095g. On TF\nmin of 100cc/c/d of PE20= 35cc q4 hours. Pt. bottling\n27-40cc q4 hours. NG tubed placed due to poor bottling at\n. Abdomen exam benign. Voiding qs. Trans stool. + \nsounds. Girth stable. Dstick at 0000 was 76. See flowsheet.\nA: TF P: Continue current.\n\n2. RESP: O: Pt. remains in RA breathing comfortable 30-50's,\nno retractions. Sats > 94%. Had one desat to 72 that\nrequired mild stim. See flowsheet. A: Stable P: Monitor\nclosely.\n\n3. G&D: O: Pt. swaddled in Air isolette, temps stable. Awake\nand alert with cares, sleeping well between. See flowsheet.\nA: AGA P: Support G&D.\n\n4. PAR: O: Parents in at . Updated on pt's status.\nAsking appropriate questions. Mother asked about having a\nlac consult. Dad bottled pt. for first time. Needed\nencouragement, but overall did well. Parent did ask about\nchanging baby's diaper and thid co-worker told them to\nchange diaper whenever baby eats which now is q4. This\nco-worker also told parents about feeding tubes, so that\nthey would be prepared to see infant with NG tubes if\nneeded. See flowsheet. A: loving, invested new parents. P:\nSupport and educate.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-13 00:00:00.000", "description": "Report", "row_id": 1890614, "text": "Examined infant and agree with above note by coworker . Infant remains on ampi and gent - no s/s of sepsis at present.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-13 00:00:00.000", "description": "Report", "row_id": 1890615, "text": "Neonatology\nRA. Comfortable. In isollette. Single spell.\n\nTolertaing feeds taking ad lib atb 120 cc/k/d. Wt unchanged.\nAbdomen benign.\n\nCOntinue as at present.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-11 00:00:00.000", "description": "Report", "row_id": 1890606, "text": "Nursing NICU NOte.\nPt admitted to NICU from L&D. Skin pink well perfused. Initial VSS. Please refer to flowsheet. Pt arrived and remains in RA at this time. Babycares given. Blood sent for CBC/diff and blood cultures; results P. Pt examined by NNP. Pt remains on radiant warmer, now nested in sheepskin. Offered bottle X1. Pt took 14cc of PE20 without difficulty. Voided in DR. meconium passed as of yet.\nBaby ID verified with L&D nurse.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-11 00:00:00.000", "description": "Report", "row_id": 1890607, "text": "1 Alteration in F/N\n2 Alt. in REsp status.\n3 Alt. in Growth and development\n4 Alt. in Parenting.\n\nREVISIONS TO PATHWAY:\n\n 1 Alteration in F/N; added\n Start date: \n 2 Alt. in REsp status.; added\n Start date: \n 3 Alt. in Growth and development; added\n Start date: \n 4 Alt. in Parenting.; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-11 00:00:00.000", "description": "Report", "row_id": 1890608, "text": "Neonatology\nPatient is 2.11 kg product of 34 week gestation born to 37 yo G1P0-->3 woman after triplet gesatation during which mother received routine Ob care. Prenatal screens show A=, ab-, RPRNR, RI, HbSag- GBS? status. Pregancy in this healthy woman apparently notable only for eval in triage at 32 4/7 weeks for PIH. Presented with PTL and taken to c-section. No sepsis risk factors. No intrapartum abx.\n\nAt delivery patient emerged vigorous. Given BBO2 and stim. Apgars 8,9. Brought to NICU after vsiting with parents.\n\nOn exam pink active non-dysmorphic infant. Well eprfused and saturated in RA.. Skin w/o lesions. HEENT WNL. Neck normal. Lungs generally clear with minor GFR. COr nl s1s2 w/o murmurs. Lungs clear. Abdomen benign. Genitalia normal preemie female. Neuro non-focal and age appropriate. Hips negative.\n\nOver course of initial hours in NICU weaned from NCO2 to EA.\n\nA- Well appearing preterm infant with resolving sx of transitional resp distress.\n\nP Admit NICU\n Clinical, non-invasive and lab monitoring of resp status.\n Titration of resp supportr via above.\n Begin PO feeds as tolerated.\n IVF to maintain TF at 80 cc/k/d.\n Monitoring of BS.\n CBC diff BC.\n No abx at present. Decide upon administration based on CBC results\n and course.\n Usual attention to metabolic issues and bili.\n Parents aware of status and plan.\n\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-12 00:00:00.000", "description": "Report", "row_id": 1890609, "text": "NICU NPN 1900-0700\n\n\nF/N: Weight 2095 grams, down 15g. TF=min 40cc/k/d. Infant is\nbottling PE20, 20-28cc q 4 hours this shift without\ndifficulty. No spits. Abdomen soft, +BS, no loops. Voiding,\ntrace amt of stool thus far. D-sticks stable. Continue per\nplan.\n\nRESP: Infant remains in RA, sats >95% this shift. RR\n30-60's. LS clear and equal. No retractions. No spells.\nContinue to monitor respiratory status.\n\nG/D: Infant received on servo controlled warmer. Infant\nswaddled and moved to an open crib at 0100 - temps stable at\npresent. Alert and active with cares, sleeping well b/w.\nWakes for feeds. Bottles well. Continue to support growth\nand development.\n\nPARENTS: Mom and Dad in to visit. Updated at bedside.\nContinue to support and update parents, schedule family\nmeeting.\n\nPOT SEPSIS: Infant remains on ampi and gent. Diff still\npending - lab contact to receive results. Continue to\nadminister abx as ordered.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-15 00:00:00.000", "description": "Report", "row_id": 1890621, "text": "NPN 1900-0700\n\n\n1 FEN\nCurrent weight 2.060 kg, up 5 grams. TF remain at\n100cc/kg/day of BM?PE 20. Bottle feeding well. Abd soft, b\ns+. Girth stable. No spits, min asp. Voiding and\nstooling.\n\n2 Resp\nSats remain greater than 96% in RA. RR 30-60's. Lung\nsounds cl/=. No increase WOB noted.\n\n3 G&D\nTemp stable in off isolette. Awake and active with cares.\nSleeps well between cares. Sucks intermittently on\npacifier. Bili sent, results pending\n\n\n4 Parenting\nMom and Dad up for cares. Dad PO fed. Mom remains\n. Will return tomorrow.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-15 00:00:00.000", "description": "Report", "row_id": 1890622, "text": "Neonatology\nRA. Comfortable Doing well. No spells but soem desats occasionally.\n\nWt up 5 to 2060. Tolerating efeds at 100 cc/k/d all po. Will increase to TF = 120 cc/k/d. Abdomen benign.\n\nBili in 5 range.\n\nParebts interested in transfer to . No beds available.\n" }, { "category": "Nursing/other", "chartdate": "2124-12-15 00:00:00.000", "description": "Report", "row_id": 1890623, "text": "1. TF increased to 120cc/k/d 42cc BM or PE20 po/pg q4h. abd\nstable, voiding and passing stools A: tolerating feedings,\nlearning to po P: follow wts, enc po when awake and alert.\n2. in RA, BBs clear and equal, no spells, sats high 90's, RR\n40-60 A: stable respiratory P: cont to monitor/assess.\n3. temps stable in off isolette, nested and swaddled with\nhat on, alert and active with cares A: appropriate\ndevelopmental behaviors P: continue to support growth and\ndevelopment.\n4. Dad in for 12 feeding, requests transfer to \nwhenever is possible, Mom being discharged home today, Mom\npumping breast milk A: involved and concerned P:\ncontinue to inform and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-15 00:00:00.000", "description": "Report", "row_id": 1890624, "text": "NICU Fellow Physical Exam\nGen: sleeping\nHEENT: AFLF, no nasal flare, OP clear\nCV: RRR no murmur\nLungs: clear\nAbd: soft, no loops\nExt: mae\nNeuro: good tone\n" }, { "category": "Nursing/other", "chartdate": "2124-12-15 00:00:00.000", "description": "Report", "row_id": 1890625, "text": "NPN 3-11P\n\n\n\n\n1. TF=120cc/k/d of pe20/bm. Receiving 42cc q4hrs. Infant bf\nx1 this evening. Tiring easily and latching for 5-10mins\nwith intermitent sucks. Infant bottled entire volume with a\ncoordinated suck. Abd soft with good bs and no loops.\nVoiding and stooling. a/ tol feeds and learning to po feed.\np/ cont to encourage po feeding, monitor weight.\n\n2. Infant received on ra. Sats 94% and greater with no\ndrifts or desats. RR 4-60's. Lungs c/e bilaterally with good\nair entry. a/ stable on ra p/ cont to monitor resp. status.\n\n3. Infant in off isolette with stable temps. Alert and\nactive during cares. Resting quietly between cares swaddled.\na/ aga p/ cont to support dev needs of infant.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2124-12-16 00:00:00.000", "description": "Report", "row_id": 1890626, "text": "NICU NPN\n\n\n1. f/N: Infant remains on 120cc/k/d of PE20 taking 42\nccq4hours. Bottle offered qfeed, taking 20-30cc. Abd.\nsoft, NT/ND, infant voiding well, no stool thus far in\nshift. A:stable, tolerating feeds, decreased wt-25g P:\nCont. to support curent feeding plan.\n\n3. G/D: TEmp. stable in off isolette. Infant turned and\nrepositioned q4hours w/ cares. A: stable P: COnt. to\nsuport G/D.\n\n4. : No contact thus far in shift.\n\n\n" } ]

[ { "category": "Nutrition", "chartdate": "2156-12-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 650766, "text": "Subjective\n reintub\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 67 kg\n 67 kg ( 03:00 PM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 100%\n Diagnosis: stroke, ? TIA\n PMH : Nasal allergies, ? HTN\n Pertinent medications: dilantin, famotidine, colace, ssri, abx,\n thiamine, folic acid, mvi, enalaprilat, kcl, others noted\n Labs:\n Value\n Date\n Glucose\n 139 mg/dL\n 02:59 AM\n Glucose Finger Stick\n 165\n 11:00 AM\n BUN\n 10 mg/dL\n 02:59 AM\n Creatinine\n 0.6 mg/dL\n 02:59 AM\n Sodium\n 134 mEq/L\n 02:59 AM\n Potassium\n 3.6 mEq/L\n 02:59 AM\n Chloride\n 98 mEq/L\n 02:59 AM\n TCO2\n 27 mEq/L\n 02:59 AM\n PO2 (arterial)\n 187 mm Hg\n 11:57 AM\n PCO2 (arterial)\n 39 mm Hg\n 11:57 AM\n pH (arterial)\n 7.45 units\n 11:57 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 11:57 AM\n Calcium non-ionized\n 8.5 mg/dL\n 02:59 AM\n Phosphorus\n 3.9 mg/dL\n 02:59 AM\n Ionized Calcium\n 1.09 mmol/L\n 04:15 AM\n Magnesium\n 2.1 mg/dL\n 02:59 AM\n Phenytoin (Dilantin)\n 16.2 ug/mL\n 02:59 AM\n WBC\n 10.0 K/uL\n 02:59 AM\n Hgb\n 13.0 g/dL\n 02:59 AM\n Hematocrit\n 36.4 %\n 02:59 AM\n Current diet order / nutrition support: 1000 mL NS Continuous at 75\n ml/hr\n GI: abd soft, nt +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to:\n Estimated Nutritional Needs\n Calories: 1500-1876 (BEE x or / 22-28 cal/kg)\n Protein: 87-101 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: inadequate\n Specifics:\n 53M presented to with complaint of left sided headache\n followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Pt intubated at OSH for airway protection,\n pt transferred to for cont care.\n Medical Nutrition Therapy Plan - Recommend the Following\n Initiate TF if unable to extub:\n Multivitamin / Mineral supplement: d/c MVI once start on TF\n Check chemistry 10 panel daily\n Start regular insulin sliding scale if serum glucose >150 mg/dL\n Other: f/u re poc, please page if has ?\n" }, { "category": "Echo", "chartdate": "2157-01-05 00:00:00.000", "description": "Report", "row_id": 87000, "text": "PATIENT/TEST INFORMATION:\nIndication: Cerebrovascular event/TIA. Hypertension. Assess LV function.\nHeight: (in) 68\nWeight (lb): 174\nBSA (m2): 1.93 m2\nBP (mm Hg): 163/73\nHR (bpm): 98\nStatus: Inpatient\nDate/Time: at 12:35\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV cavity size. Suboptimal technical quality, a focal\nLV wall motion abnormality cannot be fully excluded. Hyperdynamic LVEF >75%.\nDiastolic function could not be assessed. No resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending\naorta.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or\nvegetations on aortic valve, but cannot be fully excluded due to suboptimal\nimage quality.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. mass or\nvegetation on mitral valve. Normal LV inflow pattern for age.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or vegetation on\ntricuspid valve. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality - ventilator. Suboptimal image quality - patient unable to\ncooperate. The patient appears to be in sinus rhythm.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. The left\nventricular cavity size is normal. Due to suboptimal technical quality, a\nfocal wall motion abnormality cannot be fully excluded. Left ventricular\nsystolic function is hyperdynamic (EF>75%). Diastolic function could not be\nassessed. Right ventricular chamber size and free wall motion are normal. The\nascending aorta is mildly dilated. The aortic valve leaflets (3) appear\nstructurally normal with good leaflet excursion and no aortic regurgitation.\nNo masses or vegetations are seen on the aortic valve, but cannot be fully\nexcluded due to suboptimal image quality. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. No mass or vegetation\nis seen on the mitral valve. There is moderate pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. No cardiac source of embolism\nidentified. Hyperdynamic left ventricular systolic function. No significant\nvalvular abnormality seen.\n\nIf clinically suggested, the absence of a vegetation by 2D echocardiography\ndoes not exclude endocarditis.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1053395, "text": " 12:02 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o intrabdominal abscess/ assess pleural effusion extent\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HPI: 53M presented to this morning with complaint of left sided\n headache followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Incidental 2mm aneurysm of right basilar\n artery.Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee, just\n lifting it off the bed. He is not moving the right voluntarily. He withdraws in\n all four extremities, left side more briskly than right.\n REASON FOR THIS EXAMINATION:\n r/o intrabdominal abscess/ assess pleural effusion extent\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CT OF THE CHEST, ABDOMEN, AND PELVIS FROM \n\n HISTORY: Patient with intracranial hemorrhage and fever. Assess for intra-\n abdominal abscess and assess pleural effusion extent.\n\n COMMENT: CT of the chest, abdomen, and pelvis was performed with oral and IV\n contrast. There are no prior studies for comparison.\n\n FINDINGS: Coronary artery calcification. Atherosclerosis in the aorta and\n great vessels. Subcentimeter mediastinal nodes. Endotracheal tube with tip\n above the carina. Nasogastric tube also noted. There is no significant\n pleural or pericardial effusion. There is mild atelectasis bilateral lung\n bases, left greater than right.\n\n Emphysematous changes in the lungs with subpleural blebs at bilateral lung\n apices. Minimal subpleural probable scarring at the right lung apex. If\n there are no prior studies, recommend followup study in six months to assess\n for stability. Minimal tree-in- nodularity in the lingula and in both\n lower lobes, probably due to bronchiolitis.\n\n CT OF THE ABDOMEN: Nasogastric tube tip is in the gastric body. There is a\n 1.4-cm homogeneously enhancing dense lesion in the lateral segment of the\n liver on series 2, image 57. This is nonspecific but may represent\n hemangioma. The remainder of the liver appears unremarkable. The spleen,\n pancreas, adrenals appear unremarkable. There are tiny stones in the\n gallbladder neck. Subcentimeter hypodensity in the lower pole of each kidney\n and in the mid right kidney and upper pole of the right kidney, too small to\n characterize, but may represent tiny cysts.\n\n The proximal celiac, superior mesenteric, and inferior mesenteric arteries are\n patent. There is atherosclerosis in the abdominal aorta which is normal in\n size. Atherosclerosis is also seen in the proximal superior mesenteric\n (Over)\n\n 12:02 PM\n CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: r/o intrabdominal abscess/ assess pleural effusion extent\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt:\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n artery. The hepatic veins, portal vein, splenic vein, and superior mesenteric\n vein are patent. There is no bulky adenopathy or ascites. The stomach and\n duodenum are unremarkable by CT.\n\n CT OF THE PELVIS: Foley catheter and gas in decompressed bladder. Moderate\n distension of the colon with stool and gas. Degenerative changes in the spine.\n\n Findings of the study were discussed with Dr on at 1730.\n\n IMPRESSION:\n 1. Emphysematous changes in the lungs. Linear opacity at the right lung apex\n may represent scar, however, recommend followup study in six months to assess\n for stability. There is atelectasis at bilateral lung bases, left greater\n than right.\n 2. Minimal bronchiolitis in the lingula and bilateral lower lobes.\n 3. 1.4-cm enhancing lesion in the left lobe of the liver may represent a\n hemangioma.\n 4. Cholelithiasis.\n 5. Moderate distension of the colon with stool and gas.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1055815, "text": " 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm right pic. tip?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n 52cm right pic. tip?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLrc 3:58 PM\n Interval placement of PICC line with tip terminating within the right atrium.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male status post right PICC line\n placement. Please evaluate position.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: Comparison to chest radiograph .\n\n FINDINGS: There is interval placement of a right PICC tip that terminates\n within the right atrium. The heart, lungs, and mediastinum contours are\n unchanged in appearance. A tracheostomy tube and PEG tube seen or visualized\n in stable position.\n\n IMPRESSION: Interval right PICC placement with tip terminating within the\n right atrium. These findings were discussed with at 1:40 p.m. on .\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055069, "text": " 3:49 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for consolidations\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval for consolidations\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Evaluation for consolidations.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous examination, the retrocardiac\n atelectasis has slightly increased in extent. The other pre-described partly\n focal and partly diffuse parenchymal opacities are unchanged. Also unchanged\n is the size of the cardiac silhouette and the position of the tracheostomy\n tube.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052659, "text": " 12:36 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?position\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intubation\n REASON FOR THIS EXAMINATION:\n ?position\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Patient is a 53-year-old male status post intubation. Please\n evaluate for position.\n\n EXAMINATION: Single portable chest radiograph.\n\n COMPARISONS: There are no prior studies available for comparison.\n\n FINDINGS: There is an endotracheal tube with its tip 5.6 cm above the level\n of the carina. There is an NG tube that courses below the diaphragm with its\n tip in distal gastric body. The lungs are clear with no signs of pneumonia or\n congestive heart failure. No pleural effusions or pneumothorax is seen.\n Elevation of the left hemidiaphragm. The cardiac and mediastinal contours are\n unremarkable. The visualized osseous structures are unremarkable.\n\n IMPRESSION: Appropriate position of ET and NG tubes.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-27 00:00:00.000", "description": "CTA HEAD W&W/O C & RECONS", "row_id": 1052661, "text": " 12:42 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ?blood\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with hemmorhagic stroke;\n REASON FOR THIS EXAMINATION:\n ?blood\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa MON 2:50 PM\n 1. Hemorrhage seen in the medulla and pons. Subarachnoid hemorrhage in pre-\n pontine and pre-medullary cisterns, and also in the foramen of Luschka.\n\n 2. Small intraventricular hemorrhage in the posterior of the Left lateral\n ventricle.\n\n 3. R vertebral artery terminates at the bifurcation of PICA.\n\n 4. Outpouching seen at the origin of the right basilar artery, 2mm in\n diameter, could represent an aneurysm or an infundibulum at the right AICA.\n\n 5. No definitive evidence of AVM, but AVM could be compressed.\n\n Recommend conventional angiograph for better assessment.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male, with hemorrhagic stroke. Now assess for\n hemorrhage.\n\n TECHNIQUE: Initially contiguous helical MDCT images were obtained through the\n brain without contrast material. Subsequently, rapid helical imaging was\n performed from the base of the skull through the brain during infusion of IV\n contrast material. Images were processed on a separate workstation with\n display of curved reformats, volume-rendered images, and maximum-intensity\n projection images. Parts of the study were limited by motion artifacts.\n\n COMPARISON: No prior comparison available.\n\n FINDINGS:\n\n NONCONTRAST HEAD CT: There is a small amount of hemorrhage seen in the\n medulla and pons. There is subarachnoid hemorrhage in the prepontine and\n premedullary cisterns and also in the foramen of Luschka. There is a small\n amount of intraventricular hemorrhage seen in the dependent position of the\n posterior of the left lateral ventricle, presumably an extension of the\n other hemorrhage. The lateral ventricles appear to be slightly dilated, could\n represent an early hydrocephalus. There is no apparent mass effect, and there\n is no shift of the normally midline structures. There is no evidence of acute\n fracture.\n\n CTA OF HEAD: The right vertebral artery terminates at the level of the PICA\n (Over)\n\n 12:42 PM\n CTA HEAD W&W/O C & RECONS Clip # \n Reason: ?blood\n Contrast: OPTIRAY Amt: 80\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n bifurcation. There is a small outpouching at the right basilar origin,\n measuring about 2 mm in diameter, could represent an aneurysm or an\n infundibulum at the right AICA. The left vertebral artery and the carotid\n arteries are patent without evidence of stenosis. The distal cervical\n internal carotid arteries measure 6 mm in diameter on the right and 5 mm on\n the left. There is no definitive evidence of AVM, however, AVM could be\n compressed. There is no other evidence of aneurysm.\n\n A nasogastric tube and endotracheal tube are noted.\n\n IMPRESSION:\n 1. Small hemorrhage seen in the medulla and pons, and subarachnoid hemorrhage\n in the prepontine and premedullary cisterns, also at the foramen of Luschka.\n Also, small amount of intraventricular hemorrhage in the posterior of the\n left lateral ventricle.\n 2. Slightly dilated lateral ventricles bilaterally. Could represent a\n developing hydrocephalus.\n 3. No definitive evidence of AVM. A possible 2-mm aneurysm vs. infundibulum\n at the right basilar artery origin. Recommend conventional angiography for\n better assessment.\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054090, "text": ", NMED SICU-B 1:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever, r/o pneumonia\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage\n REASON FOR THIS EXAMINATION:\n fever, r/o pneumonia\n ______________________________________________________________________________\n PFI REPORT\n 1) worsening of LLL opacity. 2) improvement of pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052896, "text": " 3:55 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH with IVH, now reintubated\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 6:00 PM\n PFI: Good position of ETT following re-intubation. No pneumothorax. Lung\n findings unchanged.\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: Subarachnoid hematoma, now re-intubated. Evaluate ETT placement.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a similar preceding study\n obtained two and a half hours earlier. The present ETT is again seen to\n terminate in the trachea some 5 cm above the level of the carina. No new\n pneumothorax has developed and the lung findings are unchanged. The same\n holds for the position of the previously described Dobbhoff line.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052897, "text": ", NMED SICU-B 3:55 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ETT placement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with SAH with IVH, now reintubated\n REASON FOR THIS EXAMINATION:\n ETT placement\n ______________________________________________________________________________\n PFI REPORT\n PFI: Good position of ETT following re-intubation. No pneumothorax. Lung\n findings unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054721, "text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?fluid overload\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n ?fluid overload\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY: IV is given, evaluate for fluid overload.\n\n CHEST:\n\n Semi-upright film shows bilateral pleural effusions and some increase in\n interstitial , the lung fields suggesting some failure is now present.\n\n IMPRESSION: Evidence of interstitial failure.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-03 00:00:00.000", "description": "SEL CATH 2ND ORDER", "row_id": 1053573, "text": " 9:19 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 90\n ********************************* CPT Codes ********************************\n * SEL CATH 3RD ORDER SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE SEL CATH 2ND ORDER *\n * -59 DISTINCT PROCEDURAL SERVICE ADD'L 2ND/3RD ORDER *\n * ADD'L 2ND/3RD ORDER ADD'L 2ND/3RD ORDER *\n * CAROTID/CERVICAL UNILAT CAROTID/CEREBRAL BILAT *\n * EXT CAROTID BILAT VERT/CAROTID A-GRAM *\n * EXT BILAT A-GRAM -52 REDUCED SERVICES *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with brain hemorrhage\n REASON FOR THIS EXAMINATION:\n please evaluate for aneurysm\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL INDICATION: 53-year-old male with intracranial hemorrhage. Please\n evaluate for aneurysm.\n\n PHYSICIANS: Dr. , Dr. . The Attending, Dr. , was\n present and supervising throughout.\n\n TECHNIQUE: The risk, benefits and alternatives were explained to the\n patient's family including stroke, loss of vision and speech, temporary or\n permanent with possible treatment with stent and coils if needed. There are\n no prior angiograms available for comparison.\n\n The patient was brought to the neuro-interventional radiology theater and\n placed on the biplane table in the supine position. Both groins were prepped\n and draped in the usual standard sterile fashion. Access to the right common\n femoral artery was obtained using a 19-gauge single wall needle under local\n anesthesia utilizing 1% lidocaine mixed with sodium bicarbonate with aseptic\n precautions and fluoroscopy. Through the needle, a micropuncture wire was\n introduced and the needle was taken out. Over the wire, a 5 French vascular\n sheath was placed and connected to the saline infusion (mixed with heparin 500\n units in 500 cc of saline) with continuous drip. Through the sheath, a 5\n French -2 catheter was introduced and connected to the continuous\n saline infusion (mixture of 1000 units of heparin in 1000 cc of saline).\n\n The following vessels were selectively catheterized and arteriograms were\n performed: Left internal carotid artery, left external carotid artery, right\n internal carotid artery, right external carotid artery, right common carotid\n artery, right subclavian artery, left subclavian artery, left vertebral\n artery.\n\n FINDINGS:\n\n LEFT INTERNAL CAROTID ARTERY: There is no evidence of aneurysm or stenosis.\n (Over)\n\n 9:19 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n The anterior and middle cerebral arteries are patent. The distal arteries\n demonstrate normal caliber and course.\n\n LEFT EXTERNAL CAROTID ARTERY: There is atherosclerotic plaque identified at\n the origin of the left external carotid artery. There is an approximately 30%\n stenosis at the origin of the left external carotid artery. The distal\n external carotid artery is patent. There is no evidence of high-grade\n stenosis.\n\n RIGHT INTERNAL CAROTID ARTERY: There is no evidence of aneurysm or stenosis\n of the internal carotid artery. The middle cerebral and anterior cerebral\n arteries are patent without evidence of aneurysm, stenosis or arteriovenous\n malformation.\n\n RIGHT EXTERNAL CAROTID ARTERY: At the origin of the right external carotid\n artery there is atherosclerotic plaque leading to a 30% stenosis at this\n level. The remainder of the right external carotid artery is patent without\n evidence of high-grade stenosis.\n\n RIGHT COMMON CAROTID ARTERY: There is a normal origin without evidence of\n high-grade stenosis of the right common carotid artery.\n\n RIGHT SUBCLAVIAN ARTERY INJECTION: There is lack of opacification of the\n proximal right vertebral artery with distal reconstitution of the right\n vertebral artery from costocervical branches. The remainder of the right\n subclavian artery branches appear patent without evidence of high-grade\n stenosis.\n\n LEFT SUBCLAVIAN ARTERY: The subclavian artery is patent without stenosis.\n There is normal origin of the left vertebral artery. Normal contrast\n opacification is identified.\n\n LEFT VERTEBRAL ARTERY: Left vertebral artery is normal at its origin. There\n is a normal caliber left vertebral artery, basilar artery and posterior\n cerebral artery circulation. There is no evidence of high-grade stenosis.\n\n IMPRESSION: Occlusion of the proximal right vertebral artery with distal\n reconstitution of the right vertebral artery likely from costocervical\n branches. Follow up MRI is recommended in one to two months for additional\n evaluation.\n\n (Over)\n\n 9:19 AM\n CAROT/CEREB Clip # \n Reason: please evaluate for aneurysm\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 90\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2156-12-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052947, "text": " 3:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intervale exam - p reintubation the prior day\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53M presented to this morning with complaint of left sided\n headache followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Incidental 2mm aneurysm of right basilar\n artery.Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee, just\n lifting it off the bed. He is not moving the right voluntarily. He withdraws in\n all four extremities, left side more briskly than right.\n REASON FOR THIS EXAMINATION:\n intervale exam - p reintubation the prior day\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: CVA.\n\n FINDINGS: In comparison with study of , there is engorgement of poorly\n defined pulmonary vessels consistent with increased pulmonary venous pressure.\n Poor definition of the right hemidiaphragm suggests some free pleural fluid.\n Endotracheal tube remains in place. Dobbhoff tube tip lies in the general\n region of the gastroesophageal junction.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056639, "text": " 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with failed extubation\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc WED 9:30 AM\n Interval increase in pulmonary edema. Unchanged bilateral pleural effusions.\n Left retrocardiac opacity might represent atelectasis or pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Follow up of a patient with tracheostomy.\n\n Portable AP chest radiograph was compared to .\n\n The tracheostomy is at the midline with its tip approximately 5 cm above the\n carina. The PICC line tip is at the cavoatrial junction. The\n cardiomediastinal silhouette is stable. Pulmonary edema is worse compared to\n the prior study, moderate to severe. Bilateral pleural effusions are present.\n Left retrocardiac opacity is consistent most likely with atelectasis.\n\n The VP shunt is in unchanged position.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-04 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1053761, "text": " 4:44 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage, with EVD drain, with increased ICP\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KYg TUE 5:59 AM\n slightly increased amount of blood layering in the occipital horns of the\n lateral ventricles. the ventricles are otherwise unchanged in size and\n configuration.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with pontine hemorrhage with increased\n extracerebral pressure. Evaluate for interval change.\n\n NON-CONTRAST HEAD CT: Right transfrontal ventriculostomy catheter, with its\n tip in the frontal of the right lateral ventricle, is unchanged in\n position. The amount of blood layering in the occipital horns of the lateral\n ventricles is slightly larger than on , but similar to . The\n extent of ventricular dilatation is unchanged\n\n Left pontine/medullary hemorrhage with extension into the fourth ventricles is\n not significantly changed. Bilateral subarachnoid blood is not significantly\n changed. Small amount of subdural blood along the tentorium is unchanged.\n There is no evidence of a new large infarction.\n\n Mucosal thickening and fluid in the paranasal sinuses, opacification of the\n nasopharynx, and opacification of the left mastoid air cells are again seen.\n New opacification of the left middle ear cavity is noted. These findings may\n be related to the presence of the endotracheal and nasogastric tubes.\n\n IMPRESSION:\n 1. Unchanged left pontine/medullary hemorrhage. Unchanged subarachnoid and\n subdural hemorrhage.\n\n 2. Intraventricular hemorrhage is slightly increased since but\n similar to . The extent of ventricular dilatation is unchanged.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053276, "text": " 2:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? dobhoff placement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new dobhoff placement\n REASON FOR THIS EXAMINATION:\n ? dobhoff placement\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd FRI 7:56 PM\n The Dobhoff tube tip is now seen in the location of the stomach.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with new Dobbhoff placement.\n\n COMPARISON: Chest radiographs done approximately 40 minutes prior.\n\n TECHNIQUE: Portable AP view of the chest.\n\n FINDINGS: The Dobhoff tube is now seen ending within the stomach. The\n endotracheal tube is at the level of the clavicles, unchanged. Otherwise, no\n significant changes since prior study.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053277, "text": ", NMED SICU-B 2:04 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: ? dobhoff placement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new dobhoff placement\n REASON FOR THIS EXAMINATION:\n ? dobhoff placement\n ______________________________________________________________________________\n PFI REPORT\n The Dobhoff tube tip is now seen in the location of the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1054180, "text": " 11:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for new hemorrhage, s/p EVD replacement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate for new hemorrhage, s/p EVD replacement\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 1:02 AM\n Compared to prior exam from , there is slightly increased\n blood/edema along the track of the right ventriculostomy catheter.Additionally\n there is new blood around the tip of the ventriculostomy catheter in the right\n lateral ventricle as well as a new 4mm focus of high attenuation in the right\n thalamus, which likely represents blood.\n\n The remainder of the intraventricular, subarachnoid, subdural, and\n pontine/medullary hemmorrhage is not significantly changed.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male with hemorrhage. Evaluate for interval change.\n\n COMPARISON: \n\n NON-CONTRAST HEAD CT: Right frontal ventriculostomy catheter terminates in\n the frontal of the right lateral ventricle, unchanged in position from\n . Since the last exam, there is slightly increased blood and\n edema along the course of the ventriculostomy catheter and surrouding the tip.\n Note is made of increased conspicuity of a 4mm focus of high attenuation in\n the right thalamus, which likely represents a small amount of blood.\n There is continued evolution of intraventricular blood, subdural blood\n layering on the tentorium, scattered subarachnoid hemorrhage and the left\n pontine/medullary hemorrhage.\n\n Sinus mucosal thickening, opacification of the nasopharynx and left mastoid\n air cells and left middle ear cavity are unchanged. are again seen. There is\n minmally increased opacification of the right mastoid air cells.\n\n IMPRESSION: Compared to prior exam from , there is slightly\n increased blood/edema along the track of the right ventriculostomy catheter.\n Additionally there is new blood surrounding the tip of the ventriculostomy\n catheter in the right lateral ventricle as well as a new 4mm focus of high\n attenuation in the right thalamus, which likely represents blood. The\n remainder of the intraventricular, subarachnoid, and pontine/hemmorrhage is\n not significantly changed.\n\n\n\n (Over)\n\n 11:04 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for new hemorrhage, s/p EVD replacement\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2156-12-29 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1052984, "text": " 9:45 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine SAH\n REASON FOR THIS EXAMINATION:\n interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ENYa WED 11:11 AM\n No significant interval change of the size and appearance of the known\n hemorrhages. Slight interval size decrease of the temporal horns.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old man with known pontine subarachnoid hemorrhage, now\n assess for interval change.\n\n TECHNIQUE: Contiguous helical MDCT images were acquired through the brain\n without contrast.\n\n COMPARISON: Non-contrast CT head on .\n\n FINDINGS: There is no significant interval change. There is persistent\n hemorrhage seen in the pons and medulla with extension to the dependent\n portion of the occipital horns of the lateral ventricles bilaterally. There\n is a trace amount of subarachnoid hemorrhage, consistent with a small leak\n from the known hemorrhage. The ventriculostomy catheter is seen through a\n right transfrontal approach with its tip in the right lateral ventricle\n unchanged compared to prior. The lateral ventricles are still dilated but\n with evidence of a slight interval decrease of the temporal horns. There is\n no shift of normally midline structures.\n\n Other than the known burr hole, the osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Overall unchanged picture of hemorrhage in the pons and medulla and\n intraventricular bleed with a small component of subarachnoid hemorrhage.\n\n 2. Slight interval size decrease of the temporal horns, but otherwise\n unchanged hydrocephalus.\n\n 3. Unchanged position of the ventriculostomy catheter.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1054293, "text": " 8:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Increasing intrcranial pressure?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intracranial bleeding and decreasing mental status\n REASON FOR THIS EXAMINATION:\n Increasing intrcranial pressure?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 10:36 PM\n No interval change in parenchymal, subarachnoid, and intraventricular\n hemorrhage. Stable ventricular enlargement and no interval change in\n ventriculostomy catheter.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with decreasing mental status and known\n intracranial bleeding.\n\n COMPARISON: at 2341 hours.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain at 2044\n hours. No contrast was administered.\n\n FINDINGS: A right ventriculostomy catheter again traverses the right frontal\n cortex and terminates in the body of the right lateral ventricle. Its\n position is unchanged, and a small amount of high-density material coursing\n along the catheter is also unchanged.\n\n Overall, there has been little interval change in multifocal intracranial\n hemorrhage, with a large left pontine/medullary parenchymal hemorrhage,\n scattered subarachnoid hemorrhage and subdural blood layering along the\n tentorium. Within the lateral ventricles, there is further evolution of blood\n products. Enlargement of the lateral ventricles is stable. There is no\n midline shift or evidence of herniation. There are no new foci of bleeding.\n There is no evidence of acute vascular territorial infarct. Bony structures\n are unchanged, with a burr hole in the right frontal bone. There is no\n fracture. Opacification of the ethmoid air cells, sphenoid air cells, mucosal\n thickening within the maxillary sinuses, opacification of the frontal air\n cells and mastoid air cells is all unchanged.\n\n IMPRESSION: No interval change in parenchymal, subarachnoid, and\n intraventricular hemorrhage. No change in ventricular enlargement. Stable\n positioning of ventricular catheter.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-06 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1054294, "text": ", NMED SICU-B 8:22 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Increasing intrcranial pressure?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intracranial bleeding and decreasing mental status\n REASON FOR THIS EXAMINATION:\n Increasing intrcranial pressure?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No interval change in parenchymal, subarachnoid, and intraventricular\n hemorrhage. Stable ventricular enlargement and no interval change in\n ventriculostomy catheter.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054089, "text": " 1:07 PM\n CHEST (PORTABLE AP) Clip # \n Reason: fever, r/o pneumonia\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage\n REASON FOR THIS EXAMINATION:\n fever, r/o pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb WED 4:01 PM\n 1) worsening of LLL opacity. 2) improvement of pulmonary edema.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with pontine hemorrhage, fever, rule out pneumonia.\n\n COMPARISON: Prior chest radiograph on .\n\n PORTABLE AP CHEST RADIOGRAPH: ET tube was removed and there is a new\n tracheostomy in place with tip terminating 60 mm above the carina. Right\n central line and feeding tubes were removed. Interval worsening of the left\n lung base opacity that could represent area of aspiration. Unchanged\n appearance of the right lung base consolidation. Improvement of the pulmonary\n edema. Unchanged normal cardiomediastinal silhouette.\n\n IMPRESSION:\n 1. Worsening of the left lung base opacity.\n 2. Unchanged right lung base opacity.\n 3. Improvement of pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053205, "text": " 9:51 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulm process\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fever\n REASON FOR THIS EXAMINATION:\n ? pulm process\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE VIEW OF THE CHEST DATED :\n\n HISTORY: 53-year-old man with fever; question pulmonary process.\n\n FINDINGS: Single bedside AP examination labeled \"semi-upright at 10:10 AM\"\n slightly limited by motion-blurring, is compared with a series of studies\n dating to . Allowing for the technical limitation, the overall\n appearance is not much changed. Though small bilateral pleural effusions\n cannot be excluded, there has been no significant change in the heart size and\n pulmonary vessels, overall. The ET tube and endogastric feeding tube, with the\n tip looped on itself and directed cephalad in the region of the gastric\n cardia, are unchanged.\n\n IMPRESSION: Somewhat limited study, with no definite acute airspace process.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1055816, "text": ", NMED SICU-B 11:09 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: 52cm right pic. tip?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n 52cm right pic. tip?\n ______________________________________________________________________________\n PFI REPORT\n Interval placement of PICC line with tip terminating within the right atrium.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1054819, "text": " 6:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change, ? hemorrhage extension, ? swel\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage and decreased responsiveness.\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, ? hemorrhage extension, ? swelling\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): AKSb 8:16 PM\n Interval increase in size of the ventricles potentially due to shunt\n obstruction by blood products. No significant change in multiple additional\n hemorrhages including pontine hemorrhage, intraventricular hemorrhage and\n scattered subarachnoid blood.\n\n Findings were discussed with at the time of the exam.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old with pontine hemorrhage and decreased responsiveness.\n Evaluate for interval change.\n\n COMPARISON: Three days prior.\n\n NON-CONTRAST HEAD CT: The extensive left pontine hemorrhage is relatively\n unchanged in size and extent with mild surrounding edema. The fourth\n ventricle is slightly effaced by left pontine swelling, however, remains\n patent. There is persistent intraventricular extension of blood, though the\n swath of blood previously seen in the medial right lateral ventricle is no\n longer identified. The right ventriculostomy catheter remains in place\n terminating in the right lateral ventricle, and there is a small focus of\n high-attenuation fluid surrounding the tip of the catheter which may represent\n blood clots. There has been interval increase in size of the ventricles\n suggesting shunt failure. The lateral ventricles now measure 3.6 cm in\n diameter at the level of the catheter tip, previously 2.8 cm. There is no\n periventricular hypoattenuation to suggest transependymal flow of CSF. The\n third ventricle also bulges more outwardly. There remain scattered foci of\n subarachnoid hemorrhage within the parietal lobes bilaterally. Extensive\n sinus disease within the sphenoid sinuses and ethmoidal air cells is slightly\n improved. Again, there is extensive opacification within the mastoid air\n cells.\n\n IMPRESSION:\n 1. Interval increase in ventricular size with patency of the fourth\n ventricle, suggesting shunt failure, potentially due to blood clot at the tip\n of the catheter.\n\n 2. No significant change in extent of left pontine hemorrhage,\n intraventricular hemorrhage, and scattered foci of subarachnoid hemorrhage. No\n new hemorrhage.\n\n\n (Over)\n\n 6:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change, ? hemorrhage extension, ? swel\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2157-01-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1054820, "text": ", NMED SICU-B 6:05 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for interval change, ? hemorrhage extension, ? swel\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage and decreased responsiveness.\n REASON FOR THIS EXAMINATION:\n evaluate for interval change, ? hemorrhage extension, ? swelling\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in size of the ventricles potentially due to shunt\n obstruction by blood products. No significant change in multiple additional\n hemorrhages including pontine hemorrhage, intraventricular hemorrhage and\n scattered subarachnoid blood.\n\n Findings were discussed with at the time of the exam.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1052759, "text": " 12:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Is there evidence of underlying mass or vascular malformatio\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL ADDENDUM\n A thin linear focus os negative susceptibility in the right thalamus coursing\n anteriorly can relate to prior catheter tract.\n\n\n\n\n\n 12:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Is there evidence of underlying mass or vascular malformatio\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL ADDENDUM\n The conventional catheter angiogram was done on which did not reveal\n any obvious lesion on the left side at the site of known hemorrhage but\n demonstrated proximal occlusion of the right vertebral artery in the neck\n with reformation. As there is no obvious lesion on the left side, the\n appearance on MR can relate to a cavernoma ( which can be occult on\n conventional angiogram) or less likely a mass lesion. Hence, a follow up\n CTA/MR&MRA Head to evaluate for a lesion after resolution of the hemorrhage\n is recommended.\n\n\n\n 12:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Is there evidence of underlying mass or vascular malformatio\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine intracranial hemorrhage\n REASON FOR THIS EXAMINATION:\n Is there evidence of underlying mass or vascular malformation\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: NPw TUE 3:33 PM\n A few discrete enhancing foci are noted in the region of hemorrhage in the\n left side of the pons can represent vascular enhancement like related to an\n underlying vascular lesion like malformation. Though no obvious enlarged\n draining vein is noted, it is possible that the draining veins are compressed\n or thrombosed. Conventional catheter angiogram is necessary for better\n evaluation.\n No change in hemorrhage or dilation of the supratentorial ventricular system.\n D/w Dr. by Dr. on at 2.30pm.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old male patient, with pontine and intracranial\n hemorrhage, to evaluate for underlying mass or vascular malformation.\n\n This is a redictation of the report, as the prior was apparently transcribed,\n but did not come over to the CCC or the PACS.\n\n COMPARISON: CT angiogram of the head done on and CT of the head done\n on .\n\n TECHNIQUE: Multiplanar T1- and T2-weighted imaging of the brain was performed\n without and with IV contrast.\n\n FINDINGS:\n\n Again visualized is a large area of hemorrhage in the left side of the pons\n and medulla extending into the fourth ventricle as well as lateral recesses of\n the fourth ventricle. There is also moderate amount of blood in the occipital\n horns on both sides as well as in the basal cisterns. The appearance of the\n hemorrhage is not significantly changed. However, accurate assessment and\n comparison is difficult given the differences in modalities.\n\n On the post-contrast images, there are a few discrete small areas of\n enhancement in the left side of the pons within the area of hemorrhage,\n better seen on the MP-RAGE reformations (series 1001, image 83; series 10,\n image 75 and series 1000, images 57-72). These are most likely vessels\n related to the presence of an underlying vascular malformation. Some of these\n enhancing foci are identifiable on the CT angiogram and appear to relate to\n branches of the anterior-inferior cerebellar artery on the left side. However,\n these are better seen on the present MR study, likely due to improvement in\n (Over)\n\n 12:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Is there evidence of underlying mass or vascular malformatio\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n vasospasm. There is no obvious enlarged draining vein noted on the present MR\n study images. However, dedicated vascular imaging was not performed on the\n present study and it is also possible that abnormal draining veins are\n compressed by the hemorrhage and edema or thrombosed. Interestingly, there are\n no flow voids in this region on ax T2 W images, which may relate to the\n presence of hemorrhage in the area.\n\n Again noted is faintly visualized right distal vertebral artery after the\n origin of the posterior inferior cerebellar artery with a slight prominence at\n the origin of the basilar artery which may represent an infundibulum.\n\n There is compression of the fourth ventricle and moderate dilatation of the\n supratentorial ventricular system. The ventricular catheter is noted through\n the right frontal approach, with the tip in the body of the right lateral\n ventricle.\n\n There is evidence of mucosal thickening in the left side of the sphenoid\n sinus, left ethmoid air cells, the left mastoid air cells with small amount of\n fluid and/or mucosal thickening in the latter, which are not significantly\n changed compared to the most recent study.\n\n IMPRESSION:\n\n 1. Multiple small enhancing foci in the area of hemorrhage in the left side\n of the pons, most likely vessels related to an underlying vascular\n malformation. Some of these enhancing foci are identifiable on the CT\n angiogram and likely represent branches of the anterior inferior cerebellar\n artery on the left side but better seen on the MR study likely due to\n improvement in vasospasm. No obvious draining vein is visualized, which may\n relate to compression due to the edema or thrombosis. Further evaluation with\n conventional catheter angiogram is necessary for better assessment in\n delineation of the abnormality.\n\n 2. Extensive left pontine and medullary hemorrhage, intraventricular and\n subarachnoid hemorrhage, unchanged allowing for the differences in the\n modalities.\n 3. Moderate dilatation of the supratentorial ventricular system, unchanged\n compared to the most recent CT.\n Close followup as clinically recommended, with CT studies.\n\n 4. Small 1-2 mm infundibulum at the junction of the right distal\n vertebral artery and the basilar artery. This can be better assessed at the\n time of conventional catheter angiogram.\n\n Findings and recommendations for conventional catheter angiogram was discussed\n (Over)\n\n 12:18 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Is there evidence of underlying mass or vascular malformatio\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: MAGNEVIST Amt: 17\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n with Dr. by Dr. on at approximately 2:30 p.m.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1053246, "text": " 11:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with IPH\n REASON FOR THIS EXAMINATION:\n interval change?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GMdb FRI 12:39 PM\n No change in intracranial hemorrhage or ventricular size. Increase in left\n mastoid opacification.\n ______________________________________________________________________________\n FINAL REPORT\n ROUTINE UNENHANCED CT HEAD\n\n HISTORY: Hemorrhage.\n\n Comparison is made with .\n\n No significant change in the left pontine hemorrhage with intraventricular\n extension is noted. There continues to be a small amount of hemorrhage along\n the tentorial reflection. There is mild subarachnoid hemorrhage which is\n stable. There is a right frontal ventriculostomy catheter terminating in the\n frontal . The ventricles are unchanged in size and configuration. There\n is increased opacification of the left mastoid air cells with what appears to\n be a bony defect in the anterior mastoid along the posterior margin of the\n external auditory canal. This may be postsurgical in nature. Clinical\n correlation is advised.\n\n There is unchanged mucosal thickening in the sphenoid and ethmoid air cells.\n\n IMPRESSION:\n\n No change in intracranial hemorrhage.\n\n No change in ventricular size.\n\n Increase in left mastoid opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1053247, "text": ", NMED SICU-B 11:30 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: interval change?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with IPH\n REASON FOR THIS EXAMINATION:\n interval change?\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n No change in intracranial hemorrhage or ventricular size. Increase in left\n mastoid opacification.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-13 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055567, "text": " 9:12 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? going for VP shunt today, evaluate for hydrocephalus or ot\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine/medullary hemorrhage with interventricular\n extension and SAH, s/p EVD which has been clamped since midnight.\n REASON FOR THIS EXAMINATION:\n ? going for VP shunt today, evaluate for hydrocephalus or other changes since\n EVD has been clamped\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with a pontine hemorrhage. Please evaluate\n interval change.\n\n COMPARISON: Comparison is made to the prior study of .\n\n NON-CONTRAST HEAD CT: There has been interval evolvement of the hemorrhage\n within the left side of the pons, which now appears denser and is accompanied\n by more surrounding hypodensity. Small bilateral intraventricular hemorrhage\n and subarachnoid hemorrhage appear unchanged. The size of lateral ventricles\n is unchanged. The right ventriculostomy drain terminates within the right\n lateral ventricle. New focus of hemorrhage is detected. No major vascular\n territorial infarction is noted. Status post right frontal burr hole\n placement. Diffuse opacification of the ethmoid and sphenoid sinuses are\n noted.\n\n IMPRESSION:\n 1.Unchanged size of the lateral ventricles, with patency of the fourth\n ventricle\n 2.Interval evolvement of the left pontine hemorrhage. The intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage are unchanged. No\n new hemorrhage is noted.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING", "row_id": 1052756, "text": " 12:12 AM\n SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR Clip # \n Reason: ?metal\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with head bleed, needs MRI but unknown if metal in body or not\n REASON FOR THIS EXAMINATION:\n ?metal\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Rule out metallic foreign body.\n\n Eight radiographs of the skull, chest, and abdomen are submitted.\n\n SKULL: There is a radiopaque catheter projecting over the right ventricle.\n Initial images demonstrate a radiopaque bridge overlying the mandible.\n Subsequent images demonstrate the bridge removed. Metallic caps are seen\n along the lower incisors. No radiopaque metallic foreign body projects over\n the orbits.\n\n CHEST: There is an endotracheal tube present with its tip at the level of the\n clavicular heads. The lungs are clear. The cardiomediastinal contours are\n normal. There is a nasogastric tube present with its tip in the stomach. No\n pneumothorax is evident. No effusion. Trachea is midline.\n\n ABDOMEN: There may be mild degenerative change involving the bilateral\n sacroiliac joints. The hip joint spaces are maintained. The regional soft\n tissues are unremarkable. Bowel gas pattern is normal.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-27 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1058213, "text": ", NMED SICU-B 9:21 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER OF UNKNOWN ORIGIN, R/O DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fever\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n PFI REPORT\n PFI: No evidence of DVT involving the bilateral lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058604, "text": " 4:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: For comparison with previous study to evaluate for interval change.\n\n FINDINGS: In comparison with study of , there is now no definition of the\n hemidiaphragms with increased opacification at the bases. This is consistent\n with increasing pleural effusions and atelectasis of the underlying lung.\n However, some of this difference may be artifactual due to patient position\n and a repeat study would be helpful to determine whether the changes are real.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055783, "text": " 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for hydrocephalus, interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage s/p EVD, EVD has been clamped x24 hours\n REASON FOR THIS EXAMINATION:\n evaluate for hydrocephalus, interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr 2:34 PM\n 1. Unchanged size of the lateral ventricles with patency of the fourth\n ventricle.\n\n 2. Unchanged appearance of the left pontine hemorrhage, intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage. No new focus of\n hemorrhage is noted.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with pontine hemorrhage, please evaluate interval\n change of the ventricular size.\n\n Comparison is made to the prior study of .\n\n NONCONTRAST HEAD CT: There has been no interval change in the hemorrhage\n within the left side of the pons. Small amount of bilateral intraventricular\n and subarachnoid hemorrhage appears unchanged. The size of lateral ventricles\n is unchanged. The right ventriculostomy catheter terminates within the right\n lateral ventricle. New focus of hemorrhage is detected. No major vascular\n territorial infarction is noted. Status post right frontal burr hole\n placement. Diffuse opacification of the ethmoid and sphenoid sinuses is\n noted.\n\n IMPRESSION:\n 1. Unchanged size of the lateral ventricles with patent fourth ventricle.\n\n 2. Unchanged appearance of the left pontine, intraventricular hemorrhage and\n scattered subarachnoid hemorrhage. No new focus of hemorrhage is noted.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055784, "text": ", NMED SICU-B 9:40 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: evaluate for hydrocephalus, interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage s/p EVD, EVD has been clamped x24 hours\n REASON FOR THIS EXAMINATION:\n evaluate for hydrocephalus, interval change\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Unchanged size of the lateral ventricles with patency of the fourth\n ventricle.\n\n 2. Unchanged appearance of the left pontine hemorrhage, intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage. No new focus of\n hemorrhage is noted.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-09 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1054751, "text": " 9:50 AM\n RENAL U.S. PORT Clip # \n Reason: evalute for hydronephrosis, other acute process\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage s/p EVD, with new elevated Cr. Patient\n has trach and is on ventilator\n REASON FOR THIS EXAMINATION:\n evalute for hydronephrosis, other acute process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 12:00 PM\n PFI: No hydronephrosis.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: RENAL ULTRASOUND.\n\n INDICATION: New renal failure. Please evaluate for hydronephrosis.\n\n COMPARISON: CT torso of .\n\n FINDINGS: Limited portable ultrasound was performed in the ICU without a\n radiologist present. The left kidney measures 11 cm. The right kidney\n measures 10.8 cm. There is no hydronephrosis, or mass lesion identified. The\n bladder cannot be evaluated given collapse from Foley catheter. No right or\n left upper quadrant ascites.\n\n IMPRESSION: Limited portable exam without hydronephrosis or upper abdominal\n ascites.\n\n\n\n *\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-22 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1057384, "text": " 1:31 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: atelectasis/mucus plug\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with VAP\n REASON FOR THIS EXAMINATION:\n atelectasis/mucus plug\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SAT 5:01 PM\n No interval change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pneumonia.\n\n Portable AP chest radiograph was compared to prior study obtained the same day\n earlier.\n\n There is no interval change in the position of the tracheostomy, right PICC\n line, and PEG. The cardiomediastinal silhouette is unchanged. There is no\n change in the left retrocardiac consolidation as well as in multiple\n parenchymal opacities. Mild degree of pulmonary edema is present, unchanged.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-27 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1058212, "text": " 9:21 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: FEVER OF UNKNOWN ORIGIN, R/O DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with fever\n REASON FOR THIS EXAMINATION:\n r/o DVT\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 12:39 PM\n PFI: No evidence of DVT involving the bilateral lower extremities.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever.\n\n FINDINGS: Son interrogation of the bilateral lower extremities\n demonstrates normal Doppler flow, compressibility and augmentation. There is\n no evidence of DVT. Regions of subcutaneous edema are noted.\n\n IMPRESSION: No evidence of DVT involving the bilateral lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056391, "text": ", NMED SICU-B 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man on trach mask\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n PFI REPORT\n Left pleural effusion with left lower lobe opacity slightly increased since\n yesterday, significantly increased since two days ago. Interstitial markings\n are still prominent, likely due to volume overload. Right upper lobe\n consolidation increased, could be pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-20 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1056971, "text": " 1:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for pna\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ? worsening pna on CXR\n REASON FOR THIS EXAMINATION:\n eval for pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 6:33 PM\n PFI: Progression compared to the prior studies of multifocal consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Worsening pneumonia.\n\n COMPARISON: CT torso from and multiple chest radiographs\n between and .\n\n TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper\n abdomen after administration of IV contrast. Axial images were reviewed in\n conjunction with coronal and sagittal reformats.\n\n FINDINGS: The patient is after insertion of tracheostomy. Retained\n secretions are demonstrated in the low neck proximal trachea just above the\n tracheostomy. The PICC line catheter tip is at the cavoatrial junction. The\n VP shunt is demonstrated crossing the chest wall anteriorly and right to the\n sternum. A gastrostomy is seen.\n\n The thyroid gland is diffusely enlarged, unchanged in this short-term\n interval. The aorta and the pulmonary arteries are unremarkable. The heart\n size is normal. There is minimal pericardial effusion but slightly increased\n compared to the prior study. There is interval development of bilateral\n pleural effusion, small to moderate, right slightly more than left.\n\n Coronary calcifications involve LAD.\n\n The imaged portion of the upper abdomen demonstrates a high-density lesion in\n the left lobe of the liver, 15 x 9 mm, seen on the prior study unchanged in\n the short-term interval, most likely representing hemangioma. The rest of the\n upper abdomen is unremarkable.\n\n Several mediastinal lymph nodes are not pathologically enlarged based on the\n size criteria, 7.6 cm in the right upper paratracheal, 8 cm in the right lower\n paratracheal, 9 mm in subcarinal area. The airways are patent to the level of\n subsegmental bronchi bilaterally. Bibasal consolidations are demonstrated,\n left more than right, that might represent a combination of relaxation\n atelectasis with aspiration/infection. Moderate-to- severe predominantly\n upper lobe emphysema is unchanged. Compared to the prior study there is\n interval development of the right upper lobe consolidation, 3:23, 29 as well\n as focal small consolidations and centrilobular nodules in the left upper\n (Over)\n\n 1:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for pna\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lobe, 3:29, as well as similar foci in the right lower lobe, 3:38 in addition\n to the above-described consolidations. Those findings are new compared to the\n prior study but the left lower lobe consolidation was already present back in\n . There is no evidence of failure. There are no focal lesions\n worrisome for malignancy.\n\n There are no bone lesions worrisome for malignancy or infection.\n\n IMPRESSION:\n\n 1. Interval progression of right upper lobe opacity consistent with\n developing pneumonia as well as basal consolidations. Newly developed\n bilateral small-to-moderate pleural effusion.\n\n 2. Moderate-to-severe emphysema predominantly affecting the upper lungs.\n .\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-20 00:00:00.000", "description": "CT CHEST W/CONTRAST", "row_id": 1056972, "text": ", NMED SICU-B 1:47 PM\n CT CHEST W/CONTRAST Clip # \n Reason: eval for pna\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n Contrast: OPTIRAY Amt: 75\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with ? worsening pna on CXR\n REASON FOR THIS EXAMINATION:\n eval for pna\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n PFI: Progression compared to the prior studies of multifocal consolidations.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058876, "text": ", NMED SICU-B 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusions\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with increasing pleural effusion\n REASON FOR THIS EXAMINATION:\n pleural effusions\n ______________________________________________________________________________\n PFI REPORT\n No significant change in small bilateral pleural effusions and left\n retrocardiac atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-19 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056640, "text": ", NMED SICU-B 3:18 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with failed extubation\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n PFI REPORT\n Interval increase in pulmonary edema. Unchanged bilateral pleural effusions.\n Left retrocardiac opacity might represent atelectasis or pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054843, "text": " 3:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sign of infiltrate?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with intracranial bleed\n REASON FOR THIS EXAMINATION:\n sign of infiltrate?\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Intracranial bleed, to evaluate for pneumonia.\n\n FINDINGS: In comparison with the study of , there is persistent prominence\n of ill-defined interstitial markings, consistent with volume overload.\n Obscuration of the left hemidiaphragm is again seen consistent with the\n previous description of a consolidation at the left base. Ill-defined patchy\n area of opacification in the right mid lung zone could also represent a region\n of consolidation. Tracheostomy tube remains in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1056390, "text": " 3:36 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o acute process\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man on trach mask\n REASON FOR THIS EXAMINATION:\n r/o acute process\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 4:50 PM\n Left pleural effusion with left lower lobe opacity slightly increased since\n yesterday, significantly increased since two days ago. Interstitial markings\n are still prominent, likely due to volume overload. Right upper lobe\n consolidation increased, could be pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 53-year-old man on tracheal mask. Rule out acute process.\n\n Since and , tracheostomy tube, PICC, PEG tube, and VP\n shunt are in unchanged position.\n\n Left pleural effusion with left lower lobe opacity increased, could be\n atelectasis or pneumonia. Right upper lobe consolidation also increased,\n could be due to right upper lobe pneumonia. Interstitial markings are still\n prominent, likely due to volume overload.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-27 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058209, "text": " 8:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man to be evaluated for change in consolidation.\n\n COMPARISON: .\n\n SINGLE FRONTAL CHEST RADIOGRAPH: There is improved aeration bilaterally with\n only residual air space opacity within the peripheral right mid lung. Note is\n made of approximately 1 cm central lucency within this area which just may be\n due to projection of superimposed cleared lungs. However, a cavitary lesion\n should be considered with the appropriate clinical history. The left\n retrocardiac opacity is stable and is probably atelectasis. The left\n costophrenic angle is excluded limiting evaluation for effusion. There is no\n definite effusion on the right.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055932, "text": ", NMED SICU-B 7:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: new VP shunt\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new VP shunt\n REASON FOR THIS EXAMINATION:\n new VP shunt\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Unchanged size of lateral ventricles with patency of the fourth ventricle.\n\n 2. Unchanged appearance of the left frontal hemorrhage, intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage. No new focus of\n hemorrhage is detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057169, "text": ", NMED SICU-B 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume status\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with HF\n REASON FOR THIS EXAMINATION:\n volume status\n ______________________________________________________________________________\n PFI REPORT\n Minimal improvement in the severity of pulmonary edema, which is still at\n least moderated. Bilateral pleural effusions and bibasilar consolidations.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055290, "text": ", NMED SICU-B 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u on LLL infiltrate\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with LLL infiltrate\n REASON FOR THIS EXAMINATION:\n f/u on LLL infiltrate\n ______________________________________________________________________________\n PFI REPORT\n Little change from before with increased left retrocardiac patchy opacity and\n generalized increased interstitial markings suggesting fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058875, "text": " 4:13 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pleural effusions\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with increasing pleural effusion\n REASON FOR THIS EXAMINATION:\n pleural effusions\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MPtb MON 11:45 AM\n No significant change in small bilateral pleural effusions and left\n retrocardiac atelectasis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with pleural effusion. Referred for assessment of\n change.\n\n COMPARISON: .\n\n AP PORTABLE CHEST: Tracheostomy tube in standard position. Right subclavian\n catheter terminates in the lower superior vena cava near the cavoatrial\n junction. No pneumothorax. Small bilateral pleural effusions not changed.\n Left retrocardiac opacity persists and is probably atelectasis. The bones are\n unchanged.\n\n IMPRESSION: No significant change in small bilateral pleural effusions and\n retrocardiac atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-14 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1055931, "text": " 7:14 PM\n CT HEAD W/O CONTRAST; -77 BY DIFFERENT PHYSICIAN # \n Reason: new VP shunt\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new VP shunt\n REASON FOR THIS EXAMINATION:\n new VP shunt\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): FBr 9:49 PM\n 1. Unchanged size of lateral ventricles with patency of the fourth ventricle.\n\n 2. Unchanged appearance of the left frontal hemorrhage, intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage. No new focus of\n hemorrhage is detected.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with new VP shunt.\n\n Comparison is made to the prior study of same day performed 10 hours earlier.\n\n NON-CONTRAST HEAD CT: There has been no interval change in the hemorrhage\n within the left side of the pons. Small bilateral intraventricular hemorrhage\n and subarachnoid hemorrhages appear unchanged. The size of lateral ventricles\n is unchanged. The right ventriculostomy drain terminates within the right\n lateral ventricle. No new focus of hemorrhage is detected. No major vascular\n territorial infarction is noted. Status post right frontal burr hole\n placement. Diffuse opacification of ethmoid and sphenoidal sinuses are noted.\n\n IMPRESSION:\n 1. Unchanged size of lateral ventricles with patency of the fourth ventricle.\n\n 2. Unchanged appearance of the left frontal hemorrhage, intraventricular\n hemorrhage and scattered foci of subarachnoid hemorrhage. No new focus of\n hemorrhage is detected.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057168, "text": " 11:53 AM\n CHEST (PORTABLE AP) Clip # \n Reason: volume status\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with HF\n REASON FOR THIS EXAMINATION:\n volume status\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): 2:16 PM\n Minimal improvement in the severity of pulmonary edema, which is still at\n least moderated. Bilateral pleural effusions and bibasilar consolidations.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of this patient with known pulmonary edema.\n\n COMPARISON: Chest radiograph from and chest CT from , .\n\n Compared to prior chest radiograph. In the chest CT, there is minimal\n interval improvement in the volume overload but the patient is still in\n pulmonary edema. Bilateral pleural effusions and bibasilar consolidations are\n unchanged. Cardiomediastinal silhouette is unchanged. The tracheostomy, the\n right PICC line and the VP shunt are again noted, as well as the PEG.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-22 00:00:00.000", "description": "BY SAME PHYSICIAN", "row_id": 1057385, "text": ", NMED SICU-B 1:31 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: atelectasis/mucus plug\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with VAP\n REASON FOR THIS EXAMINATION:\n atelectasis/mucus plug\n ______________________________________________________________________________\n PFI REPORT\n No interval change.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1055289, "text": " 4:22 AM\n CHEST (PORTABLE AP) Clip # \n Reason: f/u on LLL infiltrate\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with LLL infiltrate\n REASON FOR THIS EXAMINATION:\n f/u on LLL infiltrate\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DDBc WED 11:24 AM\n Little change from before with increased left retrocardiac patchy opacity and\n generalized increased interstitial markings suggesting fluid overload.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph timed at 4:22 on .\n\n INDICATION: Lower lobe infiltrates in the left side.\n\n COMPARISON: .\n\n REPORT:\n\n The ileostomy appears in good position. There is patchy airspace\n consolidation in the left lower zone, particularly changed from before.\n Background generalized increased interstitial markings. Again, this most\n likely reflects fluid overload. No pneumothorax. Little change from before.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-09 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 1054752, "text": ", NMED SICU-B 9:50 AM\n RENAL U.S. PORT Clip # \n Reason: evalute for hydronephrosis, other acute process\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage s/p EVD, with new elevated Cr. Patient\n has trach and is on ventilator\n REASON FOR THIS EXAMINATION:\n evalute for hydronephrosis, other acute process\n ______________________________________________________________________________\n PFI REPORT\n PFI: No hydronephrosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054325, "text": " 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with purulent sputum and intracranial bleed\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): MLKb 11:47 AM\n Interval worsening of LLL pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 53-year-old male with purulent sputum and intracranial bleed.\n Pneumonia ?\n\n COMPARISON: Prior chest radiograph on .\n\n PORTABLE AP CHEST RADIOGRAPH: Tracheostomy is in place with tip terminating\n 14 mm above the carina. There is interval worsening of the left lower lobe\n consolidation, probably pneumonia. There is a questionable opacity projecting\n in right upper lobe, that given severity of the emphysema noted in prior CT,\n could represent asymmetric edema or area of pneumonia. Cardiac size is normal.\n\n IMPRESSION:\n 1. Interval worsening of the left lower lobe pneumonia.\n 2. Questionable consolidation projecting in right upper lobe that given\n severity of emphysematous changes seen in the CT, this could represent\n area of asymmetric edema or area of pneumonia.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052857, "text": " 1:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for dobhoff position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n assess for dobhoff position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): SP TUE 2:52 PM\n Dobbhoff line placement successful. No complication.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST AP PORTABLE SINGLE VIEW.\n\n INDICATION: Status post Dobbhoff placement. Assess position.\n\n A Dobbhoff line has been placed and the distal metallic end is seen to have\n passed through the hiatus and is curving up in the fundus of the stomach. The\n patient remains intubated, the ETT in unchanged position in comparison with\n the preceding day's () examination. No pneumothorax has developed.\n\n IMPRESSION: Successful Dobbhoff line placement.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1054326, "text": ", NMED SICU-B 4:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with purulent sputum and intracranial bleed\n REASON FOR THIS EXAMINATION:\n pneumonia?\n ______________________________________________________________________________\n PFI REPORT\n Interval worsening of LLL pneumonia.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1052858, "text": ", NMED SICU-B 1:03 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: assess for dobhoff position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man s/p dobhoff placement\n REASON FOR THIS EXAMINATION:\n assess for dobhoff position\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff line placement successful. No complication.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053259, "text": " 1:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate dobhoff position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage, with Dobhoff tube, came out slightly\n during transport\n REASON FOR THIS EXAMINATION:\n evaluate dobhoff position\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JKSd FRI 8:05 PM\n Dobbhoff tip at the mid esophagus and should be advanced. Otherwise, no\n significant changes since prior study.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 53-year-old man with pontine hemorrhage, with Dobbhoff tube which\n came out slightly during transportation. Evaluate Dobbhoff position.\n\n COMPARISON: Multiple chest radiographs, most recent of one hour prior.\n\n TECHNIQUE: Portable AP view of the chest.\n\n FINDINGS: The Dobbhoff tube tip is seen in the mid esophagus. The\n endotracheal tube is appropriately positioned, unchanged. The lungs remain\n clear. The cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: Dobbhoff tube tip at the mid esophagus and should be advanced.\n Otherwise, no significant changes since prior study.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-31 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053260, "text": ", NMED SICU-B 1:25 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: evaluate dobhoff position\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage, with Dobhoff tube, came out slightly\n during transport\n REASON FOR THIS EXAMINATION:\n evaluate dobhoff position\n ______________________________________________________________________________\n PFI REPORT\n Dobbhoff tip at the mid esophagus and should be advanced. Otherwise, no\n significant changes since prior study.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1053383, "text": ", NMED SICU-B 10:56 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: ASYMETIC LEGS ,EVAL FOR DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HPI: 53M presented to this morning with complaint of left sided\n headache followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Incidental 2mm aneurysm of right basilar\n artery.Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee, just\n lifting it off the bed. He is not moving the right voluntarily. He withdraws in\n all four extremities, left side more briskly than right.\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PFI REPORT\n No lower extremity DVT.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053463, "text": " 4:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate in patient with productive secretions\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n .HPI: 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing pontine SAH\n with IVH in left lateral ventricle. Incidental 2mm aneurysm of right basilar\n artery.Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee, just\n lifting it off the bed. He is not moving the right voluntarily. He withdraws in\n all four extremities, left side more briskly than right.\n REASON FOR THIS EXAMINATION:\n r/o infiltrate in patient with productive secretions\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Headache.\n\n A single portable radiograph of the chest demonstrates a similar\n cardiomediastinal contour to that seen on . Support lines are\n unchanged. There is worsening airspace opacity involving both lungs. No\n pneumothorax. The left costophrenic angle is excluded. Trachea is midline.\n\n IMPRESSION:\n\n Worsening airspace opacities involving both lungs. Finding represents\n worsening pulmonary edema.\n\n Support lines in place.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1053085, "text": " 2:46 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval pulm edema/effusion\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine SAH. Intubated.\n REASON FOR THIS EXAMINATION:\n eval pulm edema/effusion\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Effusion.\n\n A single portable radiograph of the chest demonstrates no interval change in\n the support lines seen on . Cardiomediastinal contours are similar\n in appearance. The lungs are clear. There may be a small left-sided pleural\n effusion. The right costophrenic angle is sharp. No consolidation is\n identified. No pneumothorax is seen. Trachea is midline.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-01 00:00:00.000", "description": "P BILAT LOWER EXT VEINS PORT", "row_id": 1053382, "text": " 10:56 AM\n BILAT LOWER EXT VEINS PORT Clip # \n Reason: ASYMETIC LEGS ,EVAL FOR DVT\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n HPI: 53M presented to this morning with complaint of left sided\n headache followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Incidental 2mm aneurysm of right basilar\n artery.Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee, just\n lifting it off the bed. He is not moving the right voluntarily. He withdraws in\n all four extremities, left side more briskly than right.\n REASON FOR THIS EXAMINATION:\n r/o dvt\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp SAT 8:22 PM\n No lower extremity DVT.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Query DVT.\n\n BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND: -scale and color Doppler\n son images were obtained that demonstrate wall-to-wall normal\n compression of the bilateral common femoral, greater saphenous, superficial\n femoral and popliteal veins, with normal response to respiration and\n augmentation. Calf veins are demonstrated bilaterally.\n\n IMPRESSION: No DVT of the lower extremities.\n\n\n" }, { "category": "Radiology", "chartdate": "2156-12-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1052735, "text": " 7:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate post bedside EVD placement.\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate post bedside EVD placement.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): GWp MON 11:08 PM\n 1. Status post right frontal approach ventriculostomy catheter with new\n subarachnoid and more prominent intraventricular hemorrhage and\n pneumocephalus, likely sequelae.\n\n 2. Unchanged appearance of the hemorrhage in the pons and medulla and\n prepontine subarachnoid hemorrhage.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Evaluate post-bedside EVD placement.\n\n COMPARISON: , at 1300.\n\n NON-CONTRAST HEAD CT: There has been interval placement of a right\n transfrontal approach ventriculostomy catheter with its tip in the right\n lateral ventricle. More prominent layering intraventricular hemorrhage and\n subarachnoid blood in the frontal sulci, bilaterally, may be secondary to the\n procedure or simply represent redistribution of prior extensive hemorrhage.\n There is pneumocephalus. The pontine and medullary parenchymal hemorrhage\n appears unchanged as does subarachnoid blood in the cisterns at the base of\n the brain. The lateral ventricular bodies are unchanged in size and shape\n since the recent study.\n\n Other than the right frontal burr hole transmitting the EVD, the osseous\n structures are unremarkable. Mastoid air cells and paranasal sinuses appear\n clear.\n\n IMPRESSION:\n\n 1. Interval placement of right frontal approach ventriculostomy catheter with\n frontal pneumocephalus and subarachnoid blood, likely secondary to this\n procedure.\n\n 2. Unchanged appearance of remaining extensive subarachnoid and\n pontomedullary parenchymal hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2156-12-27 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1052736, "text": ", NMED SICU-B 7:54 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate post bedside EVD placement.\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n please evaluate post bedside EVD placement.\n No contraindications for IV contrast\n ______________________________________________________________________________\n PFI REPORT\n 1. Status post right frontal approach ventriculostomy catheter with new\n subarachnoid and more prominent intraventricular hemorrhage and\n pneumocephalus, likely sequelae.\n\n 2. Unchanged appearance of the hemorrhage in the pons and medulla and\n prepontine subarachnoid hemorrhage.\n\n" }, { "category": "Radiology", "chartdate": "2157-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1060200, "text": " 3:32 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ?worsening infection\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old vented man with increased crackles on auscultation\n REASON FOR THIS EXAMINATION:\n ?worsening infection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Infection.\n\n A single portable radiograph of the chest demonstrates a persistent small\n left-sided pleural effusion. Support lines are unchanged from .\n There is persistent mild bibasilar atelectasis. The right mid lung opacity\n questioned on the previous chest radiograph is no longer evident and was\n likely external to the patient. Overall, there is little interval change in\n the appearance of the pulmonary parenchyma.\n\n\n" }, { "category": "ECG", "chartdate": "2156-12-27 00:00:00.000", "description": "Report", "row_id": 240099, "text": "Sinus rhythm\nST-T wave configuartion suggests in part early repolarization pattern/normal\nvariant but clinical correlation is suggested\nNo previous tracing available for comparison\n\n" }, { "category": "Radiology", "chartdate": "2157-01-25 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057689, "text": " 12:31 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for change in consolidation\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval for change in consolidation\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To evaluate for change in consolidation.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. Cardiomediastinal contours are stable. Patchy right\n upper lobe opacity is again seen, presumably related to infection as suggested\n on the recent CT scan. More symmetric bilateral perihilar and basilar\n opacities may reflect pulmonary edema with layering of bilateral pleural\n effusions.\n\n IMPRESSION: Little overall change.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057322, "text": " 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): DLnc SAT 9:34 AM\n Significant interval improvement of pulmonary edema. Still present but\n decreased bilateral pleural effusion. Patchy opacities consistent with known\n areas of infection.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Followup of a patient with pneumonia.\n\n Portable AP chest radiograph was compared to .\n\n The tracheostomy tip is at the midline. The right PICC line tip is in mid\n distal SVC. The PEG is in place. The cardiomediastinal silhouette is stable.\n There is interval improvement in pulmonary edema with still present bibasal\n opacities that might represent residuals of effusion in combination with\n multifocal pneumonia. Bilateral pleural effusions have also decreased.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-22 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057323, "text": ", NMED SICU-B 4:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: pneumonia\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pneumonia\n REASON FOR THIS EXAMINATION:\n pneumonia\n ______________________________________________________________________________\n PFI REPORT\n Significant interval improvement of pulmonary edema. Still present but\n decreased bilateral pleural effusion. Patchy opacities consistent with known\n areas of infection.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058451, "text": ", NMED SICU-B 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PFI REPORT\n No significant change.\n\n" }, { "category": "Radiology", "chartdate": "2157-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059908, "text": " 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progress of PNA?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with klebsiella PNA\n REASON FOR THIS EXAMINATION:\n Progress of PNA?\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 2:25 PM\n PFI: Left lower lobe opacity significantly improved. Bibasilar opacity\n persists, likely atelectasis. No other change.\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAM: 53-year-old man with Klebsiella pneumonia, evaluate\n progression.\n\n Since , left retrocardiac opacity significantly improved.\n Minimal bibasilar opacity persists, likely atelectasis. A tracheostomy tube\n ends in expected position. A VP shunt and right PICC are also in unchanged\n position. A PEG tube is in place.\n\n Right mid lung opacity is likely due to overlying tubes on the patient chest.\n\n On the next followup study, please remove as much as possible overlying lines\n and tubes for better assessment of lung fields.\n\n" }, { "category": "Radiology", "chartdate": "2157-02-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1059909, "text": ", NMED SICU-B 11:58 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Progress of PNA?\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with klebsiella PNA\n REASON FOR THIS EXAMINATION:\n Progress of PNA?\n ______________________________________________________________________________\n PFI REPORT\n PFI: Left lower lobe opacity significantly improved. Bibasilar opacity\n persists, likely atelectasis. No other change.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1057460, "text": " 4:24 AM\n CHEST (PORTABLE AP) Clip # \n Reason: worsening PNA\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with new PNA\n REASON FOR THIS EXAMINATION:\n worsening PNA\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST\n\n COMPARISON: .\n\n INDICATION: Pneumonia.\n\n Indwelling devices are unchanged. Cardiomediastinal contours are stable.\n Patchy peripheral right upper lobe opacity, presumably due to infection based\n on recent CT. More symmetrical perihilar and basilar opacities may represent\n a component of pulmonary edema, and there are also layering bilateral pleural\n effusions. Overall, the exam shows a similar appearance to recent study\n except for slight improved aeration in left retrocardiac region.\n\n" }, { "category": "Radiology", "chartdate": "2157-01-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1058450, "text": " 10:54 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with\n REASON FOR THIS EXAMINATION:\n eval for interval change\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): LCpc 5:29 PM\n No significant change.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST PORTABLE AP\n\n REASON FOR EXAM: 53-year-old man with interval change.\n\n A percutaneous gastrostomy tube is in place. Since yesterday, the\n tracheostomy tube has been changed and is in expected position. Right PICC\n ends in the cavoatrial junction. A ventriculoperitoneal shunt is present with\n its tip not imaged on this study.\n\n Right-sided cavitary lesion is not seen today, was probably artifactual.\n Multifocal parenchymal opacities are unchanged, with no new area of\n consolidation. Emphysema is unchanged. Minimal bilateral pleural effusions\n are overall unchanged, given the suboptimal technique on the prior study,\n probably slightly improving since .\n\n" }, { "category": "Radiology", "chartdate": "2157-01-23 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1057542, "text": " 5:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal infectious process to explain fevers\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage, fevers to 103, ? abd pain\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal infectious process to explain fevers\n CONTRAINDICATIONS for IV CONTRAST:\n Cr 1.4\n ______________________________________________________________________________\n PROVISIONAL FINDINGS IMPRESSION (PFI): JRCi 8:27 PM\n PFI: Bibasilar consolidations consistent with pneumonia versus aspiration.\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT abdomen and pelvis with contrast and reconstructions.\n\n INDICATION: Pontine hemorrhage with fevers and abdominal pain.\n\n COMPARISON: CT torso.\n\n TECHNIQUE: MDCT axially acquired images were obtained from the lung bases to\n the symphysis after the uneventful intravenous administration of 130 cc\n Optiray 350 contrast material. Multiplanar reformatted images were obtained\n and reviewed.\n\n CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: Bibasilar patchy consolidations\n are present consistent with pneumonia, possibly aspiration. Small bilateral\n pleural effusions noted. There is a trace pericardial effusion.\n\n Homogeneously enhancing 2-cm lesion within segment III of the liver is again\n demonstrated which is nonspecific but may represent a hemangioma. The\n remainder of the liver appears unremarkable. Tiny gallstones are present\n within the gallbladder without pericholecystic fluid or wall thickening to\n suggest acute cholecystitis. A percutaneous abdominal drain is identified\n along the outer aspect of the liver with tip terminating in the lower right\n abdomen. A gastrostomy tube is present within the gastric lumen without\n abnormality identified. The pancreas, spleen, adrenal glands, abdominal large\n and small bowel appear unremarkable. The kidneys enhance and excrete\n symmetrically without focal mass lesion identified. Moderate calcified\n atherosclerotic plaque is present within the abdominal aorta and iliac\n branches without aneurysmal dilatation. No free fluid or free air is present\n within the abdomen. No focal fluid collections are detected. Small amount of\n stranding is noted surrounding the distal aspect of the intra-abdominal drain.\n No wall thickening is present to suggest colitis. Mixing of oral contrast and\n colonic material in the ascending colon. Significant narrowing of the proximal\n SMA is noted (series 2; image 26) and is unchanged.\n\n CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: The bladder is collapsed around\n a Foley catheter. Prostate gland is mildly enlarged measuring 4.4 cm in\n greatest transverse dimension. The rectum, sigmoid colon and opacified loops\n of small bowel are unremarkable without evidence of obstruction.\n (Over)\n\n 5:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal infectious process to explain fevers\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions identified.\n Degenerative changes are most notable at the L5-S1 level with intervertebral\n body disc space narrowing and vacuum phenomenon. There is moderate neural\n foraminal narrowing at L5-S1 bilaterally.\n\n IMPRESSION:\n\n 1. Bibasilar consolidations consistent with pneumonia. Aspiration may also\n be considered.\n\n 2. Small pleural effusions bilaterally.\n\n 3. 2-cm enhancing lesion within the left lobe of the liver which is not fully\n characterized, however may represent a hemangioma.\n\n 4. Cholelithiasis.\n\n 5. Atheromatous plaque within the abdominal aorta without aneurysmal\n dilatation. Unchanged significant narrowing of the proximal SMA likely due to\n athlerosclerosis.\n\n\n" }, { "category": "Radiology", "chartdate": "2157-01-23 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1057543, "text": ", NMED SICU-B 5:03 PM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: eval for intraabdominal infectious process to explain fevers\n Admitting Diagnosis: STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 53 year old man with pontine hemorrhage, fevers to 103, ? abd pain\n REASON FOR THIS EXAMINATION:\n eval for intraabdominal infectious process to explain fevers\n CONTRAINDICATIONS for IV CONTRAST:\n Cr 1.4\n ______________________________________________________________________________\n PFI REPORT\n PFI: Bibasilar consolidations consistent with pneumonia versus aspiration.\n\n" }, { "category": "Physician ", "chartdate": "2157-01-05 00:00:00.000", "description": "Intensivist Note", "row_id": 652057, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:15 PM\n INSERTION - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 05:56 PM\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:15 PM\n Fentanyl - 04:00 PM\n Famotidine (Pepcid) - 08:08 PM\n Heparin Sodium (Prophylaxis) - 01:09 AM\n Hydralazine - 01:09 AM\n Labetalol - 04:03 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: 38\nC (100.4\n T current: 36.7\nC (98.1\n HR: 110 (87 - 111) bpm\n BP: 188/80(83) {114/55(78) - 193/94(132)} mmHg\n RR: 16 (14 - 26) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (1 - 23) mmHg\n Total In:\n 3,666 mL\n 650 mL\n PO:\n Tube feeding:\n 4 mL\n IV Fluid:\n 3,182 mL\n 540 mL\n Blood products:\n Total out:\n 1,711 mL\n 545 mL\n Urine:\n 1,370 mL\n 475 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 191 mL\n 70 mL\n Balance:\n 1,955 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 574 (574 - 574) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SPO2: 94%\n ABG: 7.45/40/160/27/4\n Ve: 6.9 L/min\n PaO2 / FiO2: 400\n Physical Examination\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 100 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n WBC\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 147\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 27\n 32\n 28\n 29\n Glucose\n 125\n 120\n 159\n 122\n 78\n 105\n 100\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: s/p angio which revealed right vertebral artery occlusion,\n no intervention; Dilantin therapeutic; MRI and repeat head CTs done -\n no sig interval changes; s/p drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; f/u CSF\n cxs, csf with wbc\ns, vanco started by neuromed\n Cardiovascular: goal SBP<160mmHg; lopressor75 TID, labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: CPAP+PS trach, poor mental status\n Gastrointestinal / Abdomen: s/p , restart TF today\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: no issues\n Endocrine: RISS\n Infectious Disease: Vanco for WBCs in CSF, Diflucan for yeast, Ancef\n should stop\n Lines / Tubes / Drains: trach, foley, a-line, , \n Wounds: ,,trach site clean\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: place PICC\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 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: 35 minutes\n" }, { "category": "Nutrition", "chartdate": "2157-01-03 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 651692, "text": "Pertinent medications: lasix, IV abx, MVI, thiamine, folic acid,\n famotidine, others noted\n Labs:\n Value\n Date\n Glucose\n 78 mg/dL\n 03:27 AM\n Glucose Finger Stick\n 141\n 12:00 PM\n BUN\n 19 mg/dL\n 03:27 AM\n Creatinine\n 0.6 mg/dL\n 03:27 AM\n Sodium\n 134 mEq/L\n 03:27 AM\n Potassium\n 3.6 mEq/L\n 03:27 AM\n Chloride\n 99 mEq/L\n 03:27 AM\n TCO2\n 28 mEq/L\n 03:27 AM\n PO2 (arterial)\n 135 mm Hg\n 04:41 AM\n PCO2 (arterial)\n 38 mm Hg\n 04:41 AM\n pH (arterial)\n 7.47 units\n 04:41 AM\n pH (urine)\n 5.0 units\n 09:53 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 04:41 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 8.1 mg/dL\n 03:27 AM\n Phosphorus\n 2.6 mg/dL\n 03:27 AM\n Ionized Calcium\n 1.16 mmol/L\n 04:41 AM\n Magnesium\n 2.3 mg/dL\n 03:27 AM\n Phenytoin (Dilantin)\n 15.3 ug/mL\n 03:27 AM\n WBC\n 12.4 K/uL\n 03:27 AM\n Hgb\n 11.2 g/dL\n 03:27 AM\n Hematocrit\n 31.5 %\n 03:27 AM\n Current diet order / nutrition support: Replete with Fiber @ 60 ml/hr\n (1440 kcals/ 89 g pro)\n GI: soft, +BS\n Assessment of Nutritional Status\n Specifics: Pt was tolerating TF until held for angio. TF restarted\n after procedure, propofol currently provides 317 kcals and is being\n weaned. Once propofol off recommend increasing TF to Replete with Fiber\n @ 65 ml/hr to provide 1560 kcals/ 97 g pro to better meet nutritional\n needs. Noted plan for possible PEG.\n Medical Nutrition Therapy Plan - Recommend the Following\n Change TF goal rate to Replete with Fiber @ 65 ml/hr once propofol off\n Monitor TF tolerance\n BG and lyte management as you already are\n Will continue to follow pls page with questions \n" }, { "category": "Respiratory ", "chartdate": "2157-01-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651694, "text": "Demographics\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 21 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: 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 on A/C ventilation w/ PIP/Pplat = 20/16. No vent\n changes made this shift.\n Assessment of breathing comfort: No claim of dyspnea\n Trigger work assessment: Not triggering\n Plan\n Next 24-48 hours: maintain support\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n 0900\n no complications.\n" }, { "category": "Nursing", "chartdate": "2157-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651928, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with pontine bleed, ventriculostomy drain in place, remains\n intubated for airway protection. See flowsheet for assessment.\n Action:\n Vent drain initially clamped, ICP increased, Neuro /med informed\n Response:\n ICP now back to previous levels, straw colored drainage, no change in\n neuro status\n Plan:\n For Head CT at 5am, Trach today, consent gained from pt\ns cousin.\n" }, { "category": "Physician ", "chartdate": "2157-01-02 00:00:00.000", "description": "Intensivist Note", "row_id": 651381, "text": "SICU\n HPI:\n HPI: 53M presented to this morning with complaint of\n left sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n altered mental status\n PMHx:\n PMH: ?HTN\n : Flonase\n .\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. Fluconazole\n 12. Fluconazole 13. FoLIC Acid 14. HydrALAzine 15. Insulin 16.\n Influenza Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. Nimodipine 23. NiCARdipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n FEVER - 102.6\nF - 12:00 PM\n : admit to sicu, EVD placed, A-line placed; pt pancx'd for low\n grade temp; to Xray/MRI (requested by neurosurg)\n : extubated -> failed due to mucous plugging; reintubated; started\n on CIWA scale;\n : no gag. planning for trach/peg; TF started. repeat CT head\n stable. ween FiO2 to 40%\n 12/25: still weak gag/cough. Optho consulted. Increased lopressor,\n hydral.\n : CT head done showing no change, CSF studies done prot 87, gluc\n 75, RBC , 0 WBC, no microorgs; Dobhoff replaced (fell out in CT);\n pt pan cx'd for high fever 103, U/A neg; restarted propofol\n : CT scan negative for fever source, BLE dopplers negative, oral\n BP meds added, fluconazole added,\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 12:08 PM\n Cefazolin - 02:59 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 37.8\nC (100\n HR: 95 (82 - 123) bpm\n BP: 159/75(105) {79/49(60) - 159/75(105)} mmHg\n RR: 17 (13 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (6 - 43) mmHg\n Total In:\n 3,940 mL\n 483 mL\n PO:\n Tube feeding:\n 1,441 mL\n 294 mL\n IV Fluid:\n 1,009 mL\n 189 mL\n Blood products:\n Total out:\n 1,567 mL\n 213 mL\n Urine:\n 1,336 mL\n 195 mL\n NG:\n Stool:\n Drains:\n 231 mL\n 18 mL\n Balance:\n 2,373 mL\n 270 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): 18\n RR (Spontaneous): 5\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n Compliance: 83.3 cmH2O/mL\n SPO2: 97%\n ABG: ///27/\n Ve: 14.4 L/min\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished:\n bilaterally at the bases)\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), Sedated\n Labs / Radiology\n 171 K/uL\n 12.4 g/dL\n 122 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 100 mEq/L\n 133 mEq/L\n 34.6 %\n 16.9 K/uL\n [image002.jpg]\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n Plt\n 141\n 127\n 147\n 159\n 171\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 28\n 27\n 32\n 28\n Glucose\n 116\n 139\n 138\n 125\n 120\n 159\n 122\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.5 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: Neuro checks Q: 2 hr, Ventriculostomy, Dilantin\n therapeutic; s/p EVD drain placement; neurosurg/neurology following;\n versed PRN/propofol gtt for sedation; nimodipine; having fevers, f/u\n CSF cxs; pt having hiccups, likely central in origin, trial of reglan\n yesterday\n Cardiovascular: Beta-blocker, SBP<140mmHg; lopressor25''', labetalol\n prn, hydral 50''''; nimotop 60q4, back on nicardipine GTT\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status, trach/peg likely Monday/Tuesday\n Gastrointestinal / Abdomen: peg likely Monday/Tuesday, TF at goal\n Nutrition: Tube feeding, peg likely Monday/Tuesday, TF at goal\n TF started; Replete with fiber Full strength goal 60\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, fluc, on ancef for EVD, f/u cx's,\n WBC count (having fevers)\n Lines / Tubes / Drains: Foley, ETT, ETT, foley, a-line, EVD, dobhoff\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids:\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure), Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:56 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-01-04 00:00:00.000", "description": "Intensivist Note", "row_id": 651793, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine SAH with LVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tears 5. Calcium\n Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Enalapril Maleate 10. Erythromycin 0.5%\n Ophth Oint 11. Famotidine\n 12. Fluconazole 13. FoLIC Acid 14. Furosemide 15. Insulin 16. Influenza\n Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. NiCARdipine 23. Nimodipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n ANGIOGRAPHY - At 09:00 AM\n In IR for cerebral ango for diagnostics from 0900-1200\n FEVER - 101.5\nF - 04:00 AM\n - went for angio - right vertebral artery occlusion but no intervention\n - consent obtained for trach/peg\n Post operative day:\n HD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Cefazolin - 08:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 AM\n Other medications:\n Flowsheet Data as of 05:50 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: 38.6\nC (101.5\n HR: 101 (89 - 107) bpm\n BP: 122/57(78) {95/52(66) - 184/94(129)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (10 - 22) mmHg\n Total In:\n 2,341 mL\n 530 mL\n PO:\n Tube feeding:\n 540 mL\n 4 mL\n IV Fluid:\n 1,201 mL\n 406 mL\n Blood products:\n Total out:\n 2,514 mL\n 238 mL\n Urine:\n 2,355 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 159 mL\n 38 mL\n Balance:\n -173 mL\n 292 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 90%\n ABG: ///28/\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated/sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated, follows commands\n very sporadically, weak cough/gag, few purposeful movements\n Labs / Radiology\n 260 K/uL\n 10.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 18 mg/dL\n 99 mEq/L\n 133 mEq/L\n 29.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n 260\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n 78\n 105\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53 yo M with pontine SAH and left ventricle IVH\n with persistent resp failure.\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, ICP monitor,\n Ventriculostomy, s/p angio which revealed right vertebral artery\n occlusion, no intervention done; versed PRN/propofol gtt for sedation;\n nimodipine for vasospasm; f/u CSF cxs; ICP up o/n, ventric drain\n unclamped, f/u head CT results\n Cardiovascular: goal SBP<160mmHg; lopressor75 , labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, unable to extubate as weak gag, poor mental status,\n trach/peg d/w HCP, consent obtained\n Gastrointestinal / Abdomen: peg today, TF being held\n Nutrition: TF started; currently held, when OK to restart - Replete\n with fiber Full strength goal 60\n Renal: Foley, Adequate UO, no issues\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS, FS well controlled\n Infectious Disease: Check cultures, on ancef for EVD; WBC count\n trending down; fluc for yeast on sputum\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, a-line, place trach today\n Wounds:\n Imaging: CT scan head today\n Fluids: NS, 60 cc/hr while NPO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 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": "2157-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652430, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam inconsistent, less responsive with elevated temp.\n ICP 6-13\n Action:\n Head Ct done this evening d/t pt not following any commands\n Q2 neuro assessments\n NMED HO notified of all neuro changes overnight\n Response:\n Head CT without change\n Plan:\n NMED feels that exam in inconsistent and not related to worsening\n bleed. Cont on Q2 neuro exams, notify neurology with changes in exam\n and cont to monitor ICP and notify NSURG with elevated ICP\n Hypertension, benign\n Assessment:\n SBP goal <160\n BP labile\n Action:\n On nimodipine, lopressor, hydralizine, and vasotec po\n Nicardipine gtt on/off overnight to maintain BP goal\n Response:\n BP remains < 160\n Plan:\n Cont on gtt until stable on PO regimen\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on CMV 40% 500x15 peep 5\n Breaths over vent\n Mod amt thick/frothy yellow-brown secretions\n Action:\n Freq sxn\n Follow aBG\n Response:\n Adequate oxygenation/ventilation\n No distress\n Plan:\n Cont to monitor\n Left eye infection\n Assessment:\n Left eye reddened\n Pupil difficult to assess\n Action:\n Q1 artificial tears\n Bacitracion ointment\n Cipro drops\n Attempted to tape eye shut\n Response:\n Unable to keep eye shut with paper tape, no silk tape used d/t need for\n freq drops. SICU HO notified and artificial tear ointment ordered to\n increase lubrication if eye opening.\n Plan:\n Cont to monitor closely.\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652598, "text": "Hypotension (not Shock)\n Assessment:\n SBP 80\ns sustaining x 3 hrs\n More lethargic with decreased BP\n U/o dropping off after several hours\n Action:\n Dr (SICU) and neurology HO notified and aware of all BP trends\n Nicardipine previously shut off\n All antihypertensives held\n Lasix held\n HOB to 15 to maintain SBP >80\n NS bolus given (SICU HO notified neurology)\n Response:\n SBP sustaining >100 after bolus\n U/o remains marginal\n Plan:\n Cont to hold all antiypertensives, monitor bp closely, notify SICU HO\n and neurology of all changes in BP.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n NA 125 this evening, up to 127 at 2200\n Action:\n Cont on fluid restriction, NS flush with meds, 3% saline at 20cc x 20\n hrs.\n Response:\n Na correcting slowly\n Plan:\n Cont with current plan and monitor Q6 NA level.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n More difficult to arouse, not following commands since initial\n assessment. Minimal spontaneous movment noted. No changes in strength\n or pupils.\n Action:\n Dr (SICU) and Dr ( NMED) notifed change in exam.\n Response:\n Dr up to assess and felt no acute change.\n Plan:\n Cont to monitor closely.\n Corneal Abrasion\n Assessment:\n Left eye with +corneal abrasion, sutured partially shut. Unable to\n fully shut with tape.\n Action:\n Artificial tears Q1 hr, bacitracian ointment Q6 hrs\n Response:\n No change\n Plan:\n Cont with current plant, ophthalmology following closely.\n" }, { "category": "Physician ", "chartdate": "2157-01-03 00:00:00.000", "description": "Intensivist Note", "row_id": 651647, "text": "SICU\n HPI:\n 53M presented with pontine SAH with IVH in left lateral ventricle\n Chief complaint:\n pontine SAH with IVH in left lateral ventricle\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n FEVER - 101.4\nF - 11:00 PM\n Post operative day:\n HD8\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:41 AM\n Cefazolin - 08:47 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.1\nC (100.6\n HR: 91 (75 - 105) bpm\n BP: 139/67(92) {81/47(65) - 158/76(105)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (5 - 16) mmHg\n Total In:\n 2,605 mL\n 321 mL\n PO:\n Tube feeding:\n 1,444 mL\n IV Fluid:\n 822 mL\n 321 mL\n Blood products:\n Total out:\n 1,506 mL\n 275 mL\n Urine:\n 1,300 mL\n 235 mL\n NG:\n Stool:\n Drains:\n 206 mL\n 40 mL\n Balance:\n 1,099 mL\n 46 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), left UE and Left LE\n withdraws weakly to pain\n Labs / Radiology\n 193 K/uL\n 11.2 g/dL\n 78 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 100 mEq/L\n 133 mEq/L\n 31.5 %\n 12.4 K/uL\n [image002.jpg]\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.1 mg/dL,\n Mg:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53M presented with pontine SAH with IVH in left\n lateral ventricle\n Neurologic: Dilantin therapeutic; MRI and repeat head CTs done - no sig\n interval changes; s/p EVD drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; having\n fevers, f/u CSF cxs; pt having hiccups, likely central in origin; for\n angio \n Cardiovascular: SBP<160mmHg; lopressor75 , labetalol prn, hydral\n PRN; nimotop 60q4\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status, Trach has been d/w family\n Gastrointestinal / Abdomen: will likely need PEG\n Nutrition: Tube feeding, hold at midnight\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS, t/c starting NPH after procedure today.\n Infectious Disease: on ancef for EVD, f/u cx's, WBC count (having\n fevers); fluconazole for yeast on sputum\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobhoff\n Wounds: none\n Imaging: angio\n Fluids: NS @ 60 while npo\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: ICU consent signed Comments: cousin will be\n spokesperson for pt.\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-03 00:00:00.000", "description": "Intensivist Note", "row_id": 651652, "text": "SICU\n HPI:\n 53M presented with pontine SAH with IVH in left lateral ventricle\n Chief complaint:\n pontine SAH with IVH in left lateral ventricle\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n FEVER - 101.4\nF - 11:00 PM\n Post operative day:\n HD8\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:41 AM\n Cefazolin - 08:47 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.1\nC (100.6\n HR: 91 (75 - 105) bpm\n BP: 139/67(92) {81/47(65) - 158/76(105)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (5 - 16) mmHg\n Total In:\n 2,605 mL\n 321 mL\n PO:\n Tube feeding:\n 1,444 mL\n IV Fluid:\n 822 mL\n 321 mL\n Blood products:\n Total out:\n 1,506 mL\n 275 mL\n Urine:\n 1,300 mL\n 235 mL\n NG:\n Stool:\n Drains:\n 206 mL\n 40 mL\n Balance:\n 1,099 mL\n 46 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), left UE and Left LE\n withdraws weakly to pain\n Labs / Radiology\n 193 K/uL\n 11.2 g/dL\n 78 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 100 mEq/L\n 133 mEq/L\n 31.5 %\n 12.4 K/uL\n [image002.jpg]\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.1 mg/dL,\n Mg:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53M presented with pontine SAH with IVH in left\n lateral ventricle\n Neurologic: Dilantin therapeutic; MRI and repeat head CTs done - no sig\n interval changes; s/p EVD drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; having\n fevers, f/u CSF cxs; pt having hiccups, likely central in origin; for\n angio \n Cardiovascular: SBP<160mmHg; lopressor75 , labetalol prn, hydral\n PRN; nimotop 60q4\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status, Trach has been d/w family\n Gastrointestinal / Abdomen: will likely need PEG\n Nutrition: Tube feeding, hold at midnight\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS, t/c starting NPH after procedure today.\n Infectious Disease: on ancef for EVD, f/u cx's, WBC count (having\n fevers); fluconazole for yeast on sputum\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobhoff\n Wounds: none\n Imaging: angio\n Fluids: NS @ 60 while npo\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: ICU consent signed Comments: cousin will be\n spokesperson for pt.\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651728, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains with moderate thick secretions. Weak gag and cough noted.\n Action:\n Per SICU team, pt planned for placement of trach and ? PEG tomorrow.\n Response:\n Plan:\n Consent needed. NPO after midnight.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt in Neuro Angio this am from 0900-1200. Per Procedure Note, pt noted\n to have proximal R Vertebral occlusion. Pts neuro status unchanged.\n At 1600 Neurosurgery orders ventricular drain to be clamped.\n Action:\n Sheath removed in SICU by Resident. Angio post-procedure precautions\n and monitoring as ordered x 2 hours. R groin site intact, no hematoma\n noted.\n Response:\n Pt tolerated procedure well. Tolerating ventricular drain clamped.\n Plan:\n Continue to monitor ICPs. ICP sustained over 20 to be reported to\n Neurodurgery.\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651965, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Action:\n Trach suction q4hr and oral suction q2hr\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions.\n Plan:\n Cont. to suction patient. Wean vent as tolerated\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177.\n Action:\n Hydralalize 10mg given IVP\n Response:\n BP decreased to 140/60\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n" }, { "category": "Nursing", "chartdate": "2157-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652552, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n With Neurosurgery Team at bedside, pt able to appropriately nod yes/no\n to orientation questions. Nodded yes appropriately to name and place.\n Following basic commands. Using L UE and L LE appropriately and\n spontaneously. Remained alert and obeyed commands with PT when dangled\n at bedside.\n Action:\n Continue neuro checks Q2 hours.\n Response:\n Pt intermittent with participation of neuro exam.\n Plan:\n Continue Q 2 hour neuro checks. Alert SICU and Neurosurgical Team with\n any acute changes.\n Hypertension, benign\n Assessment:\n Continued on Nicardipine gtt at 0.5 mcg/kg/min.\n Action:\n Monitoring via ABP.\n Response:\n Maintaining SBP < 160.\n Plan:\n Continue Nicardipine PRN\n Intracerebral hemorrhage (ICH)\n Assessment:\n MD , pt\ns EVD to remain open at 20cm above the tragus.\n Action:\n Continues to produce straw color csf.\n Response:\n Pt\ns ICP remains < 15 when EVD is open.\n Plan:\n If CSF is greater than 100 ml per 24 hour period throughout w/e\n? VP\n Shunt to be placed. Also awaiting pt to become afebrile.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains with copious amounts of yellow, thick secretions. Clear to\n Rhonchi BS.\n Action:\n Suctioning oral and subglottal hourly. Turning and repositioning Q2\n hours.\n Response:\n Continues to need ATC suctioning.\n Plan:\n Placed on a rate control on Ventilator to assist with easing RR r/t\n constant hiccups.\n" }, { "category": "Nursing", "chartdate": "2156-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651002, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient remained on minimal vent settings throughout the shift. RISBI\n 40. ABGs adequate. Positive cough. Poor gag. Periods of RR in the\n 40\n Action:\n Suctioning throughout the shift with majority of thick, clear\n secretions in oral cavity.\n Response:\n O2 SATS 97-100% LSCTA with diminished bases.\n Plan:\n Attempt extubation again today.\n Hypertension, benign\n Assessment:\n Periods of SBP 140\ns-170\ns with elevated HR 120\ns and RR 40\n Action:\n Increased Nicardipine gtt to 3 mcg/kg/min to maintain SBP <140.\n Anti-Hypertensive meds as ordered.\n Response:\n With Nicardipine and boluses of Vercid patient able to maintain SBP\n Goal of <140.\n Plan:\n Continue Nicardipine gtt. Attempt to wean. ? Increase PO\n antihypertensive meds.\n Anxiety\n Assessment:\n Pt demonstrating anxiety with increased HR, RR and excessive mvt of LUE\n and LLE.\n Action:\n Versid 2mg as ordered three times overnight.\n Response:\n Pt responded positively. Remained easily stimulated to voice and\n touch.\n Plan:\n Continue prn vercid for periods of agitation a/e by increased VS and\n physical signs.\n" }, { "category": "Nursing", "chartdate": "2156-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651154, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Inconsistent neurological exam. Follows commands with left side\n generally/wiggling toes and squeezing hand. No spontaneous movement\n noted with right side, no withdrawal to nailbed pressure with right\n side. Opens eyes to speech and at times sticks out tongue and opens\n mouth. Fever spike to 103.2. Ventriculostomy at 10cmH2O above tragus\n draining serosang drainage\n Action:\n Head Ct done. Tylenol and cooling blanket administered. Pan cultured.\n CSF culture per neurosurg with resulting leak from sample port\n requiring change of drainage system promptly per neurosurg resident.\n Response:\n CT results pending. No effects from Tylenol or cooling blanket-Dr. \n and neurosurg aware.\n Plan:\n Continue to monitor neurological status. F/u on CSF cx results and\n continue to address temp spike with Dr. .\n Hypertension, benign\n Assessment:\n Hypertensive to 170\n Action:\n Nicardipine IV on and off to maintain BP<140. Labetolol and Lopressor\n used PRN d/t Po meds delayed x1-2hrs after head CT due to inadvertent\n dislodging of feeding tube by CT tech, requiring reinsertion of pedi\n tube which was confirmed per CXR.\n Response:\n Po meds with good effect, weaning Nicardipine this pm. BP<140 systolic.\n Plan:\n Continue to monitor BP and keep <140sys.\n" }, { "category": "Physician ", "chartdate": "2157-01-03 00:00:00.000", "description": "Intensivist Note", "row_id": 651577, "text": "SICU\n HPI:\n 53M presented with pontine SAH with IVH in left lateral ventricle\n Chief complaint:\n pontine SAH with IVH in left lateral ventricle\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n FEVER - 101.4\nF - 11:00 PM\n Post operative day:\n HD8\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 10:41 AM\n Cefazolin - 08:47 PM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 04:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.6\nC (101.4\n T current: 38.1\nC (100.6\n HR: 91 (75 - 105) bpm\n BP: 139/67(92) {81/47(65) - 158/76(105)} mmHg\n RR: 14 (14 - 22) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (5 - 16) mmHg\n Total In:\n 2,605 mL\n 321 mL\n PO:\n Tube feeding:\n 1,444 mL\n IV Fluid:\n 822 mL\n 321 mL\n Blood products:\n Total out:\n 1,506 mL\n 275 mL\n Urine:\n 1,300 mL\n 235 mL\n NG:\n Stool:\n Drains:\n 206 mL\n 40 mL\n Balance:\n 1,099 mL\n 46 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 98%\n ABG: ////\n Ve: 10.4 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : ), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Noxious stimuli), left UE and Left LE\n withdraws weakly to pain\n Labs / Radiology\n 193 K/uL\n 11.2 g/dL\n 78 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 100 mEq/L\n 133 mEq/L\n 31.5 %\n 12.4 K/uL\n [image002.jpg]\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.1 mg/dL,\n Mg:2.3 mg/dL, PO4:2.6 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53M presented with pontine SAH with IVH in left\n lateral ventricle\n Neurologic: Dilantin therapeutic; MRI and repeat head CTs done - no sig\n interval changes; s/p EVD drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; having\n fevers, f/u CSF cxs; pt having hiccups, likely central in origin; for\n angio \n Cardiovascular: SBP<160mmHg; lopressor75 , labetalol prn, hydral\n PRN; nimotop 60q4\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status, Trach had been d/w family\n Gastrointestinal / Abdomen: will likely need PEG\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: stable\n Endocrine: RISS, t/c starting NPH after procedure today.\n Infectious Disease: on ancef for EVD, f/u cx's, WBC count (having\n fevers); fluc for yeast on sputum\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobhoff\n Wounds:\n Imaging:\n Fluids: NS @ 60 while npo\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: ICU consent signed Comments: cousin will be\n spokesperson for pt.\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651624, "text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Bp goal < 160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n No movement in right leg or arm. Moves left hand and leg/ perla.\n Propofol gtt infusing at 20mcg/kg/min. ventricular drain patent and\n draining blood tinge drainage to straw colored drainage. Vent drain 15\n above the tragus. Does not follow commands but will squeeze hand to\n command.\n Action:\n Npo after midnoc for angio neuron signs q2hrs. ventricular drain at 15\n cm above the tragus.\n Response:\n Neuro status unchanged.\n Plan:\n To angio today.\n" }, { "category": "Nursing", "chartdate": "2157-01-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651626, "text": "Hypertension, benign\n Assessment:\n Bp 120-140 occ elevates to 160-170 especially when being suctioned and\n when propofol off for neuro exam\n Action:\n Lopressor changed to . Off nicardipine gtt. Hydralazine d/c\n Response:\n Bp labile\n Plan:\n Bp goal < 160.\n Intracerebral hemorrhage (ICH)\n Assessment:\n No movement in right leg or arm. Moves left hand and leg/ perla.\n Propofol gtt infusing at 20mcg/kg/min. ventricular drain patent and\n draining blood tinge drainage to straw colored drainage. Vent drain 15\n above the tragus. Does not follow commands but will squeeze hand to\n command.\n Action:\n Npo after midnoc for angio neuron signs q2hrs. ventricular drain at 15\n cm above the tragus.\n Response:\n Neuro status unchanged.\n Plan:\n To angio today.\n" }, { "category": "Nursing", "chartdate": "2157-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651941, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with pontine bleed, ventriculostomy drain in place, remains\n intubated for airway protection. See flowsheet for assessment.\n Trach and peg done at bedside pt received atotal of 300 mgs Fentanyl\n and propofol increased to 70 mcgs\n Received 5 mgs vercuronium for trach .\n Peg may be used for meds will evaluate for t/f within 24 hours.\n Otherwise to gravity drainage.\n Action:\n Vent drain raised to 20 at tragus then clamped at 1700 after trach and\n peg, ICP increased to 23-25 opened d, Neuro /med informed\n Vent drain dropped to 10 above tragus and remained open\n Response:\n ICP , straw colored drainage, no change in neuro statuspt appeared to\n be back at baseline by 6pm off propofol for 10 m mins.\n Plan:\n For Head CT in am.\n Continue with current plan neuron will come and examine pt then\n will decide plan of care.\n Rash\n Assessment:\n Small redto pink dots over knees and outer aspects of lower legs some\n over abdomen back from shoulders to thighs covered in bright res raised\n rash md aware w\n Action:\n bathed pt and odered bleach free sheets\n reviewed medications ?ancef\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash,.\n" }, { "category": "Nursing", "chartdate": "2157-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651954, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with pontine bleed, ventriculostomy drain in place, remains\n intubated for airway protection. See flowsheet for assessment.\n Trach and peg done at bedside pt received atotal of 300 mgs Fentanyl\n and propofol increased to 70 mcgs\n Received 5 mgs vercuronium for trach .\n Peg may be used for meds will evaluate for t/f within 24 hours.\n Otherwise to gravity drainage.\n Action:\n Vent drain raised to 20 at tragus then clamped at 1700 after trach and\n peg, ICP increased to 23-25 opened d, Neuro /med informed\n Vent drain dropped to 10 above tragus and remained open\n Response:\n ICP , straw colored drainage, no change in neuro statuspt appeared to\n be back at baseline by 6pm off propofol for 10 m mins.\n Plan:\n For Head CT in am.\n Continue with current plan neuron will come and examine pt then\n will decide plan of care.\n Rash\n Assessment:\n Small redto pink dots over knees and outer aspects of lower legs some\n over abdomen back from shoulders to thighs covered in bright res raised\n rash md aware w\n Action:\n bathed pt and odered bleach free sheets\n reviewed medications ?ancef\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash,.\n" }, { "category": "Nursing", "chartdate": "2157-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651955, "text": "53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine SAH with LVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tears 5. Calcium\n Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Enalapril Maleate 10. Erythromycin 0.5%\n Ophth Oint 11. Famotidine\n 12. Fluconazole 13. FoLIC Acid 14. Furosemide 15. Insulin 16. Influenza\n Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. NiCARdipine 23. Nimodipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n ANGIOGRAPHY - At 09:00 AM\n In IR for cerebral ango for diagnostics from 0900-1200\n FEVER - 101.5\nF - 04:00 AM\n - went for angio - right vertebral artery occlusion but no intervention\n - consent obtained for trach/peg\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with pontine bleed, ventriculostomy drain in place, remains\n intubated for airway protection. See flowsheet for assessment.\n Trach and peg done at bedside pt received atotal of 300 mgs Fentanyl\n and propofol increased to 70 mcgs\n Received 5 mgs vercuronium for trach .\n Peg may be used for meds will evaluate for t/f within 24 hours.\n Otherwise to gravity drainage.\n Action:\n Vent drain raised to 20 at tragus then clamped at 1700 after trach and\n peg, ICP increased to 23-25 opened d, Neuro /med informed\n Vent drain dropped to 10 above tragus and remained open\n Response:\n ICP , straw colored drainage, no change in neuro statuspt appeared to\n be back at baseline by 6pm off propofol for 10 m mins.\n Plan:\n For Head CT in am.\n Continue with current plan neuron will come and examine pt then\n will decide plan of care.\n Rash\n Assessment:\n Small redto pink dots over knees and outer aspects of lower legs some\n over abdomen back from shoulders to thighs covered in bright res raised\n rash md aware w\n Action:\n bathed pt and odered bleach free sheets\n reviewed medications ?ancef\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash,.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651914, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 7.5mm\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\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: Rhonchi\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: Green / 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:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt on the vent changes made tol well. See respiratory page of meta\n vision for more information.\n" }, { "category": "Rehab Services", "chartdate": "2156-12-31 00:00:00.000", "description": "Generic Note", "row_id": 651085, "text": "TITLE:\n Rehab Services Department\n P.T.\n Followed up to check patient status and appropriateness of P.T.\n evaluation. Spoke with RN and reviewed chart and pt not yet appropriate\n for P.T. eval. Pt is currently intubated and vent drain remains open\n with large amounts of drainage. Pt imminently going to head CT to\n assess for neurologic changes and will have repeat angiogram Monday.\n Will follow up to reassess status next week. Thanks.\n Pager # \n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "Intensivist Note", "row_id": 651221, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Chief complaint:\n pontine hemorrhage\n PMHx:\n ?HTN\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. FoLIC Acid\n 12. HydrALAzine 13. Influenza Virus Vaccine 14. Insulin 15. Labetalol\n 16. Labetalol 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoprolol Tartrate 20. Metoclopramide 21.\n Midazolam 22. Multivitamins\n 23. Nimodipine 24. NiCARdipine 25. Phenytoin 26. Potassium Chloride 27.\n Propofol 28. Sodium Chloride 0.9% Flush\n 29. Thiamine\n 24 Hour Events:\n PAN CULTURE - At 09:14 AM\n CSF CULTURE - At 03:04 PM\n FEVER - 103.6\nF - 08:00 PM\n - CT head done showing no change\n - CSF studies done prot 87, gluc 75, RBC , 0 WBC, no microorgs\n - Dobhoff replaced (fell out in CT)\n - pt pan cx'd for high fever 103, U/A neg\n - restarted propofol\n - treated hiccups with reglan (hiccups now gone)\n Post operative day:\n HD #6\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:26 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:29 PM\n Labetalol - 04:00 PM\n Midazolam (Versed) - 08:02 PM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.8\nC (103.6\n T current: 39.1\nC (102.4\n HR: 123 (97 - 126) bpm\n BP: 148/70(93) {93/50(66) - 182/83(114)} mmHg\n RR: 25 (9 - 33) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 6 (1 - 9) mmHg\n Total In:\n 2,083 mL\n 836 mL\n PO:\n Tube feeding:\n 420 mL\n 339 mL\n IV Fluid:\n 1,023 mL\n 327 mL\n Blood products:\n Total out:\n 1,831 mL\n 323 mL\n Urine:\n 1,570 mL\n 231 mL\n NG:\n Stool:\n Drains:\n 261 mL\n 92 mL\n Balance:\n 252 mL\n 513 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): 390 (272 - 390) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 96%\n ABG: 7.47/38/135//4\n Ve: 8.4 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n Weakness), (LUE: No(t) Weakness), (RLE: Weakness), (LLE: No(t)\n Weakness), Sedated\n Labs / Radiology\n 159 K/uL\n 12.4 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 137 mEq/L\n 34.4 %\n 14.1 K/uL\n [image002.jpg]\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n WBC\n 8.4\n 10.0\n 9.9\n 9.2\n 14.1\n Hct\n 38.2\n 36.4\n 37.8\n 35.8\n 34.4\n Plt\n 152\n 141\n 127\n 147\n 159\n Creatinine\n 0.8\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n TCO2\n 28\n 28\n 27\n 32\n 28\n Glucose\n 120\n 116\n 139\n 138\n 125\n 120\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:74.2 %, Lymph:13.0 %, Mono:9.9 %,\n Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53 yo M with pontine SAH, left lateral IVH.\n Neurologic: Phenytoin - therapeutic, ICP monitor, Ventriculostomy, Pain\n controlled, MRI and repeat head CTs done - no sig interval changes; s/p\n EVD drain placement; neurosurg/neurology following; versed PRN/propofol\n gtt for sedation; nimodipine; having fevers, CSF studies benign, f/u\n CSF cxs; pt having hiccups, likely central in origin, trial of reglan\n yesterday\n Cardiovascular: SBP<140mmHg; lopressor25''', labetalol prn, hydral\n 50''''; nimotop 60q4, nicardipine gtt as needed\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, unable to extubate as weak gag, poor mental status,\n trach/peg likely Monday/Tuesday\n Gastrointestinal / Abdomen: peg likely Monday/Tuesday, TF at goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct stable.\n Endocrine: RISS, FS somewhat high, will tighten up sliding scale\n Infectious Disease: Check cultures, on ancef for EVD, f/u cx's, WBC\n count (having fevers); was pan cx'd yesterday; U/A pending\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, Surgical drains (hemovac,\n JP), a-line, PIV\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 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": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651311, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with Pontine bleed, remains affected on Right side, inconsistent\n with commands on Left side. Hypertensive on multiple medications,\n hyperthermic to 102.6F, ? central versus infectious. Awaiting culture\n results.\n Action:\n Increase in metoprolol dose, cooling blanket in place and Q6hr Tylenol,\n CT of torso to r/o infection. Fluconazole started for yeast in sputum.\n Response:\n Temp down to 100.7F, white cell count increasing, secretions thick and\n green from ETT.\n Plan:\n Follow temps and neuro checks, await culture results.\n" }, { "category": "Nursing", "chartdate": "2156-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651000, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651216, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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: 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: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Switched from PSV to vent support due to tachypnea( RR40-50\n bpm) & hiccups.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering, Abnormal trigger efforts\n (efforts during inspiratory)\n Dysynchrony assessment: Frequent alarms (High rate, High min.\n ventilation)\n Comments: Hiccups & tachypnea B4 sedation started.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n Unable to complete RSBI R > 35 bpm.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2157-01-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651776, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with pontine bleed, ventriculostomy drain in place, remains\n intubated for airway protection. See flowsheet for assessment.\n Action:\n Vent drain initially clamped, ICP increased, Neuro /med informed\n Response:\n ICP now back to previous levels, straw colored drainage, no change in\n neuro status\n Plan:\n For Head CT at 5am, Trach today, consent gained from pt\ns cousin.\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651993, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Action:\n Trach suction q4hr and oral suction q2hr. ABG sent with AM labs\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions. ABG this am 7.45/40/160\n Plan:\n Cont. to suction patient. Wean vent as tolerated. Monitor ABGs\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177. at 0400, BP 188/80\n Action:\n Hydralalize 10mg given IVP @ 0100. Labetalol 10mg given IVP at 0400.\n Response:\n 0130, BP decreased to 140/60\ns. At 0410, decreased BP to 125/61\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n Left eye with redness and periorbital edema. Limiting position towards\n left to decrease swelling. Erythromycin ointment applied. Rinsed eyes\n with NS.\n DM: FSBG q6hr. BS 130-180\ns, requiring Regular Insulin coverage per\n RISS.\n 0400 K=3.8, 40meq KCl given PO.\n RN CCRN\n" }, { "category": "Respiratory ", "chartdate": "2157-01-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651310, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Green / 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: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 14:00\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2156-12-31 00:00:00.000", "description": "Intensivist Note", "row_id": 651065, "text": "TITLE:\n SICU\n HPI:\n 53M presented to this morning with complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Chief complaint:\n inability to extubate\n PMHx:\n ?HTN\n : Flonase\n Current medications:\n Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5. CefazoLIN 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. FoLIC Acid\n 12. HydrALAzine 13. Influenza Virus Vaccine 14. Insulin 15. Labetalol\n 16. Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Multivitamins 20. Nimodipine 21. NiCARdipine 22.\n Phenytoin 23. Potassium Chloride\n 24. Propofol 25. Sodium Chloride 0.9% Flush 26. Thiamine\n 24 Hour Events:\n BP meds increased. Still weak gag/cough.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:41 AM\n Infusions:\n Nicardipine - 3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 07:57 AM\n Midazolam (Versed) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:25 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 (82 - 118) bpm\n BP: 133/61(86) {112/49(0) - 164/69(98)} mmHg\n RR: 18 (15 - 30) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 5 (1 - 7) mmHg\n Total In:\n 3,406 mL\n 521 mL\n PO:\n Tube feeding:\n 1,229 mL\n IV Fluid:\n 1,437 mL\n 351 mL\n Blood products:\n Total out:\n 1,744 mL\n 494 mL\n Urine:\n 1,460 mL\n 400 mL\n NG:\n Stool:\n Drains:\n 284 mL\n 94 mL\n Balance:\n 1,662 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 202 (187 - 394) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.47/43/159/28/7\n Ve: 6.2 L/min\n PaO2 / FiO2: 398\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : coarse B/L)\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 Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, No(t) Moves all extremities,\n (RUE: No movement), (LUE: No movement), (RLE: No movement), (LLE: No\n movement)\n Labs / Radiology\n 147 K/uL\n 12.8 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 137 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n WBC\n 8.4\n 10.0\n 9.9\n 9.2\n Hct\n 38.2\n 36.4\n 37.8\n 35.8\n Plt\n 152\n 141\n 127\n 147\n Creatinine\n 0.8\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n 27\n 32\n Glucose\n 120\n 116\n 139\n 138\n 125\n 120\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ANXIETY, ALTERED MENTAL STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY\n TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH),\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE\n (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Neurologic: neuro status unimproved, Dilantin therapeutic; MRI and\n repeat head CTs done - no sig interval changes; s/p EVD drain\n placement; neurosurg/neurology following; versed PRN for sedation;\n nimodipine, send CSF Cxs, high EVD output, may require shunt, angio\n today to eval basilar a aneurysm\n Cardiovascular: SBP<140mmHg; lopressor25''', labetalol prn, hydral\n 50''''; nimotop 60q4, wean nicardipine GTT\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as no gag,\n pending trach Monday\n Gastrointestinal / Abdomen: pending peg monday\n Nutrition: resume TF; Replete with fiber Full strength goal 60\n Renal: no issues\n Hematology: follow Hct 35.8 stable\n Endocrine: RISS, FS well-controlled\n Infectious Disease: Ancef for EVD, f/u cx (CSF, spcx, ucx, u/a, CXR,\n diff on WBC)\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobhoff\n Wounds: none\n Imaging: none\n Fluids: KVO, TF\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:55 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 22 Gauge - 02:03 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 15 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-04 00:00:00.000", "description": "Intensivist Note", "row_id": 651846, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine SAH with LVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tears 5. Calcium\n Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Enalapril Maleate 10. Erythromycin 0.5%\n Ophth Oint 11. Famotidine\n 12. Fluconazole 13. FoLIC Acid 14. Furosemide 15. Insulin 16. Influenza\n Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. NiCARdipine 23. Nimodipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n ANGIOGRAPHY - At 09:00 AM\n In IR for cerebral ango for diagnostics from 0900-1200\n FEVER - 101.5\nF - 04:00 AM\n - went for angio - right vertebral artery occlusion but no intervention\n - consent obtained for trach/peg\n Post operative day:\n HD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Cefazolin - 08:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 AM\n Other medications:\n Flowsheet Data as of 05:50 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: 38.6\nC (101.5\n HR: 101 (89 - 107) bpm\n BP: 122/57(78) {95/52(66) - 184/94(129)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (10 - 22) mmHg\n Total In:\n 2,341 mL\n 530 mL\n PO:\n Tube feeding:\n 540 mL\n 4 mL\n IV Fluid:\n 1,201 mL\n 406 mL\n Blood products:\n Total out:\n 2,514 mL\n 238 mL\n Urine:\n 2,355 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 159 mL\n 38 mL\n Balance:\n -173 mL\n 292 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 90%\n ABG: ///28/\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated/sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated, follows commands\n very sporadically, weak cough/gag, few purposeful movements\n Labs / Radiology\n 260 K/uL\n 10.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 18 mg/dL\n 99 mEq/L\n 133 mEq/L\n 29.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n 260\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n 78\n 105\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53 yo M with pontine SAH and left ventricle IVH\n with persistent resp failure.\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, ICP monitor,\n Ventriculostomy, s/p angio which revealed right vertebral artery\n occlusion, no intervention done; versed PRN/propofol gtt for sedation;\n nimodipine for vasospasm; f/u CSF cxs; ICP up o/n, ventric drain\n unclamped, f/u head CT results\n Cardiovascular: goal SBP<160mmHg; lopressor75 , labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, unable to extubate as weak gag, poor mental status,\n trach/peg d/w HCP, consent obtained\n Gastrointestinal / Abdomen: peg today, TF being held\n Nutrition: TF started; currently held, when OK to restart - Replete\n with fiber Full strength goal 60\n Renal: Foley, Adequate UO, no issues\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS, FS well controlled\n Infectious Disease: Check cultures, on ancef for EVD; WBC count\n trending down; fluc for yeast on sputum\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, a-line, place trach today\n Wounds: evd site clean\n Imaging: CT scan head today\n Fluids: NS, 60 cc/hr while NPO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 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": "2157-01-04 00:00:00.000", "description": "Intensivist Note", "row_id": 651848, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine SAH with LVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tears 5. Calcium\n Gluconate 6. CefazoLIN 7. Chlorhexidine Gluconate 0.12% Oral Rinse\n 8. Docusate Sodium (Liquid) 9. Enalapril Maleate 10. Erythromycin 0.5%\n Ophth Oint 11. Famotidine\n 12. Fluconazole 13. FoLIC Acid 14. Furosemide 15. Insulin 16. Influenza\n Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. NiCARdipine 23. Nimodipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n ANGIOGRAPHY - At 09:00 AM\n In IR for cerebral ango for diagnostics from 0900-1200\n FEVER - 101.5\nF - 04:00 AM\n - went for angio - right vertebral artery occlusion but no intervention\n - consent obtained for trach/peg\n Post operative day:\n HD #9\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Cefazolin - 08:00 PM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 09:00 AM\n Other medications:\n Flowsheet Data as of 05:50 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: 38.6\nC (101.5\n HR: 101 (89 - 107) bpm\n BP: 122/57(78) {95/52(66) - 184/94(129)} mmHg\n RR: 18 (15 - 25) insp/min\n SPO2: 90%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (10 - 22) mmHg\n Total In:\n 2,341 mL\n 530 mL\n PO:\n Tube feeding:\n 540 mL\n 4 mL\n IV Fluid:\n 1,201 mL\n 406 mL\n Blood products:\n Total out:\n 2,514 mL\n 238 mL\n Urine:\n 2,355 mL\n 200 mL\n NG:\n Stool:\n Drains:\n 159 mL\n 38 mL\n Balance:\n -173 mL\n 292 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): 18\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n Plateau: 16 cmH2O\n Compliance: 62.5 cmH2O/mL\n SPO2: 90%\n ABG: ///28/\n Ve: 8.7 L/min\n Physical Examination\n General Appearance: No acute distress, intubated/sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric)\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli), No(t) Moves all extremities, (RUE: No movement), (LUE:\n Weakness), (RLE: Weakness), (LLE: Weakness), Sedated, follows commands\n very sporadically, weak cough/gag, few purposeful movements\n Labs / Radiology\n 260 K/uL\n 10.4 g/dL\n 105 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 4.1 mEq/L\n 18 mg/dL\n 99 mEq/L\n 133 mEq/L\n 29.8 %\n 8.8 K/uL\n [image002.jpg]\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n Plt\n 141\n 127\n 147\n 159\n 171\n 193\n 260\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n TCO2\n 27\n 32\n 28\n Glucose\n 139\n 138\n 125\n 120\n 159\n 122\n 78\n 105\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:2.5 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53 yo M with pontine SAH and left ventricle IVH\n with persistent resp failure.\n Neurologic: Neuro checks Q: 2 hr, Phenytoin - therapeutic, ICP monitor,\n Ventriculostomy, s/p angio which revealed right vertebral artery\n occlusion, no intervention done; versed PRN/propofol gtt for sedation;\n nimodipine for vasospasm; f/u CSF cxs; ICP up o/n, ventric drain\n unclamped, f/u head CT results\n Cardiovascular: goal SBP<160mmHg; lopressor75 , labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: Trach, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, unable to extubate as weak gag, poor mental status,\n trach/peg d/w HCP, consent obtained\n Gastrointestinal / Abdomen: peg today, TF being held\n Nutrition: TF started; currently held, when OK to restart - Replete\n with fiber Full strength goal 60\n Renal: Foley, Adequate UO, no issues\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS, FS well controlled\n Infectious Disease: Check cultures, on ancef for EVD; WBC count\n trending down; fluc for yeast on sputum\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, a-line, place trach today\n Wounds: evd site clean\n Imaging: CT scan head today\n Fluids: NS, 60 cc/hr while NPO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 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": "2156-12-31 00:00:00.000", "description": "Intensivist Note", "row_id": 651048, "text": "TITLE:\n SICU\n HPI:\n 53M presented to this morning with complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Chief complaint:\n inability to extubate\n PMHx:\n ?HTN\n : Flonase\n Current medications:\n Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5. CefazoLIN 6.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. FoLIC Acid\n 12. HydrALAzine 13. Influenza Virus Vaccine 14. Insulin 15. Labetalol\n 16. Magnesium Sulfate 17. Metoprolol Tartrate\n 18. Midazolam 19. Multivitamins 20. Nimodipine 21. NiCARdipine 22.\n Phenytoin 23. Potassium Chloride\n 24. Propofol 25. Sodium Chloride 0.9% Flush 26. Thiamine\n 24 Hour Events:\n BP meds increased. Still weak gag/cough.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:41 AM\n Infusions:\n Nicardipine - 3 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 07:57 AM\n Midazolam (Versed) - 04:00 AM\n Other medications:\n Flowsheet Data as of 07:25 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 (82 - 118) bpm\n BP: 133/61(86) {112/49(0) - 164/69(98)} mmHg\n RR: 18 (15 - 30) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 5 (1 - 7) mmHg\n Total In:\n 3,406 mL\n 521 mL\n PO:\n Tube feeding:\n 1,229 mL\n IV Fluid:\n 1,437 mL\n 351 mL\n Blood products:\n Total out:\n 1,744 mL\n 494 mL\n Urine:\n 1,460 mL\n 400 mL\n NG:\n Stool:\n Drains:\n 284 mL\n 94 mL\n Balance:\n 1,662 mL\n 27 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 202 (187 - 394) mL\n PS : 5 cmH2O\n RR (Spontaneous): 21\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 40\n PIP: 10 cmH2O\n SPO2: 97%\n ABG: 7.47/43/159/28/7\n Ve: 6.2 L/min\n PaO2 / FiO2: 398\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic, No(t)\n Diastolic)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : coarse B/L)\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 Skin: No(t) Rash: , No(t) Jaundice\n Neurologic: No(t) Follows simple commands, No(t) Moves all extremities,\n (RUE: No movement), (LUE: No movement), (RLE: No movement), (LLE: No\n movement)\n Labs / Radiology\n 147 K/uL\n 12.8 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 137 mEq/L\n 35.8 %\n 9.2 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n WBC\n 8.4\n 10.0\n 9.9\n 9.2\n Hct\n 38.2\n 36.4\n 37.8\n 35.8\n Plt\n 152\n 141\n 127\n 147\n Creatinine\n 0.8\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n 27\n 32\n Glucose\n 120\n 116\n 139\n 138\n 125\n 120\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n ANXIETY, ALTERED MENTAL STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY\n TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH),\n RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE\n (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Neurologic: Dilantin therapeutic; MRI and repeat head CTs done - no sig\n interval changes; s/p EVD drain placement; neurosurg/neurology\n following; versed PRN for sedation; nimodipine\n Cardiovascular: SBP<140mmHg; lopressor25''', labetalol prn, hydral\n 50''''; nimotop 60q4, back on nicardipine GTT\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as no gag,\n pending trach\n Gastrointestinal / Abdomen: pending peg\n Nutrition: TF started; Replete with fiber Full strength goal 60\n Renal: no issues\n Hematology: follow Hct\n Endocrine: RISS, f/u FS\n Infectious Disease: Ancef for EVD\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobbhoff\n Wounds: none\n Imaging: none\n Fluids: KVO, TF\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:55 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 22 Gauge - 02:03 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: Patient discussed on interdisciplinary rounds Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651428, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n No movement in right arm and leg. Propofol gtt onand off for neuro\n assessmemt. Moves left arm andleft leg. Squeeeezes hand to command.\n Does not stick tongue out to command. Ventricular drain at 15 above the\n tragus. Draining pink colored drainage. Drain site clean with sterile\n dsg . perla\n Action:\n Bp goal < 140. nuero signs q2hrs. propofol gtt and off for neuron\n assessment. Vent drainage monitored.\n Response:\n Neuro status unchanged.\n Plan:\n Monitor neuron assessment.\n Problem - Description In Comments\n Assessment:\n Temp 102.6 to 99.6\n Action:\n Cooling blanket prn. Tylenol 650mg via fdg tube. Tepid bath given.\n Response:\n Temp now to 99.6\n Plan:\n Monitor temp closely.\n" }, { "category": "Physician ", "chartdate": "2157-01-02 00:00:00.000", "description": "Intensivist Note", "row_id": 651434, "text": "SICU\n HPI:\n HPI: 53M presented to this morning with complaint of\n left sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n altered mental status\n PMHx:\n PMH: ?HTN\n : Flonase\n .\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. Fluconazole\n 12. Fluconazole 13. FoLIC Acid 14. HydrALAzine 15. Insulin 16.\n Influenza Virus Vaccine 17. Labetalol\n 18. Magnesium Sulfate 19. Metoprolol Tartrate 20. Midazolam 21.\n Multivitamins 22. Nimodipine 23. NiCARdipine\n 24. Phenytoin 25. Potassium Chloride 26. Propofol 27. Sodium Chloride\n 0.9% Flush 28. Thiamine\n 24 Hour Events:\n FEVER - 102.6\nF - 12:00 PM\n : admit to sicu, EVD placed, A-line placed; pt pancx'd for low\n grade temp; to Xray/MRI (requested by neurosurg)\n : extubated -> failed due to mucous plugging; reintubated; started\n on CIWA scale;\n : no gag. planning for trach/peg; TF started. repeat CT head\n stable. ween FiO2 to 40%\n 12/25: still weak gag/cough. Optho consulted. Increased lopressor,\n hydral.\n : CT head done showing no change, CSF studies done prot 87, gluc\n 75, RBC , 0 WBC, no microorgs; Dobhoff replaced (fell out in CT);\n pt pan cx'd for high fever 103, U/A neg; restarted propofol\n : CT scan negative for fever source, BLE dopplers negative, oral\n BP meds added, fluconazole added,\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 12:08 PM\n Cefazolin - 02:59 AM\n Infusions:\n Propofol - 20 mcg/Kg/min\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 05:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.6\n T current: 37.8\nC (100\n HR: 95 (82 - 123) bpm\n BP: 159/75(105) {79/49(60) - 159/75(105)} mmHg\n RR: 17 (13 - 25) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (6 - 43) mmHg\n Total In:\n 3,940 mL\n 483 mL\n PO:\n Tube feeding:\n 1,441 mL\n 294 mL\n IV Fluid:\n 1,009 mL\n 189 mL\n Blood products:\n Total out:\n 1,567 mL\n 213 mL\n Urine:\n 1,336 mL\n 195 mL\n NG:\n Stool:\n Drains:\n 231 mL\n 18 mL\n Balance:\n 2,373 mL\n 270 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): 18\n RR (Spontaneous): 5\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 17 cmH2O\n Compliance: 83.3 cmH2O/mL\n SPO2: 97%\n ABG: ///27/\n Ve: 14.4 L/min\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Diminished:\n bilaterally at the bases)\n Abdominal: Soft, Non-tender, Distended\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: No(t) Follows simple commands, (Responds to: Noxious\n stimuli), No(t) Moves all extremities, (RUE: Weakness), (LUE:\n Weakness), Sedated\n Labs / Radiology\n 171 K/uL\n 12.4 g/dL\n 122 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 4.1 mEq/L\n 19 mg/dL\n 100 mEq/L\n 133 mEq/L\n 34.6 %\n 16.9 K/uL\n [image002.jpg]\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n WBC\n 10.0\n 9.9\n 9.2\n 14.1\n 16.9\n Hct\n 36.4\n 37.8\n 35.8\n 34.4\n 34.6\n Plt\n 141\n 127\n 147\n 159\n 171\n Creatinine\n 0.6\n 0.7\n 0.6\n 0.6\n 0.6\n TCO2\n 28\n 28\n 27\n 32\n 28\n Glucose\n 116\n 139\n 138\n 125\n 120\n 159\n 122\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.5 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n PROBLEM -\n Assessment and : 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: Neuro checks Q: 2 hr, Ventriculostomy, Dilantin\n therapeutic; s/p EVD drain placement; neurosurg/neurology following;\n nimodipine; Angio vs no angio yet to be determined b/w neuromed and\n neurosurg. If no angio/intervention then plan for trach/peg/rehab.\n Cardiovascular: Beta-blocker, SBP<140mmHg; lopressor25''', labetalol\n prn, hydral 50''''; nimotop 60q4, back on nicardipine GTT\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status, trach/peg likely Monday/Tuesday\n Gastrointestinal / Abdomen: peg likely Monday/Tuesday, TF at goal\n Nutrition: Tube feeding, peg likely Monday/Tuesday, TF at goal\n TF started; Replete with fiber Full strength goal 60\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, fluc, on ancef for EVD, f/u cx's,\n WBC count. Hyperpyrexia, given lack of source, likely due to pontine\n hemorrhage.\n Lines / Tubes / Drains: Foley, ETT, ETT, foley, a-line, EVD, dobhoff\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids:\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure), Closed head injury\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:56 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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. No family/health care proxy available yet. Will\n contact SW before angio.\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2156-12-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651115, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: 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: Pending procedure /\n OR, Cannot protect airway, Hemodynimic instability, 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 11:30\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651983, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Action:\n Trach suction q4hr and oral suction q2hr\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions.\n Plan:\n Cont. to suction patient. Wean vent as tolerated\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177. at 0400, BP 188/80\n Action:\n Hydralalize 10mg given IVP @ 0100. Labetalol 10mg given IVP at 0400.\n Response:\n 0130, BP decreased to 140/60\ns. At 0410, decreased BP to 125/61\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n Left eye with redness and periorbital edema. Limiting position towards\n left to decrease swelling. Erythromycin ointment applied. Rinsed eyes\n with NS.\n RN CCRN\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651984, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Action:\n Trach suction q4hr and oral suction q2hr. ABG sent with AM labs\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions. ABG this am 7.45/\n Plan:\n Cont. to suction patient. Wean vent as tolerated. Monitor ABGs\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177. at 0400, BP 188/80\n Action:\n Hydralalize 10mg given IVP @ 0100. Labetalol 10mg given IVP at 0400.\n Response:\n 0130, BP decreased to 140/60\ns. At 0410, decreased BP to 125/61\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n Left eye with redness and periorbital edema. Limiting position towards\n left to decrease swelling. Erythromycin ointment applied. Rinsed eyes\n with NS.\n DM: FSBG q6hr. BS 130-180\ns, requiring Regular Insulin coverage per\n RISS.\n RN CCRN\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651985, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Action:\n Trach suction q4hr and oral suction q2hr. ABG sent with AM labs\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions. ABG this am 7.45/40/160\n Plan:\n Cont. to suction patient. Wean vent as tolerated. Monitor ABGs\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177. at 0400, BP 188/80\n Action:\n Hydralalize 10mg given IVP @ 0100. Labetalol 10mg given IVP at 0400.\n Response:\n 0130, BP decreased to 140/60\ns. At 0410, decreased BP to 125/61\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n Left eye with redness and periorbital edema. Limiting position towards\n left to decrease swelling. Erythromycin ointment applied. Rinsed eyes\n with NS.\n DM: FSBG q6hr. BS 130-180\ns, requiring Regular Insulin coverage per\n RISS.\n RN CCRN\n" }, { "category": "Respiratory ", "chartdate": "2156-12-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651021, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\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 Comments:\n Secretions\n Sputum color / consistency: Clear / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Pt has occ agitation periods.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n RSBI done ~40.\n Reason for continuing current ventilatory support: Sedated / Paralyzed;\n Comments: Elective extubation planned!!!\n" }, { "category": "Physician ", "chartdate": "2157-01-01 00:00:00.000", "description": "Intensivist Note", "row_id": 651260, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Chief complaint:\n pontine hemorrhage\n PMHx:\n ?HTN\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Calcium Gluconate 5.\n CefazoLIN 6. Chlorhexidine Gluconate 0.12% Oral Rinse\n 7. Docusate Sodium (Liquid) 8. Enalapril Maleate 9. Erythromycin 0.5%\n Ophth Oint 10. Famotidine 11. FoLIC Acid\n 12. HydrALAzine 13. Influenza Virus Vaccine 14. Insulin 15. Labetalol\n 16. Labetalol 17. Magnesium Sulfate\n 18. Metoprolol Tartrate 19. Metoprolol Tartrate 20. Metoclopramide 21.\n Midazolam 22. Multivitamins\n 23. Nimodipine 24. NiCARdipine 25. Phenytoin 26. Potassium Chloride 27.\n Propofol 28. Sodium Chloride 0.9% Flush\n 29. Thiamine\n 24 Hour Events:\n PAN CULTURE - At 09:14 AM\n CSF CULTURE - At 03:04 PM\n FEVER - 103.6\nF - 08:00 PM\n - CT head done showing no change\n - CSF studies done prot 87, gluc 75, RBC , 0 WBC, no microorgs\n - Dobhoff replaced (fell out in CT)\n - pt pan cx'd for high fever 103, U/A neg\n - restarted propofol\n - treated hiccups with reglan (hiccups now gone)\n Post operative day:\n HD #6\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:26 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Metoprolol - 03:29 PM\n Labetalol - 04:00 PM\n Midazolam (Versed) - 08:02 PM\n Other medications:\n Flowsheet Data as of 05:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.8\nC (103.6\n T current: 39.1\nC (102.4\n HR: 123 (97 - 126) bpm\n BP: 148/70(93) {93/50(66) - 182/83(114)} mmHg\n RR: 25 (9 - 33) insp/min\n SPO2: 96%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 68.6 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 6 (1 - 9) mmHg\n Total In:\n 2,083 mL\n 836 mL\n PO:\n Tube feeding:\n 420 mL\n 339 mL\n IV Fluid:\n 1,023 mL\n 327 mL\n Blood products:\n Total out:\n 1,831 mL\n 323 mL\n Urine:\n 1,570 mL\n 231 mL\n NG:\n Stool:\n Drains:\n 261 mL\n 92 mL\n Balance:\n 252 mL\n 513 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): 390 (272 - 390) mL\n PS : 8 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n Plateau: 13 cmH2O\n SPO2: 96%\n ABG: 7.47/38/135//4\n Ve: 8.4 L/min\n PaO2 / FiO2: 338\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n Weakness), (LUE: No(t) Weakness), (RLE: Weakness), (LLE: No(t)\n Weakness), Sedated\n Labs / Radiology\n 159 K/uL\n 12.4 g/dL\n 120 mg/dL\n 0.6 mg/dL\n 28 mEq/L\n 3.5 mEq/L\n 13 mg/dL\n 102 mEq/L\n 137 mEq/L\n 34.4 %\n 14.1 K/uL\n [image002.jpg]\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n 04:57 AM\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n WBC\n 8.4\n 10.0\n 9.9\n 9.2\n 14.1\n Hct\n 38.2\n 36.4\n 37.8\n 35.8\n 34.4\n Plt\n 152\n 141\n 127\n 147\n 159\n Creatinine\n 0.8\n 0.6\n 0.7\n 0.6\n Troponin T\n <0.01\n TCO2\n 28\n 28\n 27\n 32\n 28\n Glucose\n 120\n 116\n 139\n 138\n 125\n 120\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:74.2 %, Lymph:13.0 %, Mono:9.9 %,\n Eos:2.2 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.1 mg/dL, PO4:2.7 mg/dL\n Assessment and Plan\n PROBLEM - ENTER DESCRIPTION IN COMMENTS, ANXIETY, ALTERED MENTAL\n STATUS (NOT DELIRIUM), .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR\n ASPIRATION, ALTERED GAG, AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE,\n ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION,\n BENIGN\n Assessment and Plan: 53 yo M with pontine SAH, left lateral IVH.\n Neurologic: Phenytoin - therapeutic, ICP monitor, Ventriculostomy, Pain\n controlled, MRI and repeat head CTs done - no sig interval changes; s/p\n EVD drain placement; neurosurg/neurology following; versed PRN/propofol\n gtt for sedation; nimodipine; having fevers, CSF studies benign, f/u\n CSF cxs; pt having hiccups, likely central in origin, trial of reglan\n yesterday\n Cardiovascular: SBP<140mmHg; lopressor25''', labetalol prn, hydral\n 50''''; nimotop 60q4, nicardipine gtt as needed\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, unable to extubate as weak gag, poor mental status,\n trach/peg likely Monday/Tuesday\n Gastrointestinal / Abdomen: peg likely Monday/Tuesday, TF at goal\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: Hct stable.\n Endocrine: RISS, FS somewhat high, will tighten up sliding scale\n Infectious Disease: Check cultures, on ancef for EVD, f/u cx's, WBC\n count (having fevers); was pan cx'd yesterday; U/A pending\n Lines / Tubes / Drains: Foley, Dobhoff, ETT, Surgical drains (hemovac,\n JP), a-line, PIV\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:00 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 01:09 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: 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": "Respiratory ", "chartdate": "2157-01-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651398, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\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: Crackles\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: On vent support/ PEEP increased for low Sats.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments: Pt has hiccuos.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n Unable to complete RSBI as RR > 35bpm.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Underlying illness not resolved;\n Comments: Bronchoscopy planned this AM.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651603, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n ETT:\n Position: 23 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Tan / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: No vent changes last 24 hrs.\n Assessment of breathing comfort: No response (sleeping / sedated);\n Comments: On propofol.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously, Frequent failed\n trigger efforts\n Dysynchrony assessment:\n Comments: Hiccups on/off.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Unable to complete RSBI r > 35bpm.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Intolerant of weaning attempts, Cannot protect airway, Underlying\n illness not resolved; Comments: ? possible trach.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653219, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 60 cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th bld tinged sput.\n ABGs respiratory alkalosis with good oxygenation ; no vent changes\n required overnoc. Cont mech vent support.\n" }, { "category": "Nursing", "chartdate": "2156-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651106, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2156-12-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651160, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Inconsistent neurological exam. Follows commands with left side\n generally/wiggling toes and squeezing hand. No spontaneous movement\n noted with right side, no withdrawal to nailbed pressure with right\n side. Opens eyes to speech and at times sticks out tongue and opens\n mouth. Fever spike to 103.2. Ventriculostomy at 10cmH2O above tragus\n draining serosang drainage\n Action:\n Head Ct done. Tylenol and cooling blanket administered. Pan cultured.\n CSF culture per neurosurg with resulting leak from sample port\n requiring change of drainage system promptly per neurosurg resident.\n Response:\n CT results pending. No effects from Tylenol or cooling blanket-Dr. \n and neurosurg aware.\n Plan:\n Continue to monitor neurological status. F/u on CSF cx results and\n continue to address temp spike with Dr. . Possible aneurysm coiling\n per Dr. .\n Hypertension, benign\n Assessment:\n Hypertensive to 170\n Action:\n Nicardipine IV on and off to maintain BP<140. Labetolol and Lopressor\n used PRN d/t Po meds delayed x1-2hrs after head CT due to inadvertent\n dislodging of feeding tube by CT tech, requiring reinsertion of pedi\n tube which was confirmed per CXR.\n Response:\n Po meds with good effect, weaning Nicardipine this pm. BP<140 systolic.\n Plan:\n Continue to monitor BP and keep <140sys.\n Problem - Social\n Assessment:\n Pt. is sole caregiver mother.\n Action:\n asked to facilitate care of mother by\n coordinating friends and family.\n Response:\n Spoke to cousin, , who is only nearby relative and put her\n in touch with who coordinated care of mother by as well as\n network of friends.\n :\n Continue to reassure pt. that his mother will be cared for.\n" }, { "category": "Physician ", "chartdate": "2157-01-06 00:00:00.000", "description": "Intensivist Note", "row_id": 652175, "text": "SICU\n HPI:\n 53M p/w left pontine and medullary hemorrhage complicated by failed\n extubation and fevers\n Chief complaint:\n left pontine and medullary hemorrhage\n PMHx:\n ?HTN\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n BLOOD CULTURED - At 12:37 PM\n URINE CULTURE - At 12:37 PM\n INTRAVENTRICULAR DRAIN INSERTED - At 11:00 PM\n FEVER - 102.5\nF - 12:00 PM\n Post operative day:\n HD11\n 24hr events: Fever, pan culture. Ordered PICC, ancef d/c as on vanco.\n Bowel regimen started- pending BM. PO Hydral added. Lasix 20 for pulm\n edema; ?traumatic foley. Optho came, cultured left cornea. EVD not\n draining. Dr. to replace. post procedure CT showing blood\n tracking EVD. HCT stable. for repeat head CT 8AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Fluconazole - 04:00 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 01:00 PM\n Labetalol - 07:05 PM\n Metoprolol - 08:26 PM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 38\nC (100.4\n HR: 97 (90 - 112) bpm\n BP: 148/64(91) {115/56(76) - 184/83(119)} mmHg\n RR: 18 (15 - 27) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (7 - 18) mmHg\n Total In:\n 1,805 mL\n 154 mL\n PO:\n Tube feeding:\n 233 mL\n 82 mL\n IV Fluid:\n 1,461 mL\n 72 mL\n Blood products:\n Total out:\n 3,654 mL\n 520 mL\n Urine:\n 3,300 mL\n 460 mL\n NG:\n 125 mL\n Stool:\n Drains:\n 229 mL\n 60 mL\n Balance:\n -1,849 mL\n -366 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 368 (368 - 756) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.47/33/128//1\n Ve: 9.7 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: frequent hiccupps\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n moves LUE and LLE weakly on verbal command. no movement on right.\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n 11:41 AM\n 06:36 PM\n WBC\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 32\n 28\n 29\n 24\n 25\n Glucose\n 159\n 122\n 78\n 105\n 100\n 103\n 115\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M p/w left pontine and medullary hemorrhage\n complicated by failed extubation and fevers\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n \n Pulmonary: Trach, (Ventilator mode: CPAP + PS), s/p Trach. on\n CPAP+PS. cont to ween to trach collar as tol.\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- may add thorazine if pt has BMs per neuro.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, keep I=O to prevent pulm edema. lasix as\n needed\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - drops added, but did not\n have ones rec by optho, placed on Cipro drops. - will revisit \n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Optho\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:50 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651228, "text": " Problem - Hyperthermia\n Assessment:\n Pt\ns TMAX 103.6. Lowest temp 99.7. Continues to spike temp thru out\n shift.\n Action:\n Cooling blanket for temps above 101.9. Tylenol 650mg. Aggressive\n pulmonary toileting. SICU resident aware of fluctuating temps\n thru out shift.\n Response:\n Actions appeared effective. Currently attempting to lower temp again\n with same actions.\n Plan:\n Continue cooling blanket PRN. Pulmonary toileting. Awaiting culture\n results from .\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt at beginning of shift presented with HTN, Tachycardic and elevated\n RR. Constant hiccups. Moderate secretions, thick yellow.\n Action:\n Vercid 2mg. Reglan ordered x1, Propofol gtt started and ventilator\n settings adjusted.\n Response:\n Pt responded well to Reglan, Propofol gtt and ventilator on assist\n control.\n Plan:\n Continue patient on ventilator. Assist Control PRN? Continue propofol\n gtt while intubated. Continue to suction frequently.\n Hypertension, benign\n Assessment:\n Pt hypertensive for most of the shift. Nicardipine gtt from 1.5mg\n 3.0\n mcg for SBP <140.\n Action:\n Nicardipine gtt off for hypotensive period this am at 0530.\n Response:\n SICU resident aware. Cuff pressure and Aline correlate.\n Propofol gtt decreased to 20mcg.\n Plan:\n Continue to monitor closely. Adjust hypertensives accordingly.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651494, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 Comments: Hiccups\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: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651539, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Opens eyes to name will follow some simple commands (show 2 fingers\n etc) on lf side only..icp <15 draining serous mod amt @ 15cm at tragus\n Action:\n Dropped bp 80/\ns after 1600 meds(nimod/lopressor/hydralazine) propol\n gtt off..repositioned & stimulated\n Response:\n Bp back up to >100/ somewhat agitated\n Plan:\n Restart propofol..will decrease lopressor & dc hydralazine..keep spb\n <160/ per neuro surgery team..angio in am..hold tf\ns after mn..continue\n with neuro checks q2h\n" }, { "category": "Respiratory ", "chartdate": "2157-01-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 651814, "text": "Demographics\n Day of mechanical ventilation: 8\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 7.5mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Green / Plug\n Sputum source/amount: Suctioned / Copious\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: Tracheostomy planned\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 5am\n" }, { "category": "Physician ", "chartdate": "2157-01-06 00:00:00.000", "description": "Intensivist Note", "row_id": 652237, "text": "SICU\n HPI:\n 53M p/w left pontine and medullary hemorrhage complicated by failed\n extubation and fevers\n Chief complaint:\n left pontine and medullary hemorrhage\n PMHx:\n ?HTN\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n BLOOD CULTURED - At 12:37 PM\n URINE CULTURE - At 12:37 PM\n INTRAVENTRICULAR DRAIN INSERTED - At 11:00 PM\n FEVER - 102.5\nF - 12:00 PM\n Post operative day:\n HD11\n 24hr events: Fever, pan culture. Ordered PICC, ancef d/c as on vanco.\n Bowel regimen started- pending BM. PO Hydral added. Lasix 20 for pulm\n edema; ?traumatic foley. Optho came, cultured left cornea. EVD not\n draining. Dr. to replace. post procedure CT showing blood\n tracking EVD. HCT stable. for repeat head CT 8AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Fluconazole - 04:00 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 01:00 PM\n Labetalol - 07:05 PM\n Metoprolol - 08:26 PM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 38\nC (100.4\n HR: 97 (90 - 112) bpm\n BP: 148/64(91) {115/56(76) - 184/83(119)} mmHg\n RR: 18 (15 - 27) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (7 - 18) mmHg\n Total In:\n 1,805 mL\n 154 mL\n PO:\n Tube feeding:\n 233 mL\n 82 mL\n IV Fluid:\n 1,461 mL\n 72 mL\n Blood products:\n Total out:\n 3,654 mL\n 520 mL\n Urine:\n 3,300 mL\n 460 mL\n NG:\n 125 mL\n Stool:\n Drains:\n 229 mL\n 60 mL\n Balance:\n -1,849 mL\n -366 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 368 (368 - 756) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.47/33/128//1\n Ve: 9.7 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: frequent hiccupps\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n moves LUE and LLE weakly on verbal command. no movement on right.\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n 11:41 AM\n 06:36 PM\n WBC\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 32\n 28\n 29\n 24\n 25\n Glucose\n 159\n 122\n 78\n 105\n 100\n 103\n 115\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M p/w left pontine and medullary hemorrhage\n complicated by failed extubation and fevers\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n \n Pulmonary: Trach, (Ventilator mode: CPAP + PS), s/p Trach. on\n CPAP+PS. cont to ween to trach collar as tol.\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- may add thorazine if pt has BMs per neuro.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, keep I=O to prevent pulm edema. lasix as\n needed\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - drops added, but did not\n have ones rec by optho, placed on Cipro drops. - will revisit \n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Optho\n Billing Diagnosis: Hemmorhage, Resp Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:50 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-06 00:00:00.000", "description": "Intensivist Note", "row_id": 652241, "text": "SICU\n HPI:\n 53M p/w left pontine and medullary hemorrhage complicated by failed\n extubation and fevers\n Chief complaint:\n left pontine and medullary hemorrhage\n PMHx:\n ?HTN\n Current medications:\n 24 Hour Events:\n TRANSTHORACIC ECHO - At 12:00 PM\n BLOOD CULTURED - At 12:37 PM\n URINE CULTURE - At 12:37 PM\n INTRAVENTRICULAR DRAIN INSERTED - At 11:00 PM\n FEVER - 102.5\nF - 12:00 PM\n Post operative day:\n HD11\n 24hr events: Fever, pan culture. Ordered PICC, ancef d/c as on vanco.\n Bowel regimen started- pending BM. PO Hydral added. Lasix 20 for pulm\n edema; ?traumatic foley. Optho came, cultured left cornea. EVD not\n draining. Dr. to replace. post procedure CT showing blood\n tracking EVD. HCT stable. for repeat head CT 8AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Fluconazole - 04:00 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 01:00 PM\n Labetalol - 07:05 PM\n Metoprolol - 08:26 PM\n Other medications:\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.2\nC (102.5\n T current: 38\nC (100.4\n HR: 97 (90 - 112) bpm\n BP: 148/64(91) {115/56(76) - 184/83(119)} mmHg\n RR: 18 (15 - 27) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 14 (7 - 18) mmHg\n Total In:\n 1,805 mL\n 154 mL\n PO:\n Tube feeding:\n 233 mL\n 82 mL\n IV Fluid:\n 1,461 mL\n 72 mL\n Blood products:\n Total out:\n 3,654 mL\n 520 mL\n Urine:\n 3,300 mL\n 460 mL\n NG:\n 125 mL\n Stool:\n Drains:\n 229 mL\n 60 mL\n Balance:\n -1,849 mL\n -366 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 368 (368 - 756) mL\n PS : 10 cmH2O\n RR (Set): 14\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 15 cmH2O\n Plateau: 15 cmH2O\n SPO2: 96%\n ABG: 7.47/33/128//1\n Ve: 9.7 L/min\n PaO2 / FiO2: 320\n Physical Examination\n General Appearance: frequent hiccupps\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : ), (Sternum: Stable )\n Abdominal: Soft, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n moves LUE and LLE weakly on verbal command. no movement on right.\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 115 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n 11:41 AM\n 06:36 PM\n WBC\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 32\n 28\n 29\n 24\n 25\n Glucose\n 159\n 122\n 78\n 105\n 100\n 103\n 115\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M p/w left pontine and medullary hemorrhage\n complicated by failed extubation and fevers\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n \n Pulmonary: Trach, (Ventilator mode: CPAP + PS), s/p Trach. on\n CPAP+PS. cont to ween to trach collar as tol.\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- may add thorazine if pt has BMs per neuro.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, keep I=O to prevent pulm edema. lasix as\n needed\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - drops added, but did not\n have ones rec by optho, placed on Cipro drops. - will revisit \n Imaging: CT scan head today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Optho\n Billing Diagnosis: Hemmorhage, Resp Failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:50 AM 20 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 AM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-14 00:00:00.000", "description": "Intensivist Note", "row_id": 653878, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n Chief complaint:\n SAH, IVH left lateral ventricle\n PMHx:\n ?Hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. CefazoLIN. Chlorhexidine\n Gluconate 0.12% Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid).\n Famotidine. Fentanyl Citrate. FoLIC Acid. Heparin. HydrALAzine.\n Insulin. Labetalol. Magnesium Sulfate. Multivitamins.\n OxycoDONE-Acetaminophen Elixir. Phenytoin. Potassium Chloride. Thiamine\n 24 Hour Events:\n PAN CULTURE - At 05:00 PM\n Blood, urine, sputum\n FEVER - 102.0\nF - 04:00 PM\n Pancultured for fever to 102\n ICP persistently 21-23 so EVD uncapped and drained at 20cm H2O\n NPO/IVF for potential VPS or EVD removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:44 AM\n Infusions:\n Other ICU medications:\n Labetalol - 10:00 PM\n Hydralazine - 02:00 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 38.2\nC (100.7\n HR: 96 (96 - 115) bpm\n BP: 136/62(88) {136/62(88) - 195/88(128)} mmHg\n RR: 22 (13 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 8 (6 - 21) mmHg\n Total In:\n 1,045 mL\n 373 mL\n PO:\n Tube feeding:\n 265 mL\n 3 mL\n IV Fluid:\n 390 mL\n 310 mL\n Blood products:\n Total out:\n 2,125 mL\n 562 mL\n Urine:\n 2,100 mL\n 540 mL\n NG:\n Stool:\n Drains:\n 25 mL\n 22 mL\n Balance:\n -1,081 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SPO2: 96%\n ABG: 7.46/34/106/24/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, Left pupil reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: coarse breath sounds bilaterally\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent, No(t) 1+), (Temperature: Warm),\n (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: No(t) Absent, 1+), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished), (Pulse - Posterior tibial:\n Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n No(t) Moves all extremities, (RUE: No movement), (RLE: No movement),\n (LLE: Weakness)\n Labs / Radiology\n 481 K/uL\n 10.2 g/dL\n 81 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 109 mEq/L\n 141 mEq/L\n 27.2 %\n 8.5 K/uL\n [image002.jpg]\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n WBC\n 15.4\n 12.0\n 9.4\n 8.5\n Hct\n 30.6\n 26.5\n 29.1\n 27.2\n Plt\n 81\n Creatinine\n 1.7\n 1.6\n 1.4\n 1.2\n 1.3\n TCO2\n 22\n 22\n 22\n 23\n 25\n Glucose\n 100\n 96\n 121\n 114\n 81\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.3 mg/dL,\n Mg:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, dilantin,\n repeat head CT, ICP sustained in 20s so EVD opened to 20cm H2O\n drainage, likely needs VPS\n CV: goal SBP < 180, labetolol po, prn Hydralazine\n Resp: s/p Trach, wean to PSV\n GI: TFs held via PEG\n GU: adequate UOP, renal failure resolving\n FEN: TFs held, NS @ 75cc/hr\n Heme: stable Hct\n Endo: RISS\n ID: Kefzol for ventric drain, pancultured for temp of 102\n TLD: trach, foley, a-line, EVD, PEG\n Wound: left corneal ulcer, optho following - on bacitracin oint\n Prophylaxis: famotidine, SQH\n Imaging: none\n ICU Care\n Nutrition: npo\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 AM\n Prophylaxis:\n DVT: SQ Heparin\n Stress ulcer: H@\n VAP bundle:\n Code status: Full code\n Disposition: SICU To OR today\n Total time spent: 31 minutes\n" }, { "category": "Nutrition", "chartdate": "2157-01-14 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 653894, "text": "Current Wt: 73.2kg\n Adm Wt: 67kg\n Pertinent medications: NS@ 75cc/hr, others noted\n Labs:\n Value\n Date\n Glucose\n 81 mg/dL\n 02:32 AM\n Glucose Finger Stick\n 139\n 11:00 AM\n BUN\n 24 mg/dL\n 02:32 AM\n Creatinine\n 1.3 mg/dL\n 02:32 AM\n Sodium\n 141 mEq/L\n 02:32 AM\n Potassium\n 4.4 mEq/L\n 02:32 AM\n Chloride\n 109 mEq/L\n 02:32 AM\n TCO2\n 24 mEq/L\n 02:32 AM\n PO2 (arterial)\n 106 mm Hg\n 04:59 AM\n PCO2 (arterial)\n 34 mm Hg\n 04:59 AM\n pH (arterial)\n 7.46 units\n 04:59 AM\n pH (urine)\n 5.0 units\n 05:00 PM\n CO2 (Calc) arterial\n 25 mEq/L\n 04:59 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 8.3 mg/dL\n 02:32 AM\n Phosphorus\n 3.7 mg/dL\n 02:32 AM\n Ionized Calcium\n 1.15 mmol/L\n 03:35 AM\n Magnesium\n 2.2 mg/dL\n 02:32 AM\n Phenytoin (Dilantin)\n 14.5 ug/mL\n 02:32 AM\n WBC\n 8.5 K/uL\n 02:32 AM\n Hgb\n 10.2 g/dL\n 02:32 AM\n Hematocrit\n 27.2 %\n 02:32 AM\n Current diet order / nutrition support: TF: off for OR\n Assessment of Nutritional Status\n Pt\ns TF again off today for VP shunt placement in OR. TF was running\n x8hrs last night prior to it being turned off at MN. TF rx is a\n concentrated formula with added protein to meet pt\ns needs with minimal\n free H20. Pt\ns hyponatremia has resolved, so will provide recs for a\n TF rx with more fluid if this becomes necessary.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Post-procedure, rec restart TF at previous goal: Nutren 2.0 @\n 30cc/hr + 30g Beneprotein (1547kcal, 84g protein).\n 2) If pt starts requiring more H20 to maintain normal Na, rec\n change TF goal to Replete with Fiber @ 65cc/hr (1560kcal, 97g protein).\n 3) Will follow plan re: long term feeding tube placement per\n family decision.\n 4) Monitor lytes and hydration.\n Please page with ?\ns #\n" }, { "category": "Physician ", "chartdate": "2157-01-10 00:00:00.000", "description": "Intensivist Note", "row_id": 653100, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tears, Bacitracin/Polymyxin B Sulfate Opht.\n Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12% Oral\n Rinse, Docusate Sodium (Liquid), Famotidine, Fentanyl Citrate,\n Fluconazole, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol,\n Magnesium Sulfate, Metoprolol Tartrate, Multivitamins, NiCARdipine,\n Nimodipine, OxycoDONE-Acetaminophen Elixir, Phenytoin,\n Piperacillin-Tazobactam Na, Potassium Chloride, Propofol, Thiamine\n 24 Hour Events:\n ULTRASOUND - At 09:30 AM\n kidney ultrasound\n FEVER - 101.1\nF - 12:00 AM\n : due to elevated creatinine urine electrolytes requested by renal,\n lasix stopped, renal ultrasound ordered no hydronephrosis, decreased\n responsiveness = Head CT slight increase in ventric size, other\n hemmorhages stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Flowsheet Data as of 09:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 38.3\nC (100.9\n HR: 86 (75 - 103) bpm\n BP: 129/57(81) {103/51(69) - 179/81(115)} mmHg\n RR: 16 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (2 - 14) mmHg\n Total In:\n 1,556 mL\n 560 mL\n PO:\n Tube feeding:\n 720 mL\n 220 mL\n IV Fluid:\n 656 mL\n 100 mL\n Blood products:\n Total out:\n 2,340 mL\n 650 mL\n Urine:\n 2,200 mL\n 565 mL\n NG:\n Stool:\n Drains:\n 140 mL\n 85 mL\n Balance:\n -784 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 61\n PIP: 24 cmH2O\n Plateau: 13 cmH2O\n SPO2: 97%\n ABG: 7.43/32/126/22/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Labs / Radiology\n 451 K/uL\n 11.6 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 25 mg/dL\n 102 mEq/L\n 131 mEq/L\n 31.8 %\n 11.3 K/uL\n [image002.jpg]\n 12:34 PM\n 04:00 PM\n 06:15 PM\n 03:00 AM\n 03:11 AM\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n WBC\n 8.1\n 9.3\n 11.3\n Hct\n 32.1\n 32.1\n 31.8\n Plt\n \n Creatinine\n 1.4\n 1.5\n 1.6\n 1.7\n TCO2\n 21\n 21\n 21\n 22\n Glucose\n 163\n 122\n 136\n 134\n 100\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.0 mg/dL,\n Mg:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: left pontine and medullary hemorrhage; EVD drain replaced\n . Cont dilantin; Cont nomodipine. neurosurg/neurology following;\n minimize PPF gtt sedation\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n but currently off\n Pulmonary: (Ventilator mode: CMV), s/p Trach. cont to ween to trach\n collar as tol\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr\n Nutrition: Tube feeding, TF started - Replete with fiber Full strength\n goal 60\n Renal: Foley, Adequate UO, keep I=O to prevent pulm edema. follow serum\n osm, hyponatremia improving, q6h Na checks per renal. concern for\n increasing Cr\n Hematology: Serial Hct, follow Hct - trending down somewhat, will\n continue to follow\n Endocrine: RISS, FS well controlled\n Infectious Disease: continue to follow cultures for spiking fevers,\n change zosyn to ancef, WBC count (trending down); fluc for yeast on\n sputum but has been on it for 10 days.\n Lines / Tubes / Drains: Trach, will eventually need PICC, trach, foley,\n a-line, EVD, PEG\n Wounds:\n Imaging: CXR today\n Fluids: KVO, TF\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-01-10 00:00:00.000", "description": "Intensivist Note", "row_id": 653101, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tears, Bacitracin/Polymyxin B Sulfate Opht.\n Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12% Oral\n Rinse, Docusate Sodium (Liquid), Famotidine, Fentanyl Citrate,\n Fluconazole, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol,\n Magnesium Sulfate, Metoprolol Tartrate, Multivitamins, NiCARdipine,\n Nimodipine, OxycoDONE-Acetaminophen Elixir, Phenytoin,\n Piperacillin-Tazobactam Na, Potassium Chloride, Propofol, Thiamine\n 24 Hour Events:\n ULTRASOUND - At 09:30 AM\n kidney ultrasound\n FEVER - 101.1\nF - 12:00 AM\n : due to elevated creatinine urine electrolytes requested by renal,\n lasix stopped, renal ultrasound ordered no hydronephrosis, decreased\n responsiveness = Head CT slight increase in ventric size, other\n hemmorhages stable\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Flowsheet Data as of 09:58 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 38.3\nC (100.9\n HR: 86 (75 - 103) bpm\n BP: 129/57(81) {103/51(69) - 179/81(115)} mmHg\n RR: 16 (15 - 21) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (2 - 14) mmHg\n Total In:\n 1,556 mL\n 560 mL\n PO:\n Tube feeding:\n 720 mL\n 220 mL\n IV Fluid:\n 656 mL\n 100 mL\n Blood products:\n Total out:\n 2,340 mL\n 650 mL\n Urine:\n 2,200 mL\n 565 mL\n NG:\n Stool:\n Drains:\n 140 mL\n 85 mL\n Balance:\n -784 mL\n -90 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 61\n PIP: 24 cmH2O\n Plateau: 13 cmH2O\n SPO2: 97%\n ABG: 7.43/32/126/22/-1\n Ve: 8.8 L/min\n PaO2 / FiO2: 315\n Physical Examination\n Neuro: unchanged, moving spontaneously\n Resp: trached on CMV.\n CV: RRR, stable\n Abd: soft NT/ND\n Ext: dependent edema\n Labs / Radiology\n 451 K/uL\n 11.6 g/dL\n 100 mg/dL\n 1.7 mg/dL\n 22 mEq/L\n 3.8 mEq/L\n 25 mg/dL\n 102 mEq/L\n 131 mEq/L\n 31.8 %\n 11.3 K/uL\n [image002.jpg]\n 12:34 PM\n 04:00 PM\n 06:15 PM\n 03:00 AM\n 03:11 AM\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n WBC\n 8.1\n 9.3\n 11.3\n Hct\n 32.1\n 32.1\n 31.8\n Plt\n \n Creatinine\n 1.4\n 1.5\n 1.6\n 1.7\n TCO2\n 21\n 21\n 21\n 22\n Glucose\n 163\n 122\n 136\n 134\n 100\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.0 mg/dL,\n Mg:2.4 mg/dL, PO4:2.9 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: left pontine and medullary hemorrhage; EVD drain replaced\n . Cont dilantin; Cont nomodipine. neurosurg/neurology following;\n minimize PPF gtt sedation\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n but currently off\n Pulmonary: (Ventilator mode: CMV), s/p Trach. cont to ween to PS as\n tolerated\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr\n Nutrition: Tube feeding, TF started - Replete with fiber Full strength\n goal 60\n Renal: Foley, Adequate UO, keep I=O to prevent pulm edema. follow serum\n osm, hyponatremia improving, q6h Na checks per renal. concern for\n increasing Cr\n Hematology: Serial Hct, follow Hct - trending down somewhat, will\n continue to follow\n Endocrine: RISS, FS well controlled\n Infectious Disease: continue to follow cultures for spiking fevers,\n change zosyn to ancef, WBC count (trending down); fluc for yeast on\n sputum but has been on it for 10 days.\n Lines / Tubes / Drains: Trach, will eventually need PICC, trach, foley,\n a-line, EVD, PEG\n Imaging: CXR today\n Fluids: KVO, TF\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition: TF\n Glycemic Control RISS:\n Lines: arterial line, PIV, trach, foley\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\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": "2157-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653175, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - neuro assessment: pupil on R side is and reactive, pupil\n on L side is unable to assess, eye is clouded and has one suture\n - pt will inconsistently squeeze L hand and L toes, pt does\n not move R side\n - pt does not communicate in any way\n - ventriculostomy drain at 20 above the tragus\n Action:\n - q1h eye drops for R eye and q4h ointment for L eye\n - monitor ICP and ventriculostomy\n Response:\n - neuro assessments consistent throughout the day\n - minimal drainage from ventriculostomy\n - dressing changed by neurosurg\n Plan:\n - continue q1h neuro assessments\n - continue eye drops as ordered\n - continue ventriculostomy at 20 above tragus\n - to OR tomorrow for VP shunt\n - hold tube feeds after midnight\n - start on IV fluids\n - PICC line tomorrow ?\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n - tmax 101.7\n Action:\n - given Tylenol 650\n Response:\n - awaiting response from Tylenol\n Plan:\n - continue to assess and treat temperature\n Hypertension, benign\n Assessment:\n - pt hypertensive this afternoon > systolic 180\n - pt had been on CPAP for a few hours\n Action:\n - Hydralazine 10mg given\n - Fentanyl 50mcg given\n - Vent settings changed back to CMV\n Response:\n - BP stabilized to < 180 after vent settings changed\n Plan:\n - continue to assess and treat hypertension\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n - low sodium level on AM labs\n Action:\n - pt started on sodium tabs and is receiving NS as TF flushes\n Response:\n - sodium level increased to normal range this afternoon\n Plan:\n - continue with salt tabs as ordered and assess sodium levels\n" }, { "category": "Respiratory ", "chartdate": "2157-01-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652308, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 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 / Thin\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use, Gasping\n efforts\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment: Vigorous inspiratory efforts\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 Patients spontaneous efforts very inconsistent with quick gasping\n efforts while on CPAP/PSV. More consistant efforts while on CMV mode as\n well as a more controlled work of breathing.\n" }, { "category": "Physician ", "chartdate": "2157-01-08 00:00:00.000", "description": "Intensivist Note", "row_id": 652628, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n FEVER - 102.4\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:37 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 04:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.1\nC (102.4\n T current: 36.7\nC (98\n HR: 87 (69 - 109) bpm\n BP: 134/61(85) {86/44(57) - 178/76(110)} mmHg\n RR: 19 (12 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 11 (6 - 16) mmHg\n Total In:\n 3,652 mL\n 1,278 mL\n PO:\n Tube feeding:\n 891 mL\n 143 mL\n IV Fluid:\n 2,401 mL\n 1,135 mL\n Blood products:\n Total out:\n 2,025 mL\n 127 mL\n Urine:\n 1,895 mL\n 113 mL\n NG:\n Stool:\n Drains:\n 130 mL\n 14 mL\n Balance:\n 1,627 mL\n 1,151 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (550 - 600) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 153\n PIP: 26 cmH2O\n Plateau: 16 cmH2O\n SPO2: 99%\n ABG: 7.41/37/125/19/0\n Ve: 9.8 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 368 K/uL\n 8.6 g/dL\n 106 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.3 mEq/L\n 14 mg/dL\n 101 mEq/L\n 126 mEq/L\n 23.7 %\n 7.3 K/uL\n [image002.jpg]\n 09:47 PM\n 10:08 PM\n 01:15 AM\n 01:18 AM\n 05:56 AM\n 06:05 AM\n 03:36 PM\n 10:14 PM\n 02:37 AM\n 03:01 AM\n WBC\n 10.7\n 7.3\n Hct\n 28.6\n 23.7\n Plt\n 390\n 368\n Creatinine\n 0.5\n 0.6\n 0.5\n 0.6\n 0.8\n TCO2\n 30\n 29\n 27\n 27\n 24\n Glucose\n 127\n 115\n 138\n 117\n 106\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.2 mg/dL,\n Mg:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY),\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M withpontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . Cont dilantin; Cont nomodipine. minimize PPF gtt\n sedation; Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN;\n Pulmonary: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6, nimotop\n 60q4; labetalol prn, hydral PRN;\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- thorazine\n Nutrition: Tube feeding\n Renal: keep I=O to prevent pulm edema. lasix 20BID per renal; follow\n serum osmhyponatremic this AM. hypertonic saline, q6h Na checks per\n renal\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:56 PM 30 mL/hour\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35min\n" }, { "category": "Respiratory ", "chartdate": "2157-01-14 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653959, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 18\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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 / Frothy\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 Periodic SBT's for conditioning\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 0930\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654020, "text": "Demographics\n Day of mechanical ventilation: 19\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\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 / Frothy\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Transported to ct without incident.\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652599, "text": "Hypotension (not Shock)\n Assessment:\n SBP 80\ns sustaining x 3 hrs\n More lethargic with decreased BP\n U/o dropping off after several hours\n Action:\n Dr (SICU) and neurology HO notified and aware of all BP trends\n Nicardipine previously shut off\n All antihypertensives held\n Lasix held\n HOB to 15 to maintain SBP >80\n NS bolus given (SICU HO notified neurology)\n Response:\n SBP sustaining >100 after bolus\n U/o remains marginal\n Plan:\n Cont to hold all antiypertensives, monitor bp closely, notify SICU HO\n and neurology of all changes in BP.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n NA 125 this evening, up to 127 at 2200\n Action:\n Cont on fluid restriction, NS flush with meds, 3% saline at 20cc x 20\n hrs.\n Response:\n Na correcting slowly\n Plan:\n Cont with current plan and monitor Q6 NA level.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Corneal Abrasion\n Assessment:\n Left eye with +corneal abrasion, sutured partially shut. Unable to\n fully shut with tape.\n Action:\n Artificial tears Q1 hr, bacitracian ointment Q6 hrs\n Response:\n No change\n Plan:\n Cont with current plant, ophthalmology following closely.\n ------ Protected Section------\n ------ Protected Section Error Entered By: , RN\n on: 02:32 ------\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652992, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt pupils pinpoint right pupil does reactive to light, left pupil\n unable to assess secondary to cloudiness\n pt does not open his eyes to stimuli, no withdrawal of extremties to\n painful stimuli, pt had just finished receiving iv thorazine\n Action:\n Dr. called and up to assess patient.\n Response:\n Pt to have head ct\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-01-05 00:00:00.000", "description": "Intensivist Note", "row_id": 652005, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:15 PM\n PEG INSERTION - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 05:56 PM\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:15 PM\n Fentanyl - 04:00 PM\n Famotidine (Pepcid) - 08:08 PM\n Heparin Sodium (Prophylaxis) - 01:09 AM\n Hydralazine - 01:09 AM\n Labetalol - 04:03 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: 38\nC (100.4\n T current: 36.7\nC (98.1\n HR: 110 (87 - 111) bpm\n BP: 188/80(83) {114/55(78) - 193/94(132)} mmHg\n RR: 16 (14 - 26) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (1 - 23) mmHg\n Total In:\n 3,666 mL\n 650 mL\n PO:\n Tube feeding:\n 4 mL\n IV Fluid:\n 3,182 mL\n 540 mL\n Blood products:\n Total out:\n 1,711 mL\n 545 mL\n Urine:\n 1,370 mL\n 475 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 191 mL\n 70 mL\n Balance:\n 1,955 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 574 (574 - 574) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SPO2: 94%\n ABG: 7.45/40/160/27/4\n Ve: 6.9 L/min\n PaO2 / FiO2: 400\n Physical Examination\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 100 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n WBC\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 147\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 27\n 32\n 28\n 29\n Glucose\n 125\n 120\n 159\n 122\n 78\n 105\n 100\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: s/p angio which revealed right vertebral artery occlusion,\n no intervention; Dilantin therapeutic; MRI and repeat head CTs done -\n no sig interval changes; s/p EVD drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; f/u CSF\n cxs\n Cardiovascular: goal SBP<160mmHg; lopressor75 , labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: CPAP+PS intubated/sedated, unable to extubate as weak gag,\n poor mental status\n Gastrointestinal / Abdomen: s/p PEG, restart TF today\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: no issues\n Endocrine: RISS\n Infectious Disease:\n on ancef for EVD, f/u cx's, WBC count (trending down); fluc for yeast\n on sputum, started on Vanc \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 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: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652012, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\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: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Weaned from vent suport/assist to PSV as tol!!!\n Assessment of breathing comfort: No response (sleeping / sedated)\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 Maintain PEEP at current level and reduce FiO2 as tolerated, Reduce\n PEEP as tolerated; Comments: RSBI done ~43.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652013, "text": "53M presented to on with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery. Initial neuro exam on admission:\n able to follow basic commands. brainstem reflexes appear preserved. He\n squeezes his hands bilaterally, more strongly on the left, and is able\n to voluntarily bend his left knee, just lifting it off the bed. He is\n not moving the right voluntarily. He withdraws in all four extremities,\n left side more briskly than right.\n PMHx: HTN\n Recent events:\n : IR for cerebral angio- right vertebral artery occlusion\n without intervention.\n : Trach and Peg done\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, ventric drain in place- open at 10cm above Tragus. ICP\n . Draining straw colored CSF, approx 10-15ml/hr. CPP 80-100. See\n neuro assessment.\n Action:\n Minimize stimuli, lights low.\n Response:\n No changes in neuro assessment, propofol help q2hr for neuro\n assessment. Pt wakes up in 15-20 minutes. ? purposeful or\n reflective movement to hand grasps.\n Plan:\n Per neurosurg team, will leave drain open at 10cm above Tragus.\n Follow-up CT in am.\n Rash\n Assessment:\n Small pink/red dots over knees, lower legs, abdomen, back, shoulders,\n and thighs.\n Action:\n Bathed. Medication review\n Response:\n Rash remains\n Plan:\n Continue to observe / contact rash versus drug rash.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Intubated for airway protection. Trach done . Draining minimal\n amt of blood around trach site. Sx trach for thin clear secretions.\n Inc. amt of oral secretions, oral suction q 2hr. RT weaning vent.\n Weaned to CPAP.40/8/10. RR 20\ns/TV 400\ns. RSBI=43.\n Action:\n Trach suction q4hr and oral suction q2hr. ABG sent with AM labs.\n Weaned pt to CPAP\n Response:\n Trach secretion improved from clear blood tinged secretions to clear\n secretions. ABG this am 7.45/40/160. After vent wean to CPAP, pt with\n periodic hiccups, RT aware.\n Plan:\n Cont. to suction patient. Wean vent as tolerated. Monitor ABGs\n Hypertension, benign\n Assessment:\n SBP goal <160. SBP 140-150\ns. At 0100, SBP 177. at 0400, BP 188/80\n Action:\n Hydralazine 10mg given IVP @ 0100. Labetalol 10mg given IVP at 0400.\n Response:\n At 0130, BP decreased to 140/60\ns post hydralazine. At 0410, decreased\n BP to 125/61 post labetalol.\n Plan:\n Continue to assess BP for HTN. Hydralazine/Labetalol Prn.\n Addendum:\n Peg may be used for meds. Will evaluate for TF within 24hrs (approx\n at 4pm). Currently Peg to gravity.\n Left eye with redness and periorbital edema. Limiting position towards\n left to decrease swelling. Erythromycin ointment applied. Rinsed eyes\n with NS.\n DM: FSBG q6hr. BS 130-180\ns, requiring Regular Insulin coverage per\n RISS.\n 0400 K=3.8, 40meq KCl given PO.\n Plan: CT in am, Resume TF this am, cont. to monitor ICP/CPP, wean vent\n as tolerated & monitor respiratory status, cont. q2hr neuron\n assessments, prn labetalol/hydralazine to keep SBP<160, monitor FSBG\n q6hr, t&pq2hr (minimal time turned to the left due to left eye\n periorbital edema).\n RN CCRN\n" }, { "category": "Respiratory ", "chartdate": "2157-01-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654189, "text": "Demographics\n Day of mechanical ventilation: 20\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\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 Assessment of breathing comfort: No claim of dyspnea)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Attempted to change to psv. Pt tolerated for 1 hour then rr inc to 50\n and appeared agitated.Pt placed back on a/c.\n" }, { "category": "Nursing", "chartdate": "2157-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654282, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt continues to have periods elevated temps. TMAX this shift 101\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652818, "text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium Chloride 3% (Hypertonic) infusion completed at 1200.\n Action:\n Continue to administer NS flushes and limit fluid intake.\n Response:\n Awaiting Evening electrolytes for updated NA+.\n Plan:\n Continue to monitor NA+ closely. Awaiting result from 1800 Lytes.\n Report abnormalities to SICU Team and treat accordingly.\n Hypertension, benign\n Assessment:\n Pt now hypertensive, average SBP 140\ns-170\ns. Increased SBP with any\n activity-repositioning, suctioning, etc.\n Action:\n SICU Resident aware. Boluses of IVP metoprol as ordered. Continued PO\n hypertensives\n Response:\n Responds, maintaining SBP 150\ns-160\n Plan:\n Attempt Fentanyl boluses for better SBP control. ? higher dose of\n anti hypertensives v pain control.\n Anemia, other /Hypotension (not Shock)\n Assessment:\n Pt Hct this am 23.7. Pt appears more lethargic and less interactive\n with neuro exam. U/O diminished < 200 cc/hr. SBP this am 70-80\n sustained. Stool Guiac negative.\n Action:\n SICU team made aware. 1 Liter NS bolus. 2 URBC\n Response:\n Pt responded positively. SBP 140\ns-180. More alert with increased\n general mvt. HCT s/p transfusion 32.1. Pt diuresing appropriately.\n Plan:\n Awaiting result from 1800 HCT. Continue to monitor stool, sputum and\n TF Residual for any signs of bleeding. Continue to monitor strict\n I&O\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653008, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt pupils pinpoint right pupil does reactive to light, left pupil\n unable to assess secondary to cloudiness\n pt does not open his eyes to stimuli, no withdrawal of extremties to\n painful stimuli, pt unresponsive pt had just finished receiving iv\n thorazine, icp have been , ventricular drain remain 20cm above\n tragus, draining blood tinged csf.\n Action:\n Dr. called and up to assess patient.\n Response:\n Pt to have head ct\n Plan:\n Await results for head ct,\n Check neuro signs as ordered.\n Hypertension, benign\n Assessment:\n Neuro team liberalized to keep sbp less than 180\n Action:\n Iv nicardipine weaned to off\n Response:\n Sbp less than 180\n Plan:\n Continue to monitor, give antihypertensives as ordered, keep sbp less\n than 180 per dr. \n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat na 132,k 4.1, serum osomolaity 280\n Action:\n Dr. called and aware\n Response:\n No action taken\n Plan:\n Continue to monitor, check labs as ordered.\n Add: vanco level back as 37.3, dr. aware, vancomycin held.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652130, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation.\n Visual assessment of breathing pattern: Normal quiet breathing.\n Assessment of breathing comfort: No claim of dyspnea.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously.\n Plan\n Next 24-48 hours: Continue weaning as tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts.\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652136, "text": " Problem - Description In Comments\n Assessment:\n Left eye continue to be red, edemous , left eye cloudy at times\n difficult to assess pupil\n Action:\n Optomolgy into assess patient\n Response:\n Cultures taken from left eye ?corneal ulcer\n Plan:\n optomology, continue with antibiotic eye ointmet\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt more lethargic this afternoon. Propofol gtt off. Temp\n 102.5-101 Pt will open his eyes when you call his name. pt will\n intermittently follow commands, pt does move left side spontanouesly\n on bed. Pt will withdraw right leg to painful stimuli, no movement\n noted from right arm with painful stimuli, dr. . hang aware icp drain\n raised to 20cm by neurosurgical team, icp have been less than 16. pt\n drains yellowish/tannish color csf.\n Action:\n Icp drain raised to 20cm\n Pt slightly more lethargic this afternoon\n Response:\n Icp have been less than 20\n Plan:\n Continue to monitor, check nuero signs every 2 hours as\n ordered.\n Hypertension, benign\n Assessment:\n Hypertensive as high as 190\n Hiccups noted dr. aware.\n Action:\n Dr. , dr. . bender aware.Pt received lopressor a\n total of 15mg iv with some effect. Pt received total of 20mg of iv\n hydralazine with some effect, pt received 20mg of iv labetalol, pt\n started on hydralazine via peg and lopressor increased to 75mg tid.\n Response:\n bp less than 160\n Plan:\n continue to monitor, give antihypertensives meds as ordered,\n keep sbp less than 160\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n temp 102.5\n Action:\n blood cultures drawn, urine sent pt received Tylenol supp.\n Pt continues on vanco, and fluconazole as ordered.\n Response:\n Temp down to 101\n Plan:\n Continue to monitor, give antibiotics as ordered\n Await results for blood cultures\n Give antipyretics as ordered.\n Pt with no urine output, foley catheter balloon deflated, some blood\n noted from penis, dr. aware, foley catheter removed, foley catheter\n replaced, no hematuria noted, small amt bleeding noted around penis.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 652529, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: ICH / 431\n Reason of referral: Eval & Treat\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , now\n trials of EVD clamping not well tolerated and will likely have shunt\n placed. SBP goal <160, ICP goal <20\n Past Medical / Surgical History: HTN\n Medications: nicardipine, piperacillin, vancomycin, insulin, heparin\n Radiology: Head CT : No interval change in parenchymal,\n subarachnoid, and\n intraventricular hemorrhage. No change in ventricular enlargement. CXR\n : worsening LLL pna\n Labs:\n 28.6\n 10.6\n 390\n 10.7\n [image002.jpg]\n Other labs:\n pH 7.46\n Activity Orders: OK for sitting at MD \n Social / Occupational History: Pt is primary primary caretaker to his\n mother who is now hospitalized\n Living Environment: unknown\n Prior Functional Status / Activity Level: presumed independent pta\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic but\n arousable with voice, follows very simple commands inconsistently\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 99\n 140/67\n 96% on CMV\n Sit\n /\n Activity\n 110\n 183/82\n 96% on CMV\n Stand\n /\n Recovery\n 104\n 153/70\n 95% on CMV\n Total distance walked: 0\n Minutes:\n Pulmonary Status: On CMV with 40% FIO2, TV 300-800; Coarse breath\n sounds throughout, coughing at edge of bed, inline suction for mod\n amount thick yellow secretions, oral suction large amount of thin clear\n secretions\n Integumentary / Vascular: R sided EVD- clamped t/o tx, R radial a-line,\n 3 PIVs: L hand and forearm, R forearm; foley, vented via trach\n Sensory Integrity: not formally assessed cognitive status\n Pain / Limiting Symptoms: no withdrawal to pain B LE's\n Posture: rounded shoulders in sitting\n Range of Motion\n Muscle Performance\n all extremeties grossly WNL\n not formally assessed, LUE/LE appears grossly , RLE 2-/5, RUE 0/5\n Motor Function: Moves LUE/LE spontaneously and occasionally\n volitionally although inconsistent, spontaneous movement of RLE noted,\n RLE flaccid.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Patient overall dependent for all mobility\n Rolling:\n\n\n\n\n\n X2\n Supine /\n Sidelying to Sit:\n\n\n\n\n X2\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: patient maintained static sitting at edge of bed with max A x5\n min. No postural reflexes noted with weight-shifting\n Education / Communication: Communicated with nsg re: status, encouraged\n patient to use 'thumbs up/down' for communication\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performace, Impaired\n 5. Vent-dependent\n Clinical impression / Prognosis: 53 yo M with ICH p/w above impairments\n a/w non-progressive CNS disorder. He is vent-dependent and will likely\n require shunt, patient may demonstrate improvements in mobility and\n cognition once weaned from vent and shunt placed. As he is following\n commands at this time, rehab potential is optomistic, however this will\n be re-assessed when patient stable enough to tolerate more PT\n intervention.\n Goals\n Time frame: 1 week\n 1.\n Tolerate sitting at edge of bed x 15 min\n 2.\n Follows 50% of simple commands consistently\n 3.\n Able to sit at statically with min-mod assist\n 4.\n Tolerates daily strengthening\n 5.\n Tolerates CPAP with mobility\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, sitting balance, endurance, strengthening,\n education, d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652531, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 11\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 24 cmH2O\n Cuff volume: 8 mL / Air\n Airway problems: P > 30cm/H2O\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: High flow demand\n Assessment of breathing comfort: Pt acknowledges dyspnea\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patients spontaneous inspiratory efforts are erratic with diaphragm in\n an obvious two stage effort. Increased flow, tidal volume and rate has\n made little difference in what appears to be similar to the hiccups.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 652532, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: ICH / 431\n Reason of referral: Eval & Treat\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , now\n trials of EVD clamping not well tolerated and will likely have shunt\n placed. SBP goal <160, ICP goal <20\n Past Medical / Surgical History: HTN\n Medications: nicardipine, piperacillin, vancomycin, insulin, heparin\n Radiology: Head CT : No interval change in parenchymal,\n subarachnoid, and\n intraventricular hemorrhage. No change in ventricular enlargement. CXR\n : worsening LLL pna\n Labs:\n 28.6\n 10.6\n 390\n 10.7\n [image002.jpg]\n Other labs:\n pH 7.46\n Activity Orders: OK for sitting at MD \n Social / Occupational History: Pt is primary primary caretaker to his\n mother who is now hospitalized\n Living Environment: unknown\n Prior Functional Status / Activity Level: presumed independent pta\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic but\n arousable with voice, follows very simple commands inconsistently\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 99\n 140/67\n 96% on CMV\n Sit\n /\n Activity\n 110\n 183/82\n 96% on CMV\n Stand\n /\n Recovery\n 104\n 153/70\n 95% on CMV\n Total distance walked: 0\n Minutes:\n Pulmonary Status: On CMV with 40% FIO2, TV 300-800; Coarse breath\n sounds throughout, coughing at edge of bed, inline suction for mod\n amount thick yellow secretions, oral suction large amount of thin clear\n secretions\n Integumentary / Vascular: R sided EVD- clamped t/o tx, R radial a-line,\n 3 PIVs: L hand and forearm, R forearm; foley, vented via trach\n Sensory Integrity: not formally assessed cognitive status\n Pain / Limiting Symptoms: no withdrawal to pain B LE's\n Posture: rounded shoulders in sitting\n Range of Motion\n Muscle Performance\n all extremeties grossly WNL\n not formally assessed, LUE/LE appears grossly , RLE 2-/5, RUE 0/5\n Motor Function: Moves LUE/LE spontaneously and occasionally\n volitionally although inconsistent, spontaneous movement of RLE noted,\n RLE flaccid.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Patient overall dependent for all mobility\n Rolling:\n\n\n\n\n\n X2\n Supine /\n Sidelying to Sit:\n\n\n\n\n X2\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: patient maintained static sitting at edge of bed with max A x5\n min. No postural reflexes noted with weight-shifting\n Education / Communication: Communicated with nsg re: status, encouraged\n patient to use 'thumbs up/down' for communication\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performace, Impaired\n 5. Vent-dependent\n Clinical impression / Prognosis: 53 yo M with ICH p/w above impairments\n a/w non-progressive CNS disorder. He is vent-dependent and will likely\n require shunt, patient may demonstrate improvements in mobility and\n cognition once weaned from vent and shunt placed. As he is following\n commands at this time, rehab potential is optomistic, however this will\n be re-assessed when patient stable enough to tolerate more PT\n intervention.\n Goals\n Time frame: 1 week\n 1.\n Tolerate sitting at edge of bed x 15 min\n 2.\n Follows 50% of simple commands consistently\n 3.\n Able to sit at statically with min-mod assist\n 4.\n Tolerates daily strengthening\n 5.\n Tolerates CPAP with mobility\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, sitting balance, endurance, strengthening,\n education, d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652784, "text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium Chloride 3% (Hypertonic) infusion completed at 1200.\n Action:\n Continue to administer NS flushes and limit fluid intake.\n Response:\n Awaiting Evening electrolytes for updated NA+.\n Plan:\n Continue to monitor NA+ closely. Awaiting result from 1800 Lytes.\n Report abnormalities to SICU Team and treat accordingly.\n Hypertension, benign\n Assessment:\n Pt now hypertensive, average SBP 140\ns-170\ns. Increased SBP with any\n activity-repositioning, suctioning, etc.\n Action:\n SICU Resident aware. Boluses of IVP metoporol as ordered. Continued\n PO hypertensives\n Response:\n Plan:\n Anemia, other /Hypotension (not Shock)\n Assessment:\n Pt Hct this am 23.7. Pt appears more lethargic and less interactive\n with neuro exam. U/O diminished < 200 cc/hr. SBP this am 70-80\n sustained. Stool Guiac negative.\n Action:\n SICU team made aware. 1 Liter NS bolus. 2 URBC\n Response:\n Pt responded positively. SBP 140\ns-180. More alert with increased\n general mvt. HCT s/p transfusion 32.1. Pt diuresing appropriately.\n Plan:\n Awaiting result from 1800 HCT. Continue to monitor stool, sputum and\n TF Residual for any signs of bleeding. Continue to monitor strict\n I&O\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652886, "text": "Anemia, other\n Assessment:\n Repeat HCT 31 post transfusion.\n No s/sx bleeding\n Action:\n Monitor HCT\n Response:\n HCT stable this am\n Plan:\n Cont to monitor HCT and s/sx bleeding.\n Hypertension, benign\n Assessment:\n SBP sustaining >160\n Action:\n Given antihypertensives lopressor, nimodipine, and hydralizine\n Given fentanyl for ? discomfort\n Given versed for anxiety\n Restarted nicardipine gtt\n Response:\n Good effect from antihypertensives initially but BP increasing with\n stimulation and not correcting. Lightly sedated after fentanyl and\n versed and BP remained elevated. Good BP control with nicardipine gtt.\n Plan:\n Cont to titrate gtt to maintain SBP <160.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Became tachypnice and sats down to 92% at 0300\n Action:\n ABG drawn- paO2 80\n Dr aware\n Resp tx and peep increased\n CXR done\n Response:\n Sats up and rr down with peep increase\n CXR shows increasing fluid overload\n Plan:\n F/u on rounds re: plan.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged\n Minimal output from ventriculostomy except with coughing pt putting out\n 20-30cc at times\n ICP remains <20\n Action:\n Cont on Q2 neuro exams\n Monitor ICP and drain output\n Response:\n ICP drops significantly if large output from coughing, at times ICP\n <0. NP and NP aware and up\n to assess drain.\n Plan:\n Cont to monitor ICP, vent ouput, neuron exam. Dr to reevaluate\n need for shunt next week. No plans at this time for clamping trial.\n Electrolyte/Fluid disorder\n Assessment:\n Noted to have elevated BUN/Creat\n NA improving\n Action:\n Renal to consult in am\n Per renal cont on ns flushes via g tube although no need for further\n hypertonic saline\n Dr aware of all lab values.\n Response:\n NA stable this am\n BUN/Creat slight bump this am\n Plan:\n Cont to monitor closely. Renal to assess pt this am.\n" }, { "category": "Physician ", "chartdate": "2157-01-09 00:00:00.000", "description": "Intensivist Note", "row_id": 652933, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Artificial Tears 5. Artificial\n Tear Ointment 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Enalapril Maleate 12. Famotidine 13. Fentanyl Citrate 14.\n Fluconazole 15. Folic Acid 16. Furosemide\n 17. Heparin 18. Hydralazine 19. 20. Insulin 21. Influenza Virus Vaccine\n 22. Labetalol 23. Magnesium Sulfate\n 24. Metoprolol Tartrate 25. Metoprolol Tartrate 26. Metoprolol Tartrate\n 27. Midazolam 28. Multivitamins\n 29. Nicardipine 30. Nimodipine 31. Phenytoin 32.\n Piperacillin-Tazobactam Na 33. Potassium Chloride\n 34. Propofol 35. Sodium Chloride 0.9% Flush 36. Thiamine 37. Vancomycin\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n FEVER - 101.9\nF - 08:00 PM\n : multiple episodes of hyperdynamic vital signs, but responds well\n to bb, Metoprolol, and sedations. hypotension resolved after two units\n PRBC\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Vancomycin - 12:00 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 PM\n Metoprolol - 08:20 PM\n Hydralazine - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:00 AM\n Midazolam (Versed) - 01:30 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: 38.8\nC (101.9\n T current: 37.4\nC (99.3\n HR: 89 (79 - 102) bpm\n BP: 143/71(95) {95/48(64) - 201/91(131)} mmHg\n RR: 23 (15 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 6 (-2 - 16) mmHg\n Total In:\n 4,479 mL\n 412 mL\n PO:\n Tube feeding:\n 615 mL\n 144 mL\n IV Fluid:\n 3,060 mL\n 268 mL\n Blood products:\n 564 mL\n Total out:\n 1,860 mL\n 270 mL\n Urine:\n 1,732 mL\n 270 mL\n NG:\n Stool:\n Drains:\n 128 mL\n Balance:\n 2,619 mL\n 142 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 6\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n SPO2: 96%\n ABG: 7.42/32/80./18/-2\n Ve: 17 L/min\n PaO2 / FiO2: 200\n Physical Examination\n Labs / Radiology\n 451 K/uL\n 11.6 g/dL\n 136 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 131 mEq/L\n 31.8 %\n 11.3 K/uL\n [image002.jpg]\n 03:36 PM\n 10:14 PM\n 02:37 AM\n 03:01 AM\n 10:00 AM\n 12:34 PM\n 04:00 PM\n 06:15 PM\n 03:00 AM\n 03:11 AM\n WBC\n 7.3\n 8.1\n 9.3\n 11.3\n Hct\n 23.7\n 32.1\n 32.1\n 31.8\n Plt\n 368\n 386\n 422\n 451\n Creatinine\n 0.6\n 0.8\n 1.4\n 1.5\n TCO2\n 27\n 24\n 21\n Glucose\n 117\n 106\n 148\n 163\n 122\n 136\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.7 mg/dL,\n Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n Nimodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; Labetalol prn, hydral PRN; Nicardipine gtt restarted \n Pulmonary: (Ventilator mode: CMV), trach. increased PEEP for decreased\n sat's. checking CXR for possible fluid excess after transfusion. may\n require lasix\n Gastrointestinal / Abdomen: cont TF\n Nutrition: Tube feeding\n Renal: -150ml. Nephrology following. Na improved\n Hematology: Serial Hct, improved and stable after two units PRBC\n Endocrine: RISS\n Infectious Disease: Check cultures, re cx'd for temp spike\n Lines / Tubes / Drains: trach, Foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652193, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n temp max 101.8 cultures pending left eye reddened sclera and purulent\n drainage. Seen by opthamology today and started on bacitracin and cipro\n eye drops.\n Action:\n Tylenol 650mg per gtube.\n Response:\n temp down to 100.4 this am\n Plan:\n monitor response to new eye drops. Monitor temp . treat with Tylenol as\n needed. Await culture results.\n Hypertension, benign\n Assessment:\n start of shift pt hypertensive with sbp greater than 160. pt treated\n with prn Lopressor, labetolol and hydralazine with little response. Dr.\n aware.\n Action:\n po Lopressor increased to 100mg and po hydralazine Increased to 75mg.\n pt started on iv nicardipine and titrated for sbp less than 160.\n currently on between .5 -1.5 mcg/kg\n Response:\n sbp under better control on iv nicardipine.\n Plan:\n titrate nicardipine as needed.\n Intracerebral hemorrhage (ICH)\n Assessment:\n neuro exam pt will intermittanly follow commands on left side. Pupils\n reactive to light. Difficult to assess left eye due to infection and\n drainage . vent drain at 20cmof h2o. icp 17. developed dampened\n waveform and not draining csf. Seen by \nneurosurg.\n Vent drain flushed but still with no tracing and not draining.\n Action:\n dr. in and vent drain changed for clot. Icp 10 and draininge tea\n colored csf. Vent drain started at 15cm and increased to 20cm. repeat\n head ct done after drain insertions.\n Response:\n pt able to lift and fall with left arm this am. Wiggles toes and moves\n left leg on bed. Pt\ns icp remains .\n Plan:\n continue with neuro checks. Repeat head ct this am.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n pt on cpap with pressure support. Pt suctioned for thick tan sputum.\n Trache site is clean and dry with no drainage.\n Action:\n suction as needed. Pt briefly on a rate for vent drain insertion and\n head ct. pt back on cpap at this time.\n Response:\n pt appears comfortable on current vent settings.\n Plan:\n suction as needed . await culture results monitor trache site.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652627, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 12\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th yellow sput. ABGs\n stable; no vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653007, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt pupils pinpoint right pupil does reactive to light, left pupil\n unable to assess secondary to cloudiness\n pt does not open his eyes to stimuli, no withdrawal of extremties to\n painful stimuli, pt unresponsive pt had just finished receiving iv\n thorazine, icp have been , ventricular drain remain 20cm above\n tragus, draining blood tinged csf.\n Action:\n Dr. called and up to assess patient.\n Response:\n Pt to have head ct\n Plan:\n Await results for head ct,\n Check neuro signs as ordered.\n Hypertension, benign\n Assessment:\n Neuro team liberalized to keep sbp less than 180\n Action:\n Iv nicardipine weaned to off\n Response:\n Sbp less than 180\n Plan:\n Continue to monitor, give antihypertensives as ordered, keep sbp less\n than 180 per dr. \n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat na 132,k 4.1, serum osomolaity 280\n Action:\n Dr. called and aware\n Response:\n No action taken\n Plan:\n Continue to monitor, check labs as ordered.\n Add: vanco level back as 37.3, dr. aware, vancomycin held.\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652117, "text": "Rash\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652119, "text": "Rash\n Assessment:\n Action:\n Response:\n Plan:\n Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Hypertensive as high as 190\n Action:\n Dr. , dr. . bender aware.Pt received lopressor a\n total of 15mg iv with some effect. Pt received total of 20mg of iv\n hydralazine with some effect, pt received 20mg of iv labetalol, pt\n started on hydralazine via peg and lopressor increased to 75mg tid.\n Response:\n bp less than 160\n Plan:\n continue to monitor, give antihypertensives meds as ordered,\n keep sbp less than 160\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n temp 102.5\n Action:\n blood cultures drawn, urine sent pt received Tylenol supp.\n Pt continues on vanco, and fluconazole as ordered.\n Response:\n Temp down to 101\n Plan:\n Continue to monitor, give antk\n" }, { "category": "Physician ", "chartdate": "2157-01-08 00:00:00.000", "description": "Intensivist Note", "row_id": 652705, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n FEVER - 102.4\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 11:00 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:37 PM\n Famotidine (Pepcid) - 09:00 PM\n Other medications:\n Flowsheet Data as of 04:54 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.1\nC (102.4\n T current: 36.7\nC (98\n HR: 87 (69 - 109) bpm\n BP: 134/61(85) {86/44(57) - 178/76(110)} mmHg\n RR: 19 (12 - 23) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 11 (6 - 16) mmHg\n Total In:\n 3,652 mL\n 1,278 mL\n PO:\n Tube feeding:\n 891 mL\n 143 mL\n IV Fluid:\n 2,401 mL\n 1,135 mL\n Blood products:\n Total out:\n 2,025 mL\n 127 mL\n Urine:\n 1,895 mL\n 113 mL\n NG:\n Stool:\n Drains:\n 130 mL\n 14 mL\n Balance:\n 1,627 mL\n 1,151 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (550 - 600) mL\n Vt (Spontaneous): 319 (319 - 319) mL\n RR (Set): 12\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 153\n PIP: 26 cmH2O\n Plateau: 16 cmH2O\n SPO2: 99%\n ABG: 7.41/37/125/19/0\n Ve: 9.8 L/min\n PaO2 / FiO2: 313\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Temperature: Warm), (Pulse - Dorsalis pedis:\n Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 368 K/uL\n 8.6 g/dL\n 106 mg/dL\n 0.8 mg/dL\n 19 mEq/L\n 3.3 mEq/L\n 14 mg/dL\n 101 mEq/L\n 126 mEq/L\n 23.7 %\n 7.3 K/uL\n [image002.jpg]\n 09:47 PM\n 10:08 PM\n 01:15 AM\n 01:18 AM\n 05:56 AM\n 06:05 AM\n 03:36 PM\n 10:14 PM\n 02:37 AM\n 03:01 AM\n WBC\n 10.7\n 7.3\n Hct\n 28.6\n 23.7\n Plt\n 390\n 368\n Creatinine\n 0.5\n 0.6\n 0.5\n 0.6\n 0.8\n TCO2\n 30\n 29\n 27\n 27\n 24\n Glucose\n 127\n 115\n 138\n 117\n 106\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.2 mg/dL,\n Mg:1.8 mg/dL, PO4:3.2 mg/dL\n Assessment and Plan\n HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY),\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M withpontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . Cont dilantin; Cont nomodipine. minimize PPF gtt\n sedation; Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN. Has required volume boluses\n over the evening shift. No evidence of bleeding. Hct-23. Will\n continue fluid bolus with saline, given hyponatremia. Will transfuse 2\n units PRBCs and check coag status.\n Pulmonary: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6, nimotop\n 60q4; labetalol prn, hydral PRN;\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- thorazine\n Nutrition: Tube feeding\n Renal: keep I=O to prevent pulm edema. lasix 20BID per renal; follow\n serum osmhyponatremic this AM. hypertonic saline, q6h Na checks per\n renal\n Hematology: follow Hct - trending down somewhat, will continue to\n follow\n Endocrine: RISS\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 06:56 PM 30 mL/hour\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: boots\n Stress ulcer: H2\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35min\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652348, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.7-102.1\n Suctioning for brownish thinnish secretions\n Action:\n Tylenol pr\n Cooling blanket applied\n Sputum sent for culture\n Response:\n Pt started on zosyn\n Plan:\n Continue to monitor\n Give antibiotics as ordered\n Await results from blood/sputum cultures\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli\n Right pupils 3mm and briskly reactive to light\n Left pupil at times difficult to asses pupils secondary to\n pupils cloudy\n Pt will intermittently will wiggle toes and will squeeze\n hand on command, other times pt will not follow any commands\n pt is more lethargic than earlier today\n sodium 124 this afternoon\n ventricular drain remain 20 above tragus, continues to drain\n tea colored drainage, icp have been less than 20\n Action:\n dr. aware and into assess patient\n ns d/c\n Response:\n Icp remain less than 20\n Plan:\n Continue to monitor\n Check na labs at 2100\n Monitor neuro signs\n Pt on fluid restriction\n Monitor electroyles\n Call nueromed/neurosurgical if icp is greater than 20\n Hypertension, benign\n Assessment:\n Sbp greater than 160\n Action:\n Pt continues on nicardipine, lopressor, hydralazine\n Response:\n Sbp has been less than 160\n Plan:\n Continue to monitor, titrate nicardipine to keep sbp less\n than 160\n Problem - Description In Comments\n Assessment:\n Left eye remains reddened, edemous, at times difficult to\n assess left pupil at times\n Action:\n Pt continues on eye drop as ordered\n Both eyes partially taped\n Response:\n Left eye unchanged\n Plan:\n Continue to monitor\n Give eyes gtts as ordered.\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652349, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.7-102.1\n Suctioning for brownish thinnish secretions\n Action:\n Tylenol pr\n Cooling blanket applied\n Sputum sent for culture\n Response:\n Pt started on zosyn\n Plan:\n Continue to monitor\n Give antibiotics as ordered\n Await results from blood/sputum cultures\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli\n Right pupils 3mm and briskly reactive to light\n Left pupil at times difficult to asses pupils secondary to\n pupils cloudy\n Pt will intermittently will wiggle toes and will squeeze\n hand on command, other times pt will not follow any commands\n pt is more lethargic than earlier today\n sodium 124 this afternoon\n ventricular drain remain 20 above tragus, continues to drain\n tea colored drainage, icp have been less than 20\n Action:\n dr. aware and into assess patient\n ns d/c\n Response:\n Icp remain less than 20\n Plan:\n Continue to monitor\n Check na labs at 2100\n Monitor neuro signs\n Pt on fluid restriction\n Monitor electroyles\n Call nueromed/neurosurgical if icp is greater than 20\n Hypertension, benign\n Assessment:\n Sbp greater than 160\n Action:\n Pt continues on nicardipine, lopressor, hydralazine\n Response:\n Sbp has been less than 160\n Plan:\n Continue to monitor, titrate nicardipine to keep sbp less\n than 160\n Problem - Description In Comments\n Assessment:\n Left eye remains reddened, edemous, at times difficult to\n assess left pupil at times\n Action:\n Pt continues on eye drop as ordered\n Both eyes partially taped\n Response:\n Left eye unchanged\n Plan:\n Continue to monitor\n Give eyes gtts as ordered.\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652350, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt on cpap with ps\n Rr rate up to 35-40\n Abg sent\n Pt with hiccups\n Suctioning pt for tannish/yellowish secretions\n Action:\n Pt put back on cmv dr. aware\n Response:\n Rr rate down to 18-20\n Plan:\n Continue to monitor\n Suction as needed\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652691, "text": "Hypotension (not Shock)\n Assessment:\n SBP 80\ns sustaining x 3 hrs\n More lethargic with decreased BP\n U/o dropping off after several hours\n Action:\n Dr (SICU) and neurology HO notified and aware of all BP trends\n Nicardipine previously shut off\n All antihypertensives held\n Lasix held\n HOB to 15 to maintain SBP >80\n NS bolus given (SICU HO notified neurology)\n Response:\n SBP sustaining >100 after bolus\n U/o remains marginal\n Plan:\n Cont to hold all antiypertensives, monitor bp closely, notify SICU HO\n and neurology of all changes in BP.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n NA 125 this evening, up to 127 at 2200\n Action:\n Cont on fluid restriction, NS flush with meds, 3% saline at 20cc x 20\n hrs.\n Response:\n Na correcting slowly\n Plan:\n Cont with current plan and monitor Q6 NA level.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n More difficult to arouse, not following commands since initial\n assessment. Minimal spontaneous movment noted. No changes in strength\n or pupils.\n Action:\n Dr (SICU) and Dr ( NMED) notifed change in exam.\n Response:\n Dr up to assess and felt no acute change.\n Plan:\n Cont to monitor closely.\n Corneal Abrasion\n Assessment:\n Left eye with +corneal abrasion, sutured partially shut. Unable to\n fully shut with tape.\n Action:\n Artificial tears Q1 hr, bacitracian ointment Q6 hrs\n Response:\n No change\n Plan:\n Cont with current plant, ophthalmology following closely.\n ------ Protected Section ------\n Additional episode hypotension. Dr and neurology HO notified.\n Given additional liter NS. AM labs show HCT drop from 23 to 28. Both Dr\n and neurology aware. No obvious s/sx bleeding. U/o remains\n marginal, given 20 mg po Lasix with increased bp this am per Dr \n although no effect. SBP back down to 90\ns at 0700, D rNovikov aware,\n will round shortly with attending.\n ------ Protected Section Addendum Entered By: , RN\n on: 07:39 ------\n" }, { "category": "Respiratory ", "chartdate": "2157-01-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653037, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 14\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 60 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 / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th bld tinged sput.\n ABGs stable ; no other vent changes required overnoc. Cont mech vent\n support.\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653004, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n pt pupils pinpoint right pupil does reactive to light, left pupil\n unable to assess secondary to cloudiness\n pt does not open his eyes to stimuli, no withdrawal of extremties to\n painful stimuli, pt unresponsive pt had just finished receiving iv\n thorazine, icp have been , ventricular drain remain 20cm above\n tragus, draining blood tinged csf.\n Action:\n Dr. called and up to assess patient.\n Response:\n Pt to have head ct\n Plan:\n Await results for head ct,\n Check neuro signs as ordered.\n Hypertension, benign\n Assessment:\n Neuro team liberalized to keep sbp less than 180\n Action:\n Iv nicardipine weaned to off\n Response:\n Sbp less than 180\n Plan:\n Continue to monitor, give antihypertensives as ordered, keep sbp less\n than 180 per dr. \n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Repeat na 132,k 4.1, serum osomolaity 280\n Action:\n Dr. called and aware\n Response:\n No action taken\n Plan:\n Continue to monitor, check labs as ordered.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652400, "text": "Demographics\n Day of mechanical ventilation: 11\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems: P > 30cm/H2O\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Exp Wheeze\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: Hiccoughing\n Assessment of breathing comfort: No claim of dyspnea)\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Hemodynimic instability, Underlying illness not\n resolved; Comments: AM RSBI-153\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n ICU to CT\n \n without incident\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652771, "text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652778, "text": "Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Sodium Chloride 3% (Hypertonic) infusion completed at 1200.\n Action:\n Continue to administer NS flushes and limit fluid intake.\n Response:\n Awaiting Evening electrolytes for updated NA+.\n Plan:\n Continue to monitor NA+ closely. Report abnormalities to SICU Team\n and treat accordingly.\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Anemia, other /Hypotension (not Shock)\n Assessment:\n Pt Hct this am\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-01-11 00:00:00.000", "description": "Intensivist Note", "row_id": 653284, "text": "SICU\n HPI:\n Chief complaint:\n 53M presented to with left sided headache followed by\n right sided hemiparesis. CTA showing pontine SAH with IVH in left\n lateral ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, CefazoLIN, Chlorhexidine\n Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid), Famotidine,\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza\n Virus Vaccine, Labetalol, Magnesium Sulfate, Metoprolol Tartrate ,\n Multivitamins, OxycoDONE-Acetaminophen Elixir, Phenytoin, Thiamine\n 24 Hour Events:\n FEVER - 101.7\nF - 08:00 PM\n Vanc/Zosyn/Fluc stopped\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Cefazolin - 04:00 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:30 PM\n Hydralazine - 03:09 AM\n Other medications:\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 38.4\nC (101.2\n HR: 90 (85 - 108) bpm\n BP: 150/65(94) {147/62(90) - 186/80(118)} mmHg\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 11 (8 - 17) mmHg\n Total In:\n 1,551 mL\n 761 mL\n PO:\n Tube feeding:\n 721 mL\n IV Fluid:\n 200 mL\n 731 mL\n Blood products:\n Total out:\n 1,930 mL\n 718 mL\n Urine:\n 1,825 mL\n 710 mL\n NG:\n Stool:\n Drains:\n 105 mL\n 8 mL\n Balance:\n -379 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 585 (585 - 607) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 27 cmH2O\n Plateau: 11 cmH2O\n SPO2: 97%\n ABG: 7.42/33/105/21/-1\n Ve: 11.4 L/min\n PaO2 / FiO2: 263\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No movement), (LUE: Weakness), (RLE: No movement), (LLE: Weakness)\n Labs / Radiology\n 516 K/uL\n 11.1 g/dL\n 96 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 105 mEq/L\n 136 mEq/L\n 30.6 %\n 15.4 K/uL\n [image002.jpg]\n 03:00 AM\n 03:11 AM\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n WBC\n 11.3\n 15.4\n Hct\n 31.8\n 30.6\n Plt\n 451\n 516\n Creatinine\n 1.5\n 1.6\n 1.7\n 1.6\n TCO2\n 21\n 21\n 21\n 22\n 22\n 22\n Glucose\n 136\n 134\n 100\n 96\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.1 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, continue dilantin, to OR for\n VPS\n Cardiovascular: goal SBP < 180, lopressor 100 TID, prn Hydralazine and\n labetolol\n Pulmonary: s/p Trach, cont to ween to trach collar, CXR in am (stable\n LLL opacification\n Gastrointestinal / Abdomen: NPO for VPS\n Nutrition: NPO\n Renal: Foley, Adequate UO, adequate UOP, renal failure likely Vanc\n level\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn (empiric for fever)/Fluc (yeast in\n sputum) stopped, Kefzol started for ventric drain, f/u cultures, CBC\n today\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: NS, 75 ml/hr\n Consults: General surgery, Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 08:09 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": "2157-01-11 00:00:00.000", "description": "Intensivist Note", "row_id": 653289, "text": "SICU\n HPI:\n Chief complaint:\n 53M presented to with left sided headache followed by\n right sided hemiparesis. CTA showing pontine SAH with IVH in left\n lateral ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, CefazoLIN, Chlorhexidine\n Gluconate 0.12% Oral Rinse, Docusate Sodium (Liquid), Famotidine,\n Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Influenza\n Virus Vaccine, Labetalol, Magnesium Sulfate, Metoprolol Tartrate ,\n Multivitamins, OxycoDONE-Acetaminophen Elixir, Phenytoin, Thiamine\n 24 Hour Events:\n FEVER - 101.7\nF - 08:00 PM\n Vanc/Zosyn/Fluc stopped\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 12:00 AM\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Cefazolin - 04:00 AM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Fentanyl - 04:30 PM\n Hydralazine - 03:09 AM\n Flowsheet Data as of 09:17 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 38.4\nC (101.2\n HR: 90 (85 - 108) bpm\n BP: 150/65(94) {147/62(90) - 186/80(118)} mmHg\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 11 (8 - 17) mmHg\n Total In:\n 1,551 mL\n 761 mL\n PO:\n Tube feeding:\n 721 mL\n IV Fluid:\n 200 mL\n 731 mL\n Blood products:\n Total out:\n 1,930 mL\n 718 mL\n Urine:\n 1,825 mL\n 710 mL\n NG:\n Stool:\n Drains:\n 105 mL\n 8 mL\n Balance:\n -379 mL\n 43 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 585 (585 - 607) mL\n PS : 8 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 105\n PIP: 27 cmH2O\n Plateau: 11 cmH2O\n SPO2: 97%\n ABG: 7.42/33/105/21/-1\n Ve: 11.4 L/min\n PaO2 / FiO2: 263\n Physical Examination\n General Appearance: No acute distress\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Rhonchorous : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Neurologic: Follows simple commands, No(t) Moves all extremities, (RUE:\n No movement), (LUE: Weakness), (RLE: No movement), (LLE: Weakness)\n Labs / Radiology\n 516 K/uL\n 11.1 g/dL\n 96 mg/dL\n 1.6 mg/dL\n 21 mEq/L\n 3.9 mEq/L\n 26 mg/dL\n 105 mEq/L\n 136 mEq/L\n 30.6 %\n 15.4 K/uL\n [image002.jpg]\n 03:00 AM\n 03:11 AM\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n WBC\n 11.3\n 15.4\n Hct\n 31.8\n 30.6\n Plt\n 451\n 516\n Creatinine\n 1.5\n 1.6\n 1.7\n 1.6\n TCO2\n 21\n 21\n 21\n 22\n 22\n 22\n Glucose\n 136\n 134\n 100\n 96\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.1 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, continue dilantin, to OR\n Thursday for VPS\n Cardiovascular: goal SBP < 180, lopressor 100 TID, prn Hydralazine and\n labetolol\n Pulmonary: s/p Trach, cont to ween to trach collar, CXR in am (stable\n LLL opacification\n Gastrointestinal / Abdomen: NPO for VPS\n Nutrition: NPO\n Renal: Foley, Adequate UO, adequate UOP, renal failure likely Vanc\n level\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn (empiric for fever)/Fluc (yeast in\n sputum) stopped, Kefzol started for ventric drain, f/u cultures, CBC\n today\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG. Will get PICC\n when afebrile\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: NS, 75 ml/hr\n Consults: General surgery, Neuro surgery, Neurology, Nephrology\n Billing Diagnosis: Resp failure\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 08:09 PM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\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": "2157-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653054, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n right pupil pinpoint ,does react to light, left pupil unable to assess\n secondary to cloudiness.\n opens his eyes to stimuli, withdraws left extremities to painful\n stimuli, wiggles toes left side to command, squeezes left hand to\n command. Icp\ns , ventricular drain remains 20cm above tragus,\n draining clear csf, occasionally slightly blood tinged. Repeat head ct\n just prior to my 7pm shift done, neuro med to review results.neuro\n status improved as time lapsed from last administration of thorazine.\n Occasionally appears uncomfortable with slight restlessness evident in\n left hand, eyes opened wide, and increased bp.\n Action:\n spoke with neuro med at start of shift. Reported head ct showed a very\n slight increase in hydrocephalus. Was instructed to watch vent drain\n carefully to make sure it continues draining. Oxycodone elixir given\n for pain.\n Response:\n vent drain working adequately, moderate amounts of csf draining. Neuro\n status improved overnight. Appears more comfortable after\n administration of pain medication.\n Plan:\n Check neuro signs as ordered. Monitor function of drain. Medicate for\n pain prn. Will hold 6am dose of thorazine until speaking to team this\n am.\n Hypertension, benign\n Assessment:\n Neuro team liberalized to keep sbp less than 180\n Action:\n Iv nicardipine weaned to off previous shift, remained off all night.\n Response:\n Sbp less than 180, no additional antihypertensive given.\n Plan:\n Continue to monitor, give antihypertensive as ordered, keep sbp less\n than 180 per dr. \n" }, { "category": "Physician ", "chartdate": "2157-01-09 00:00:00.000", "description": "Intensivist Note", "row_id": 652858, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 1. 2. 1000 mL LR 3. Acetaminophen 4. Artificial Tears 5. Artificial\n Tear Ointment 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Enalapril Maleate 12. Famotidine 13. Fentanyl Citrate 14.\n Fluconazole 15. FoLIC Acid 16. Furosemide\n 17. Heparin 18. HydrALAzine 19. 20. Insulin 21. Influenza Virus Vaccine\n 22. Labetalol 23. Magnesium Sulfate\n 24. Metoprolol Tartrate 25. Metoprolol Tartrate 26. Metoprolol Tartrate\n 27. Midazolam 28. Multivitamins\n 29. NiCARdipine 30. Nimodipine 31. Phenytoin 32.\n Piperacillin-Tazobactam Na 33. Potassium Chloride\n 34. Propofol 35. Sodium Chloride 0.9% Flush 36. Thiamine 37. Vancomycin\n 24 Hour Events:\n BLOOD CULTURED - At 09:00 PM\n SPUTUM CULTURE - At 09:00 PM\n URINE CULTURE - At 09:00 PM\n FEVER - 101.9\nF - 08:00 PM\n : multiple episodes of hyperdynamic vital signs, but reponds well to\n bb, metoprolol, and sedations. hypotension resolved after two units\n PRBC\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 10:30 PM\n Vancomycin - 12:00 AM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:01 PM\n Metoprolol - 08:20 PM\n Hydralazine - 10:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:00 AM\n Midazolam (Versed) - 01:30 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: 38.8\nC (101.9\n T current: 37.4\nC (99.3\n HR: 89 (79 - 102) bpm\n BP: 143/71(95) {95/48(64) - 201/91(131)} mmHg\n RR: 23 (15 - 32) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 6 (-2 - 16) mmHg\n Total In:\n 4,479 mL\n 412 mL\n PO:\n Tube feeding:\n 615 mL\n 144 mL\n IV Fluid:\n 3,060 mL\n 268 mL\n Blood products:\n 564 mL\n Total out:\n 1,860 mL\n 270 mL\n Urine:\n 1,732 mL\n 270 mL\n NG:\n Stool:\n Drains:\n 128 mL\n Balance:\n 2,619 mL\n 142 mL\n Respiratory support\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 6\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 27 cmH2O\n Plateau: 20 cmH2O\n SPO2: 96%\n ABG: 7.42/32/80./18/-2\n Ve: 17 L/min\n PaO2 / FiO2: 200\n Physical Examination\n Labs / Radiology\n 451 K/uL\n 11.6 g/dL\n 136 mg/dL\n 1.5 mg/dL\n 18 mEq/L\n 4.0 mEq/L\n 21 mg/dL\n 105 mEq/L\n 131 mEq/L\n 31.8 %\n 11.3 K/uL\n [image002.jpg]\n 03:36 PM\n 10:14 PM\n 02:37 AM\n 03:01 AM\n 10:00 AM\n 12:34 PM\n 04:00 PM\n 06:15 PM\n 03:00 AM\n 03:11 AM\n WBC\n 7.3\n 8.1\n 9.3\n 11.3\n Hct\n 23.7\n 32.1\n 32.1\n 31.8\n Plt\n 368\n 386\n 422\n 451\n Creatinine\n 0.6\n 0.8\n 1.4\n 1.5\n TCO2\n 27\n 24\n 21\n Glucose\n 117\n 106\n 148\n 163\n 122\n 136\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.7 mg/dL,\n Mg:2.2 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted \n Pulmonary: (Ventilator mode: CMV), trach. increased PEEP for decreased\n sat's. checking CXR for possible fluid excess after transfusion. may\n requre lasix\n Gastrointestinal / Abdomen: cont TF\n Nutrition: Tube feeding\n Renal: -150ml. Nephrology following. Na improved\n Hematology: Serial Hct, improved and stable after two units PRBC\n Endocrine: RISS\n Infectious Disease: Check cultures, re cx'd for temp spike\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 10:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 18 Gauge - 04:00 PM\n 20 Gauge - 09:00 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Social Work", "chartdate": "2157-01-05 00:00:00.000", "description": "Social Work Progress Note", "row_id": 652091, "text": "Spoke with pt\ns cousin, who reports that pt\ns mother is\n currently hospitalized. has promised pt\ns mother that she will\n continue to maintain communication with the hospital and help pt\n mother with decision making with re: to pt\ns medical needs. Explained\n the potential need for a legal guardian for pt to move onto rehab, \n agrees\nto do anything needs\n Will speak with team re: pt\ns progress and initiate guardianship if\n appropriate.\n" }, { "category": "Physician ", "chartdate": "2157-01-12 00:00:00.000", "description": "Intensivist Note", "row_id": 653545, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n 24 Hour Events:\n PAN CULTURE - At 11:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Cefazolin - 04:00 AM\n Other ICU medications:\n Hydralazine - 08:00 AM\n Fentanyl - 08:20 AM\n Metoprolol - 10:30 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\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: 38.2\nC (100.8\n T current: 38\nC (100.4\n HR: 82 (70 - 100) bpm\n BP: 143/66(93) {111/51(71) - 200/88(129)} mmHg\n RR: 19 (15 - 31) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (2 - 15) mmHg\n Total In:\n 1,932 mL\n 313 mL\n PO:\n Tube feeding:\n 300 mL\n 203 mL\n IV Fluid:\n 1,422 mL\n 50 mL\n Blood products:\n Total out:\n 1,933 mL\n 414 mL\n Urine:\n 1,880 mL\n 390 mL\n NG:\n Stool:\n Drains:\n 53 mL\n 24 mL\n Balance:\n -1 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n SPO2: 95%\n ABG: 7.42/35/102/21/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 255\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), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 473 K/uL\n 9.7 g/dL\n 121 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 108 mEq/L\n 136 mEq/L\n 26.5 %\n 12.0 K/uL\n [image002.jpg]\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n WBC\n 15.4\n 12.0\n Hct\n 30.6\n 26.5\n Plt\n 516\n 473\n Creatinine\n 1.6\n 1.7\n 1.6\n 1.4\n TCO2\n 21\n 21\n 22\n 22\n 22\n 23\n Glucose\n 134\n 100\n 96\n 121\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.2 mg/dL,\n Mg:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, continue dilantin, OR for VPS\n on Thursday\n Cardiovascular: goal SBP < 180, lopressor 100 TID, labetolol drip, prn\n Hydralazine\n Pulmonary: s/p Trach, cont to wean to trach collar, CXR in am (stable\n LLL opacification)\n Gastrointestinal / Abdomen: TF via PEG\n Nutrition: Tube feeding\n Renal: Adequate UO\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn (empiric for fever)/Fluc (yeast in\n sputum) stopped, Kefzol started for ventric drain, f/u cultures\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: normal saline @ 75cc/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652339, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.7-102.1\n Suctioning for brownish thinnish secretions\n Action:\n Tylenol pr\n Cooling blanket applied\n Sputum sent for culture\n Response:\n Pt started on zosyn\n Plan:\n Continue to monitor\n Give antibiotics as ordered\n Await results from blood/sputum cultures\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli\n Right pupils 3mm and briskly reactive to light\n Left pupil at times difficult to asses pupils secondary to\n pupils cloudy\n Pt will intermittently will wiggle toes and will squeeze\n hand on command, other times pt will not follow any commands\n pt is more lethargic than earlier today\n sodium 124 this afternoon\n ventricular drain remain 20 above tragus, continues to drain\n tea colored drainage, icp have been less than 20\n Action:\n dr. aware and into assess patient\n ns d/c\n Response:\n Icp remain less than 20\n Plan:\n Continue to monitor\n Check na labs at 2100\n Monitor neuro signs\n Pt on fluid restriction\n Monitor electroyles\n Call nueromed/neurosurgical if icp is greater than 20\n Hypertension, benign\n Assessment:\n Sbp greater tha 160\n Action:\n Pt continues on nicardipine, lopressor, hydralazine\n Response:\n Sbp has been less than 160\n Plan:\n Continue to monitor, titrate nicardipen to keep sbp less\n than 160\n Problem - Description In Comments\n Assessment:\n Left eye remains reddened, edemous, at times difficult to\n assess pupils\n Action:\n Pt continues on eye drop as ordered\n Both eyes partially taped\n Response:\n Left eye unchanged\n Plan:\n Continue to monitor\n Give eyes gtts as ordered.\n" }, { "category": "Nursing", "chartdate": "2157-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652570, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n With Neurosurgery Team at bedside, pt able to appropriately nod yes/no\n to orientation questions. Nodded yes appropriately to name and place.\n Following basic commands. Using L UE and L LE appropriately and\n spontaneously. Remained alert and obeyed commands with PT when dangled\n at bedside.\n Action:\n Continue neuro checks Q2 hours.\n Response:\n Pt intermittent with participation of neuro exam.\n Plan:\n Continue Q 2 hour neuro checks. Alert SICU and Neurosurgical Team with\n any acute changes.\n Hypertension, benign\n Assessment:\n Continued on Nicardipine gtt at 0.5 mcg/kg/min.\n Action:\n Monitoring via ABP.\n Response:\n Maintaining SBP < 160.\n Plan:\n Continue Nicardipine PRN\n Intracerebral hemorrhage (ICH)\n Assessment:\n MD , pt\ns EVD to remain open at 20cm above the tragus.\n Action:\n Continues to produce straw color csf.\n Response:\n Pt\ns ICP remains < 15 when EVD is open.\n Plan:\n If CSF is greater than 100 ml per 24 hour period throughout w/e\n? VP\n Shunt to be placed. Also awaiting pt to become afebrile.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains with copious amounts of yellow, thick secretions. Clear to\n Rhonchi BS.\n Action:\n Suctioning oral and sub glottal hourly. Turning and repositioning Q2\n hours.\n Response:\n Continues to need ATC suctioning.\n Plan:\n Placed on a rate control on Ventilator to assist with easing RR r/t\n constant hiccups. Thorazine Q12 to alleviate hiccups.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n Pt\ns am NA+ 121. SICU Team and Attending made aware.\n Action:\n TF concentrated. NS only for PEG Tube flushes. Fluid restricted.\n Response:\n NA + 125 at 1500.\n Plan:\n Sodium Chloride 3% (Hypertonic) @ 20cc/hr x 20 hours. Running thru an\n 18 G in R AC. Serial NA+ checks Q6 hours.\n Problem\nCorneal Abrasion\n Assessment:\n Continue prescribed eye drops as ordered. Unable to keep L eyelid\n sealed.\n Action:\n Ophthalmology Team at bedside to place sutures to outer eyelid to\n assist with closing of the lid.\n Response:\n Pt tolerated procedure.\n Plan:\n Will continue to monitor and treat as ordered.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652844, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 13\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\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: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th yellow sput. ABGs\n stable though PaO2 down from previous study, increased PEEP with good\n effect; no other vent changes required overnoc. Cont mech vent support.\n" }, { "category": "Nursing", "chartdate": "2157-01-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652846, "text": "Anemia, other\n Assessment:\n Repeat HCT 31 post transfusion.\n No s/sx bleeding\n Action:\n Monitor HCT\n Response:\n HCT stable this am\n Plan:\n Cont to monitor HCT and s/sx bleeding.\n Hypertension, benign\n Assessment:\n SBP sustaining >160\n Action:\n Given antihypertensives lopressor, nimodipine, and hydralizine\n Given fentanyl for ? discomfort\n Given versed for anxiety\n Restarted nicardipine gtt\n Response:\n Good effect from antihypertensives initially but BP increasing with\n stimulation and not correcting. Lightly sedated after fentanyl and\n versed and BP remained elevated. Good BP control with nicardipine gtt.\n Plan:\n Cont to titrate gtt to maintain SBP <160.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam unchanged\n Minimal output from ventriculostomy except with coughing pt putting out\n 20-30cc at times\n ICP remains <20\n Action:\n Cont on Q2 neuro exams\n Monitor ICP and drain output\n Response:\n ICP drops significantly if large output from coughing, at times ICP\n <0. NP and NP aware and up\n to assess drain.\n Plan:\n Cont to monitor ICP, vent ouput, neuron exam. Dr to reevaluate\n need for shunt next week. No plans at this time for clamping trial.\n Electrolyte/Fluid disorder\n Assessment:\n Noted to have elevated BUN/Creat\n NA improving\n Action:\n Renal to consult in am\n Per renal cont on ns flushes via g tube although no need for further\n hypertonic saline\n Dr aware of all lab values.\n Response:\n NA stable this am\n BUN/Creat slight bump this am\n Plan:\n Cont to monitor closely. Renal to assess pt this am.\n" }, { "category": "Nursing", "chartdate": "2157-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652566, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n With Neurosurgery Team at bedside, pt able to appropriately nod yes/no\n to orientation questions. Nodded yes appropriately to name and place.\n Following basic commands. Using L UE and L LE appropriately and\n spontaneously. Remained alert and obeyed commands with PT when dangled\n at bedside.\n Action:\n Continue neuro checks Q2 hours.\n Response:\n Pt intermittent with participation of neuro exam.\n Plan:\n Continue Q 2 hour neuro checks. Alert SICU and Neurosurgical Team with\n any acute changes.\n Hypertension, benign\n Assessment:\n Continued on Nicardipine gtt at 0.5 mcg/kg/min.\n Action:\n Monitoring via ABP.\n Response:\n Maintaining SBP < 160.\n Plan:\n Continue Nicardipine PRN\n Intracerebral hemorrhage (ICH)\n Assessment:\n MD , pt\ns EVD to remain open at 20cm above the tragus.\n Action:\n Continues to produce straw color csf.\n Response:\n Pt\ns ICP remains < 15 when EVD is open.\n Plan:\n If CSF is greater than 100 ml per 24 hour period throughout w/e\n? VP\n Shunt to be placed. Also awaiting pt to become afebrile.\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains with copious amounts of yellow, thick secretions. Clear to\n Rhonchi BS.\n Action:\n Suctioning oral and sub glottal hourly. Turning and repositioning Q2\n hours.\n Response:\n Continues to need ATC suctioning.\n Plan:\n Placed on a rate control on Ventilator to assist with easing RR r/t\n constant hiccups. Thorazine Q12 to alleviate hiccups.\n" }, { "category": "Nursing", "chartdate": "2157-01-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652332, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.7-102.1\n Suctioning for brownish thinnish secretions\n Action:\n Tylenol pr\n Cooling blanket applied\n Sputum sent for culture\n Response:\n Pt started on zosyn\n Plan:\n Continue to monitor\n Give antibiotics as ordered\n Await results from blood/sputum cultures\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt arousable to stimuli\n Right pupils 3mm and briskly reactive to light\n Left pupil at times difficult to asses pupils secondary to\n pupils cloudy\n Pt will intermittently will wiggle toes and will squeeze\n hand\n Action:\n Response:\n Plan:\n Hypertension, benign\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": "2157-01-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653193, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - neuro assessment: pupil on R side is and reactive, pupil\n on L side is unable to assess, eye is clouded and has one suture\n - pt will inconsistently squeeze L hand and L toes, pt does\n not move R side\n - pt does not communicate in any way\n - ventriculostomy drain at 20 above the tragus\n Action:\n - q1h eye drops for R eye and q4h ointment for L eye\n - monitor ICP and ventriculostomy\n Response:\n - neuro assessments consistent throughout the day\n - minimal drainage from ventriculostomy\n - dressing changed by neurosurg\n Plan:\n - continue q1h neuro assessments\n - continue eye drops as ordered\n - continue ventriculostomy at 20 above tragus\n - to OR tomorrow for VP shunt\n - hold tube feeds after midnight\n - start on IV fluids\n - PICC line tomorrow ?\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n - tmax 101.7\n Action:\n - given Tylenol 650\n Response:\n - awaiting response from Tylenol\n Plan:\n - continue to assess and treat temperature\n Hypertension, benign\n Assessment:\n - pt hypertensive this afternoon > systolic 180\n - pt had been on CPAP for a few hours\n Action:\n - Hydralazine 10mg given\n - Fentanyl 50mcg given\n - Vent settings changed back to CMV\n Response:\n - BP stabilized to < 180 after vent settings changed\n Plan:\n - continue to assess and treat hypertension\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n - low sodium level on AM labs\n Action:\n - pt started on sodium tabs and is receiving NS as TF flushes\n Response:\n - sodium level increased to normal range this afternoon\n Plan:\n - continue with salt tabs as ordered and assess sodium levels\n" }, { "category": "Nutrition", "chartdate": "2157-01-05 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 652080, "text": "Current Wt: 74.2kg\n Pertinent medications: NS @60c/hr, RISS, Colace, Famotidine, Folic\n Acid, Thiamine, Mvit, Vanco, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 103 mg/dL\n 11:41 AM\n Glucose Finger Stick\n 153\n 10:00 AM\n BUN\n 13 mg/dL\n 03:31 AM\n Creatinine\n 0.5 mg/dL\n 03:31 AM\n Sodium\n 132 mEq/L\n 03:31 AM\n Potassium\n 3.9 mEq/L\n 11:41 AM\n Chloride\n 98 mEq/L\n 03:31 AM\n TCO2\n 27 mEq/L\n 03:31 AM\n PO2 (arterial)\n 109 mm Hg\n 11:41 AM\n PCO2 (arterial)\n 28 mm Hg\n 11:41 AM\n pH (arterial)\n 7.53 units\n 11:41 AM\n pH (urine)\n 5.0 units\n 09:53 AM\n CO2 (Calc) arterial\n 24 mEq/L\n 11:41 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 7.9 mg/dL\n 03:31 AM\n Phosphorus\n 3.6 mg/dL\n 03:31 AM\n Ionized Calcium\n 1.16 mmol/L\n 04:41 AM\n Magnesium\n 2.3 mg/dL\n 03:31 AM\n Current diet order / nutrition support: TF: Replete with Fiber ordered\n @ 60cc/hr (1440kcal, 89g protein)\n GI:\n Assessment of Nutritional Status\n 53 y.o. M adm with SAH and left ventricle IVH, now with persistent\n respiratory failure. Pt found to have R-vertebral artery occlusion in\n angio, but no intervention done. Pt now s/p trach and PEG placement\n , and TF was just restarted this a.m. Rec slightly increasing TF\n goal rate to better meet pt\ns kcal needs. Noted hyponatremia, pt may\n need a more concentrated TF formula if this continues to be a problem.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec TF goal of Replete with Fiber @ 65cc/hr (1560kcal, 97g\n protein).\n 2) Monitor lytes and BG with TF initiation.\n 3) Monitor tolerance with residual checks and abd exam.\n Please page with ?\ns \n" }, { "category": "Respiratory ", "chartdate": "2157-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653589, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 60 cmH2O\n Cuff volume: 13 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: Brown / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Pending procedure / OR, Hemodynimic instability,\n Underlying illness not resolved.\n" }, { "category": "Physician ", "chartdate": "2157-01-07 00:00:00.000", "description": "Intensivist Note", "row_id": 652496, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n ?HTN\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Artificial Tear Ointment 5.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Ciprofloxacin 0.3% Ophth Soln\n 10. Docusate Sodium (Liquid) 11. Enalapril Maleate 12. Famotidine 13.\n Fentanyl Citrate 14. Fluconazole\n 15. FoLIC Acid 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20.\n Insulin 21. Influenza Virus Vaccine\n 22. Labetalol 23. Magnesium Sulfate 24. Metoprolol Tartrate 25.\n Metoprolol Tartrate 26. Midazolam\n 27. Multivitamins 28. NiCARdipine 29. Nimodipine 30. Phenytoin 31.\n Piperacillin-Tazobactam Na 32. Piperacillin-Tazobactam Na\n 33. Potassium Chloride 34. Propofol 35. Sodium Chloride 0.9% Flush 36.\n Thiamine 37. Vancomycin\n 24 Hour Events:\n FEVER - 102.2\nF - 09:00 PM\n IVF dc'd and free water flushed decreased due to decreased serum\n OSM and hyponatremia per neuro, decreased MS reported by nursing, stat\n non/con CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Fluconazole - 04:00 PM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Nicardipine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 37.8\nC (100.1\n HR: 85 (69 - 112) bpm\n BP: 112/51(73) {79/40(53) - 178/76(110)} mmHg\n RR: 17 (16 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (2 - 13) mmHg\n Total In:\n 2,582 mL\n 801 mL\n PO:\n Tube feeding:\n 827 mL\n 329 mL\n IV Fluid:\n 1,725 mL\n 412 mL\n Blood products:\n Total out:\n 2,431 mL\n 513 mL\n Urine:\n 2,190 mL\n 460 mL\n NG:\n Stool:\n Drains:\n 241 mL\n 53 mL\n Balance:\n 151 mL\n 288 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 319 (319 - 520) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 5\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 153\n PIP: 14 cmH2O\n Plateau: 11 cmH2O\n Compliance: 91.7 cmH2O/mL\n SPO2: 96%\n ABG: 7.46/37/91/26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 228\n Physical Examination\n Labs / Radiology\n 390 K/uL\n 10.6 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 91 mEq/L\n 121 mEq/L\n 28.6 %\n 10.7 K/uL\n [image002.jpg]\n 04:12 AM\n 12:58 PM\n 01:32 PM\n 05:42 PM\n 09:47 PM\n 10:08 PM\n 01:15 AM\n 01:18 AM\n 05:56 AM\n 06:05 AM\n WBC\n 10.7\n Hct\n 28.6\n Plt\n 390\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 25\n 27\n 26\n 30\n 29\n 27\n Glucose\n 131\n 113\n 127\n 115\n 138\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.8 mg/dL,\n Mg:2.3 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n \n Pulmonary: Trach, s/p Trach. on CPAP+PS. cont to ween to trach collar\n as tol. Recent CXR showing incr Left base opacity\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- may add thorazine if pt has BMs per neuro.\n Nutrition: Tube feeding, TF started - Replete with fiber Full strength\n goal 60\n Renal: keep I=O to prevent pulm edema. lasix as needed; follow serum\n osmhyponatremic this AM. t/c salt tabs, minimize free water flushes\n Hematology: follow Hct - trending down somewhat, will continue to\n follow.\n Endocrine: RISS, RISS, FS well controlled\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: Foley, Trach, trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - drops added, but did not\n have ones rec by optho, placed on Cipro drops. - will revisit \n Imaging:\n Fluids: KVO\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:37 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 05:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n" }, { "category": "Rehab Services", "chartdate": "2157-01-07 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 652497, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: ICH / 431\n Reason of referral: Eval & Treat\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , now\n trials of EVD clamping not well tolerated and will likely have shunt\n placed. SBP goal <160, EVD goal <20\n Past Medical / Surgical History: HTN\n Medications: nicardipine, piperacillin, vancomycin, insulin, heparin\n Radiology: Head CT : No interval change in parenchymal,\n subarachnoid, and\n intraventricular hemorrhage. No change in ventricular enlargement. CXR\n : worsening LLL pna\n Labs:\n 28.6\n 10.6\n 390\n 10.7\n [image002.jpg]\n Other labs:\n pH 7.46\n Activity Orders: OK for sitting at MD \n Social / Occupational History: Pt is primary primary caretaker to his\n mother who is now hospitalized\n Living Environment: unknown\n Prior Functional Status / Activity Level: presumed independent pta\n Objective Test\n Arousal / Attention / Cognition / Communication: lethargic but\n arousable with voice, follows very simple commands inconsistently\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 99\n 140/67\n 96% on CMV\n Sit\n /\n Activity\n 110\n 183/82\n 96% on CMV\n Stand\n /\n Recovery\n 104\n 153/70\n 95% on CMV\n Total distance walked: 0\n Minutes:\n Pulmonary Status: On CMV with 40% FIO2, TV 300-800; Coarse breath\n sounds throughout, coughing at edge of bed, inline suction for mod\n amount thick yellow secretions, oral suction large amount of thin clear\n secretions\n Integumentary / Vascular: R sided EVD- clamped t/o tx, R radial a-line,\n 3 PIVs: L hand and forearm, R forearm; foley, vented via trach\n Sensory Integrity: not formally assessed cognitive status\n Pain / Limiting Symptoms: no withdrawal to pain B LE's\n Posture: rounded shoulders in sitting\n Range of Motion\n Muscle Performance\n all extremeties grossly WNL\n not formally assessed, LUE/LE appears grossly , RLE 2-/5, RUE 0/5\n Motor Function: Moves LUE/LE spontaneously and occasionally\n volitionally although inconsistent, spontaneous movement of RLE noted,\n RLE flaccid.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Patient overall dependent for all mobility\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n\n\n\n\n T\n Transfer:\n\n\n\n\n\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: patient maintained static sitting at edge of bed with max A x5\n min. No postural reflexes noted with weight-shifting\n Education / Communication: Communicated with nsg re: status, encouraged\n patient to use 'thumbs up/down' for communication\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performace, Impaired\n Clinical impression / Prognosis: 53 yo M with ICH p/w above impairments\n a/w non-progressive CNS disorder. He is vent-dependent and will likely\n require shunt, patient may demonstrate improvements in mobility and\n cognition once weaned from vent and shunt placed. As he is following\n commands at this time, rehab potential is optomistic, however this will\n be re-assessed when patient stable enough to tolerate more PT\n intervention.\n Goals\n Time frame: 1 week\n 1.\n Tolerate sitting at edge of bed x 15 min\n 2.\n Follows 50% of simple commands consistently\n 3.\n Able to sit at statically with min-mod assist\n 4.\n Tolerates daily strengthening\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/wk\n bed mobility, transfers, sitting balance, endurance, strengthening,\n education, d/c planning\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Nutrition", "chartdate": "2157-01-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 652476, "text": "Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 67 kg\n 74.2 kg ( 01:00 AM)\n Pertinent medications: Nicardipine gtt, RISS, Colace, Famotidine, MVI,\n Thi, Folic Acid, Abx; SSl ytes - Magnesium sulfate 2gm, Ca 4gm, KCl\n 40mEq; Na tabs\n Labs:\n Value\n Date\n Glucose\n 138 mg/dL\n 05:56 AM\n Glucose Finger Stick\n 158\n 11:00 AM\n BUN\n 12 mg/dL\n 05:56 AM\n Creatinine\n 0.5 mg/dL\n 05:56 AM\n Sodium\n 121 mEq/L\n 05:56 AM\n Potassium\n 4.1 mEq/L\n 05:56 AM\n Chloride\n 91 mEq/L\n 05:56 AM\n TCO2\n 26 mEq/L\n 05:56 AM\n PO2 (arterial)\n 91 mm Hg\n 06:05 AM\n PCO2 (arterial)\n 37 mm Hg\n 06:05 AM\n pH (arterial)\n 7.46 units\n 06:05 AM\n pH (urine)\n 8.0 units\n 01:10 PM\n CO2 (Calc) arterial\n 27 mEq/L\n 06:05 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 7.8 mg/dL\n 05:56 AM\n Phosphorus\n 3.3 mg/dL\n 05:56 AM\n Ionized Calcium\n 1.06 mmol/L\n 06:05 AM\n Magnesium\n 2.3 mg/dL\n 05:56 AM\n Phenytoin (Dilantin)\n 14.5 ug/mL\n 03:55 AM\n WBC\n 10.7 K/uL\n 01:15 AM\n Hgb\n 10.6 g/dL\n 01:15 AM\n Hematocrit\n 28.6 %\n 01:15 AM\n Current diet order / nutrition support: DIET: NPO\n TF: Replete w/ Fiber @ 65ml/hr (goal)\n GI: soft, (+)bs, (+) flatus; (+) sm brown/mucoid bm\n Assessment of Nutritional Status\n Estimation of previous intake:\n Estimation of current intake: Inadequate d/t held TF\n Specifics:\n s/p PEG/trach . TF resumed, up to 40ml/hr, now being held \n residual of 90ml. RN, plan to resume TF at noon (1 hour). Noted\n Na = 121. IVF d/c\nd and feeding tube being flushed w/ NS. Also, plan\n to begin Na tabs today RN. ? of SIADH per neuro note. Would\n change to more concentrated TF to minimize excess water.\n Medical Nutrition Therapy Plan - Recommend the Following\n Multivitamin / Mineral supplement: continue current\n Tube feeding recommendations: Rec change TF to Nutren 2.0 @ 30ml/hr +\n 30g Beneprotein = 1547calories and 84g protein\n Continue lytes, BS and hydration mgmt\n Will continue to follow\n page if ?s *\n" }, { "category": "Physician ", "chartdate": "2157-01-05 00:00:00.000", "description": "Intensivist Note", "row_id": 652046, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n PERCUTANEOUS TRACHEOSTOMY - At 03:15 PM\n INSERTION - At 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 05:56 PM\n Vancomycin - 08:00 PM\n Cefazolin - 04:00 AM\n Infusions:\n Propofol - 30 mcg/Kg/min\n Other ICU medications:\n Vecuronium - 03:15 PM\n Fentanyl - 04:00 PM\n Famotidine (Pepcid) - 08:08 PM\n Heparin Sodium (Prophylaxis) - 01:09 AM\n Hydralazine - 01:09 AM\n Labetalol - 04:03 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: 38\nC (100.4\n T current: 36.7\nC (98.1\n HR: 110 (87 - 111) bpm\n BP: 188/80(83) {114/55(78) - 193/94(132)} mmHg\n RR: 16 (14 - 26) insp/min\n SPO2: 94%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (1 - 23) mmHg\n Total In:\n 3,666 mL\n 650 mL\n PO:\n Tube feeding:\n 4 mL\n IV Fluid:\n 3,182 mL\n 540 mL\n Blood products:\n Total out:\n 1,711 mL\n 545 mL\n Urine:\n 1,370 mL\n 475 mL\n NG:\n 150 mL\n Stool:\n Drains:\n 191 mL\n 70 mL\n Balance:\n 1,955 mL\n 105 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 574 (574 - 574) mL\n PS : 10 cmH2O\n RR (Set): 8\n RR (Spontaneous): 0\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 43\n PIP: 21 cmH2O\n Plateau: 14 cmH2O\n SPO2: 94%\n ABG: 7.45/40/160/27/4\n Ve: 6.9 L/min\n PaO2 / FiO2: 400\n Physical Examination\n Labs / Radiology\n 308 K/uL\n 11.2 g/dL\n 100 mg/dL\n 0.5 mg/dL\n 27 mEq/L\n 3.8 mEq/L\n 13 mg/dL\n 98 mEq/L\n 132 mEq/L\n 31.6 %\n 9.3 K/uL\n [image002.jpg]\n 05:08 AM\n 04:28 AM\n 04:46 AM\n 04:08 AM\n 04:41 AM\n 02:12 AM\n 03:27 AM\n 03:10 AM\n 03:31 AM\n 03:48 AM\n WBC\n 9.2\n 14.1\n 16.9\n 12.4\n 8.8\n 9.3\n Hct\n 35.8\n 34.4\n 34.6\n 31.5\n 29.8\n 31.6\n Plt\n 147\n 159\n 171\n 193\n 260\n 308\n Creatinine\n 0.6\n 0.6\n 0.6\n 0.6\n 0.6\n 0.5\n TCO2\n 27\n 32\n 28\n 29\n Glucose\n 125\n 120\n 159\n 122\n 78\n 105\n 100\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.9 mg/dL,\n Mg:2.3 mg/dL, PO4:3.6 mg/dL\n Assessment and Plan\n RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE\n (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: s/p angio which revealed right vertebral artery occlusion,\n no intervention; Dilantin therapeutic; MRI and repeat head CTs done -\n no sig interval changes; s/p drain placement; neurosurg/neurology\n following; versed PRN/propofol gtt for sedation; nimodipine; f/u CSF\n cxs, csf with wbc\ns, vanco started by neuromed\n Cardiovascular: goal SBP<160mmHg; lopressor75 TID, labetalol prn,\n hydral PRN; nimotop 60q4\n Pulmonary: CPAP+PS trach, poor mental status\n Gastrointestinal / Abdomen: s/p , restart TF today\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: no issues\n Endocrine: RISS\n Infectious Disease: Vanco for WBCs in CSF, Diflucan for yeast, Ancef\n should stop\n Lines / Tubes / Drains: trach, foley, a-line, , \n Wounds: ,,trach site clean\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines: place PICC\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 09:19 AM\n 18 Gauge - 10:00 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: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652593, "text": "Hypotension (not Shock)\n Assessment:\n SBP 80\ns sustaining x 3 hrs\n More lethargic with decreased BP\n U/o dropping off after several hours\n Action:\n Dr (SICU) and neurology HO notified and aware of all BP trends\n Nicardipine previously shut off\n All antihypertensives held\n Lasix held\n HOB to 15 to maintain SBP >80\n NS bolus given (SICU HO notified neurology)\n Response:\n SBP sustaining >100 after bolus\n U/o remains marginal\n Plan:\n Cont to hold all antiypertensives, monitor bp closely, notify SICU HO\n and neurology of all changes in BP.\n Hyponatremia (low sodium, hyposmolality)\n Assessment:\n NA 125 this evening, up to 127 at 2200\n Action:\n Cont on fluid restriction, NS flush with meds, 3% saline at 20cc x 20\n hrs.\n Response:\n Na correcting slowly\n Plan:\n Cont with current plan and monitor Q6 NA level.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Corneal Abrasion\n Assessment:\n Left eye with +corneal abrasion, sutured partially shut. Unable to\n fully shut with tape.\n Action:\n Artificial tears Q1 hr, bacitracian ointment Q6 hrs\n Response:\n No change\n Plan:\n Cont with current plant, ophthalmology following closely.\n" }, { "category": "Nursing", "chartdate": "2157-01-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 652442, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro exam inconsistent, less responsive with elevated temp.\n ICP 6-13\n Action:\n Head Ct done this evening d/t pt not following any commands\n Q2 neuro assessments\n NMED HO notified of all neuro changes overnight\n Response:\n Head CT without change\n Plan:\n NMED feels that exam in inconsistent and not related to worsening\n bleed. Cont on Q2 neuro exams, notify neurology with changes in exam\n and cont to monitor ICP and notify NSURG with elevated ICP\n Hypertension, benign\n Assessment:\n SBP goal <160\n BP labile\n Action:\n On nimodipine, lopressor, hydralizine, and vasotec po\n Nicardipine gtt on/off overnight to maintain BP goal\n Response:\n BP remains < 160\n Plan:\n Cont on gtt until stable on PO regimen\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains ventilated on CMV 40% 500x15 peep 5\n Breaths over vent\n Mod amt thick/frothy yellow-brown secretions\n Action:\n Freq sxn\n Follow aBG\n Response:\n Adequate oxygenation/ventilation\n No distress\n Plan:\n Cont to monitor\n Left eye infection\n Assessment:\n Left eye reddened\n Pupil difficult to assess\n Action:\n Q1 artificial tears\n Bacitracion ointment\n Cipro drops\n Attempted to tape eye shut\n Response:\n Unable to keep eye shut with paper tape, no silk tape used d/t need for\n freq drops. SICU HO notified and artificial tear ointment ordered to\n increase lubrication if eye opening.\n Plan:\n Cont to monitor closely.\n ------ Protected Section ------\n NA 125 last evening (from 124). SICU resident notifed (Dr and\n NMED notified by SICU resident. This am NA 121. Dr and NMED\n notified. ? start hypertonic saline.\n ------ Protected Section Addendum Entered By: , RN\n on: 07:35 ------\n" }, { "category": "Physician ", "chartdate": "2157-01-07 00:00:00.000", "description": "Intensivist Note", "row_id": 652458, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n PMHx:\n ?HTN\n Current medications:\n 1. 2. Acetaminophen 3. Artificial Tears 4. Artificial Tear Ointment 5.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. Ciprofloxacin 0.3% Ophth Soln\n 10. Docusate Sodium (Liquid) 11. Enalapril Maleate 12. Famotidine 13.\n Fentanyl Citrate 14. Fluconazole\n 15. FoLIC Acid 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20.\n Insulin 21. Influenza Virus Vaccine\n 22. Labetalol 23. Magnesium Sulfate 24. Metoprolol Tartrate 25.\n Metoprolol Tartrate 26. Midazolam\n 27. Multivitamins 28. NiCARdipine 29. Nimodipine 30. Phenytoin 31.\n Piperacillin-Tazobactam Na 32. Piperacillin-Tazobactam Na\n 33. Potassium Chloride 34. Propofol 35. Sodium Chloride 0.9% Flush 36.\n Thiamine 37. Vancomycin\n 24 Hour Events:\n FEVER - 102.2\nF - 09:00 PM\n IVF dc'd and free water flushed decreased due to decreased serum\n OSM and hyponatremia per neuro, decreased MS reported by nursing, stat\n non/con CT\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:00 AM\n Fluconazole - 04:00 PM\n Vancomycin - 09:00 PM\n Piperacillin/Tazobactam (Zosyn) - 06:00 AM\n Infusions:\n Nicardipine - 0.5 mcg/Kg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39\nC (102.2\n T current: 37.8\nC (100.1\n HR: 85 (69 - 112) bpm\n BP: 112/51(73) {79/40(53) - 178/76(110)} mmHg\n RR: 17 (16 - 23) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 7 (2 - 13) mmHg\n Total In:\n 2,582 mL\n 801 mL\n PO:\n Tube feeding:\n 827 mL\n 329 mL\n IV Fluid:\n 1,725 mL\n 412 mL\n Blood products:\n Total out:\n 2,431 mL\n 513 mL\n Urine:\n 2,190 mL\n 460 mL\n NG:\n Stool:\n Drains:\n 241 mL\n 53 mL\n Balance:\n 151 mL\n 288 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 550 (550 - 550) mL\n Vt (Spontaneous): 319 (319 - 520) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 5\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 153\n PIP: 14 cmH2O\n Plateau: 11 cmH2O\n Compliance: 91.7 cmH2O/mL\n SPO2: 96%\n ABG: 7.46/37/91/26/2\n Ve: 11.5 L/min\n PaO2 / FiO2: 228\n Physical Examination\n Labs / Radiology\n 390 K/uL\n 10.6 g/dL\n 138 mg/dL\n 0.5 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 12 mg/dL\n 91 mEq/L\n 121 mEq/L\n 28.6 %\n 10.7 K/uL\n [image002.jpg]\n 04:12 AM\n 12:58 PM\n 01:32 PM\n 05:42 PM\n 09:47 PM\n 10:08 PM\n 01:15 AM\n 01:18 AM\n 05:56 AM\n 06:05 AM\n WBC\n 10.7\n Hct\n 28.6\n Plt\n 390\n Creatinine\n 0.5\n 0.5\n 0.6\n 0.5\n TCO2\n 25\n 27\n 26\n 30\n 29\n 27\n Glucose\n 131\n 113\n 127\n 115\n 138\n Other labs: PT / PTT / INR:12.6/29.9/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.7 mmol/L, Albumin:3.3 g/dL, Ca:7.8 mg/dL,\n Mg:2.3 mg/dL, PO4:3.3 mg/dL\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint of left sided headache followed by right sided hemiparesis.\n CTA showing pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Neurologic: left pontine and medullary hemorrhage; EVD drain clogged,\n replaced . f/u repeat Head CT in AM. Cont dilantin; Cont\n nomodipine. neurosurg/neurology following; minimize PPF gtt sedation;\n Vanc for WBC in CSF - f/u CSF cxs\n Cardiovascular: goal SBP<160mmHg; lopressor100 TID, Hydral 75 q6,\n nimotop 60q4; labetalol prn, hydral PRN; Nicardipine gtt restarted\n \n Pulmonary: Trach, s/p Trach. on CPAP+PS. cont to ween to trach collar\n as tol. Recent CXR showing incr Left base opacity\n Gastrointestinal / Abdomen: restarted TF ; constipation- bowel\n regimen incr. Hiccups- may add thorazine if pt has BMs per neuro.\n Nutrition: Tube feeding, TF started - Replete with fiber Full strength\n goal 60\n Renal: keep I=O to prevent pulm edema. lasix as needed; follow serum\n osmhyponatremic this AM. t/c salt tabs, minimize free water flushes\n Hematology: follow Hct - trending down somewhat, will continue to\n follow.\n Endocrine: RISS, RISS, FS well controlled\n Infectious Disease: on Vanc (start ) for WBC in CSF. if vanc d/c,\n will need ancef for EVD. f/u cx's, WBC count (trending down); fluc\n for yeast on sputum. fever \n Lines / Tubes / Drains: Foley, Trach, trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - drops added, but did not\n have ones rec by optho, placed on Cipro drops. - will revisit \n Imaging:\n Fluids: KVO\n Consults:\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:37 AM 40 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 05:17 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2157-01-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 652197, "text": "Demographics\n Day of mechanical ventilation: 10\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\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: Intermittent invasive ventilation\n Visual assessment of breathing pattern: High flow demand; Comments: Pt\n hiccoughing frequently. Episode of vomiting early in shift, no evidence\n of aspiration.\n Assessment of breathing comfort: No claim of dyspnea)\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Vigorous inspiratory efforts\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n ICU to CT\n No complications\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651222, "text": " Problem - Hyperthermia\n Assessment:\n Action:\n Response:\n Plan:\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt at beginning of shift presented with HTN, Tachycardic and elevated\n RR. Constant hiccups. Moderate secretions, thick yellow.\n Action:\n Vercid 2mg. Reglan ordered x1, Propofol gtt started and ventilator\n settings adjusted.\n Response:\n Pt responded well to Reglan, Propofol gtt and vent on assist control.\n Plan:\n Continue patient on ventilator. Assist Control PRN? Continue propofol\n gtt while intubated. Continue to suction frequently.\n Hypertension, benign\n Assessment:\n Pt hypertensive for most of the shift. Nicardipine gtt from 1.5mg\n 3.0\n mcg for SBP <140.\n Action:\n Nicardipine gtt off for hypotensive period this am at 0530.\n Response:\n SICU resident aware. Cuff pressure and Aline correlate.\n Propofol gtt decreased to 20mcg.\n Plan:\n Continue to monitor closely. Adjust hypertensives accordingly.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 651223, "text": " Problem - Hyperthermia\n Assessment:\n Pt\ns TMAX 103.6. Lowest temp 99.\n Action:\n Response:\n Plan:\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt at beginning of shift presented with HTN, Tachycardic and elevated\n RR. Constant hiccups. Moderate secretions, thick yellow.\n Action:\n Vercid 2mg. Reglan ordered x1, Propofol gtt started and ventilator\n settings adjusted.\n Response:\n Pt responded well to Reglan, Propofol gtt and vent on assist control.\n Plan:\n Continue patient on ventilator. Assist Control PRN? Continue propofol\n gtt while intubated. Continue to suction frequently.\n Hypertension, benign\n Assessment:\n Pt hypertensive for most of the shift. Nicardipine gtt from 1.5mg\n 3.0\n mcg for SBP <140.\n Action:\n Nicardipine gtt off for hypotensive period this am at 0530.\n Response:\n SICU resident aware. Cuff pressure and Aline correlate.\n Propofol gtt decreased to 20mcg.\n Plan:\n Continue to monitor closely. Adjust hypertensives accordingly.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2156-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650695, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Continues to follow commands appropriately. Pupils are equal and\n reactive to light. Right hemiperesis persists. Left upper and lower\n extremities move with equal strength. Continues to be hypertensive\n overnight. Slightly restless overnight.\n Action:\n Hydralazine added Q6h. Valium 5 mg Q1hr given x3 over night.\n Response:\n Hypertension improved with IV hydralazine.\n Plan:\n Continue to monitor neuro status hourly. Continue to treat\n hypertension with hydralazine as ordered.\n" }, { "category": "Respiratory ", "chartdate": "2156-12-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650863, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\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: cmH2O\n Cuff volume: mL /\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Diminished\n LUL Lung Sounds: Diminished\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Visual assessment of breathing pattern: Normal quiet breathing\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Comments: Latest abg results determined a very mild metabolic\n alkalemia with very good oxygenation on the current settings.\n RSBI = 52 on 0-PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2156-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650559, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2156-12-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650546, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Admitted from ED s/p intracranial bleed..on propofol\n intubated..initially follows some simple commands moves Lf side to\n command Rt leg withdraws no movement of Rt arm..pupils sm equal &\n react sluggishly\n Action:\n Vent drain placed by Dr ..icp 1..10cm at tragus draining sm amt\n serous sang..rt radial a-line placed\n Response:\n Sedated on propofol..given 5mgm of mso4 for drain placement\n Plan:\n Repeat head ct & possible mri tonite..neuro checks Q 1..monitor icp\n" }, { "category": "Nursing", "chartdate": "2156-12-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650794, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n However patient continues to have impaired gag and cough. Suctioned\n moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Patient to have a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow commands. Right ue/le no\n movement to command. Right le withdraws to stimuli. Left strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm, and\n patient had ctscan of head this am.\n Response:\n No change in neuron checks remains off sedation. Iv diazepam mgs\n given for etoh withdrawls\n Plan:\n To continue with current plan, monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Iv hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n Patient unable to protect airway, so will have trach and peg placed.\n" }, { "category": "Respiratory ", "chartdate": "2156-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650687, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\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: Blood Tinged / 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:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: ? possible extubation\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": "2156-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650914, "text": "airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n patient continues to have impaired gag and cough., but some improvement\n noted from yesterday. Suctioned moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated.\n Response:\n Patient is tolerating current vent settings..\n Plan:\n Tomorrow Patient to be extubated, if gag and cough continues to\n improve, if patient fails trail of exturbation then patient will have\n a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow simple commands. Right\n ue/le no movement to command. Right le withdraws to stimuli. Left\n strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm,\n Response:\n No change in neuro checks. Iv versed given for comfort, while\n intubated.\n Plan:\n To continue with current plan, monitor and treat accordingly.\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Po hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n" }, { "category": "Physician ", "chartdate": "2156-12-28 00:00:00.000", "description": "Intensivist Note", "row_id": 650589, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Possible 2mm aneurysm\n of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine hemorrhage with extension into ventricles.\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tear Ointment 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium (Liquid)\n 9. Famotidine 10. HydrALAzine\n 11. Insulin 12. Influenza Virus Vaccine 13. Magnesium Sulfate 14.\n Morphine Sulfate 15. Nimodipine\n 16. Phenytoin 17. Potassium Chloride 18. Propofol 19. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 03:43 PM\n ICP CATHETER - START 04:00 PM\n BLOOD CULTURED - At 04:06 PM\n PERIP BLD CULT X2 SENT\n INTRAVENTRICULAR DRAIN INSERTED - At 04:06 PM\n ARTERIAL LINE - START 05:00 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n Post operative day:\n HD #2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:16 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 03:45 AM\n Famotidine (Pepcid) - 04:16 AM\n Other medications:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.5\nC (97.7\n HR: 80 (76 - 98) bpm\n BP: 102/45(64) {97/45(2) - 177/78(108)} mmHg\n RR: 14 (14 - 15) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n ICP: 4 (0 - 10) mmHg\n Total In:\n 1,361 mL\n 688 mL\n PO:\n Tube feeding:\n IV Fluid:\n 881 mL\n 618 mL\n Blood products:\n Total out:\n 1,040 mL\n 431 mL\n Urine:\n 215 mL\n 355 mL\n NG:\n Stool:\n Drains:\n 35 mL\n 76 mL\n Balance:\n 321 mL\n 257 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): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n Compliance: 75 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/42/209/27/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: No acute distress, intubated sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), Moves all extremities, moves all\n extremities, L>R\n Labs / Radiology\n 152 K/uL\n 13.9 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 38.2 %\n 8.4 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n WBC\n 8.4\n Hct\n 38.2\n Plt\n 152\n Creatinine\n 0.8\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n Glucose\n 120\n 116\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53 yo m with pontine hemorrhage with left\n ventricular extension.\n Neurologic: Phenytoin - therapeutic, Dilantin started, follow levels;\n MRI read pending to help determine etiology of bleed; will have repeat\n CT head this morning; s/p EVD drain placement; neurosurg/neurology\n following - plan of action being decided; propofol for sedation\n Cardiovascular: SBP<140mmHg via Nimodipine, Hydral prn\n Pulmonary: Cont ETT, intubated/sedated, wean vent as tolerated\n Gastrointestinal / Abdomen: NPO\n Nutrition: NPO\n Renal: Foley, Adequate UO, hyponatremia 130 on admission, Na improving,\n continue to follow\n Hematology: Hct 38.2 currently, stable, will follow\n Endocrine: RISS, FS adequately controlled\n Infectious Disease: ancef for EVD\n Lines / Tubes / Drains: Foley, ETT, a-line, EVD\n Wounds:\n Imaging: CT scan head today, F/u MRI results\n Fluids: NS\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:56 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 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: 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": "Physician ", "chartdate": "2156-12-28 00:00:00.000", "description": "Intensivist Note", "row_id": 650602, "text": "SICU\n HPI:\n 53M presented to this morning with complaint of left\n sided headache followed by right sided hemiparesis. CTA showing\n pontine SAH with IVH in left lateral ventricle. Possible 2mm aneurysm\n of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right.\n Chief complaint:\n pontine hemorrhage with extension into ventricles.\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tear Ointment 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Docusate Sodium (Liquid)\n 9. Famotidine 10. HydrALAzine\n 11. Insulin 12. Influenza Virus Vaccine 13. Magnesium Sulfate 14.\n Morphine Sulfate 15. Nimodipine\n 16. Phenytoin 17. Potassium Chloride 18. Propofol 19. Sodium Chloride\n 0.9% Flush\n 24 Hour Events:\n INVASIVE VENTILATION - START 03:43 PM\n ICP CATHETER - START 04:00 PM\n BLOOD CULTURED - At 04:06 PM\n PERIP BLD CULT X2 SENT\n INTRAVENTRICULAR DRAIN INSERTED - At 04:06 PM\n ARTERIAL LINE - START 05:00 PM\n MAGNETIC RESONANCE IMAGING - At 01:15 AM\n Post operative day:\n HD #2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:16 AM\n Infusions:\n Propofol - 40 mcg/Kg/min\n Other ICU medications:\n Hydralazine - 03:45 AM\n Famotidine (Pepcid) - 04:16 AM\n Other medications:\n Flowsheet Data as of 06:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.5\nC (97.7\n HR: 80 (76 - 98) bpm\n BP: 102/45(64) {97/45(2) - 177/78(108)} mmHg\n RR: 14 (14 - 15) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n ICP: 4 (0 - 10) mmHg\n Total In:\n 1,361 mL\n 688 mL\n PO:\n Tube feeding:\n IV Fluid:\n 881 mL\n 618 mL\n Blood products:\n Total out:\n 1,040 mL\n 431 mL\n Urine:\n 215 mL\n 355 mL\n NG:\n Stool:\n Drains:\n 35 mL\n 76 mL\n Balance:\n 321 mL\n 257 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): 14\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 46\n PIP: 15 cmH2O\n Plateau: 13 cmH2O\n Compliance: 75 cmH2O/mL\n SPO2: 100%\n ABG: 7.42/42/209/27/3\n Ve: 8.8 L/min\n PaO2 / FiO2: 523\n Physical Examination\n General Appearance: No acute distress, intubated sedated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), Moves all extremities, moves all\n extremities, L>R\n Labs / Radiology\n 152 K/uL\n 13.9 g/dL\n 116 mg/dL\n 0.8 mg/dL\n 27 mEq/L\n 3.7 mEq/L\n 9 mg/dL\n 96 mEq/L\n 133 mEq/L\n 38.2 %\n 8.4 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n WBC\n 8.4\n Hct\n 38.2\n Plt\n 152\n Creatinine\n 0.8\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n Glucose\n 120\n 116\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53 yo m with pontine hemorrhage with left\n ventricular extension.\n Neurologic: Phenytoin - therapeutic, Dilantin started, follow levels;\n MRI read pending to help determine etiology of bleed; will have repeat\n CT head this morning; s/p EVD drain placement; neurosurg/neurology\n following - plan of action being decided; propofol for sedation, exam\n improving, hold off on repeat ct\n Cardiovascular: SBP<140mmHg via Nimodipine, Hydral prn\n Pulmonary: Cont ETT, intubated/sedated, switch to pressure support,\n extubate later\n Gastrointestinal / Abdomen: NPO, place dobhoff\n Nutrition: NPO\n Renal: Foley, Adequate UO, hyponatremia 130 on admission, Na improving,\n continue to follow\n Hematology: Hct 38.2 currently, stable, will follow\n Endocrine: RISS, FS adequately controlled\n Infectious Disease: ancef for EVD\n Lines / Tubes / Drains: Foley, ETT, a-line, EVD\n Wounds: evd site clean\n Imaging: CT scan head today, F/U MRI results\n Fluids: NS\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:56 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 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: 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": "2156-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650917, "text": "airway, Inability to Protect (Risk for Aspiration, Altered Gag, Airway\n Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n patient continues to have impaired gag and cough., but some improvement\n noted from yesterday. Suctioned moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated.\n Response:\n Patient is tolerating current vent settings..\n Plan:\n Tomorrow Patient to be extubated, if gag and cough continues to\n improve, if patient fails trail of exturbation then patient will have\n a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow simple commands. Right\n ue/le no movement to command. Right le withdraws to stimuli. Left\n strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm,\n Response:\n No change in neuro checks. Iv versed given for comfort, while\n intubated.\n Plan:\n To continue with current plan, monitor and treat accordingly.\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Po hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n" }, { "category": "Physician ", "chartdate": "2156-12-29 00:00:00.000", "description": "Intensivist Note", "row_id": 650753, "text": "SICU\n HPI:\n 53M presented to this morning with complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Chief complaint:\n headache\n PMHx:\n PMH: ?HTN\n : Flonase\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tear Ointment 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Diazepam 9. Docusate\n Sodium (Liquid) 10. Enalaprilat\n 11. Famotidine 12. FoLIC Acid 13. HydrALAzine 14. HydrALAzine 15.\n Insulin 16. Influenza Virus Vaccine\n 17. Labetalol 18. Magnesium Sulfate 19. Metoprolol Tartrate 20.\n Multivitamins 21. Nimodipine 22. Nimodipine\n 23. NiCARdipine 24. Phenytoin 25. Potassium Chloride 26. Propofol 27.\n Sodium Chloride 0.9% Flush\n 28. Thiamine\n 24 Hour Events:\n EXTUBATION - At 03:26 PM\n INVASIVE VENTILATION - STOP 03:26 PM\n INTUBATION - At 03:45 PM\n INVASIVE VENTILATION - START 03:45 PM\n : admit to sicu, EVD placed, A-line placed; pt pancx'd for low\n grade temp; to Xray/MRI (requested by neurosurg)\n : extubated -> failed due to mucous plugging; reintubated; started\n on CIWA scale;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:11 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:28 AM\n Hydralazine - 03:30 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.1\nC (98.8\n HR: 86 (71 - 119) bpm\n BP: 133/57(81) {90/48(65) - 235/93(146)} mmHg\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n ICP: 6 (-8 - 15) mmHg\n Total In:\n 3,377 mL\n 747 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,997 mL\n 657 mL\n Blood products:\n Total out:\n 2,158 mL\n 454 mL\n Urine:\n 1,882 mL\n 380 mL\n NG:\n Stool:\n Drains:\n 276 mL\n 74 mL\n Balance:\n 1,219 mL\n 294 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 576 (398 - 576) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 98%\n ABG: 7.45/39/187/27/3\n Ve: 7.3 L/min\n PaO2 / FiO2: 374\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: @bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: :(PERRL) r sl. irreg. eyes open spont, follows commands, L\n side strong, RLE triple flex, RUE no movement with nox.\n Labs / Radiology\n 141 K/uL\n 13.0 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 98 mEq/L\n 134 mEq/L\n 36.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n WBC\n 8.4\n 10.0\n Hct\n 38.2\n 36.4\n Plt\n 152\n 141\n Creatinine\n 0.8\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n Glucose\n 120\n 116\n 139\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Neurologic: Dilantin started, follow levels; MRI read pending to help\n determine etiology of bleed; will have repeat CT head this morning; s/p\n EVD drain placement; neurosurg/neurology following - plan of action\n being decided; propofol for sedation; nimodipine\n Cardiovascular: Beta-blocker, SBP<140mmHg; lopressor10q6, labetalol\n prn, hydral 20q6h; nimotop 60q4\n Pulmonary: IS, failed extubation yesterday due to poor cough/gag, will\n need trach\n Gastrointestinal / Abdomen: NPO for now; TFs if not extubated\n Nutrition: Tube feeding, NPO for now; TFs if not extubated, will need\n peg\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: on ancef for EVD\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobbhoff\n Wounds: Dry dressings\n Imaging: none\n Fluids: NS\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:56 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 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:\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2156-12-29 00:00:00.000", "description": "Intensivist Note", "row_id": 650754, "text": "SICU\n HPI:\n 53M presented to this morning with complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Chief complaint:\n headache\n PMHx:\n PMH: ?HTN\n : Flonase\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tear Ointment 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Diazepam 9. Docusate\n Sodium (Liquid) 10. Enalaprilat\n 11. Famotidine 12. FoLIC Acid 13. HydrALAzine 14. HydrALAzine 15.\n Insulin 16. Influenza Virus Vaccine\n 17. Labetalol 18. Magnesium Sulfate 19. Metoprolol Tartrate 20.\n Multivitamins 21. Nimodipine 22. Nimodipine\n 23. NiCARdipine 24. Phenytoin 25. Potassium Chloride 26. Propofol 27.\n Sodium Chloride 0.9% Flush\n 28. Thiamine\n 24 Hour Events:\n EXTUBATION - At 03:26 PM\n INVASIVE VENTILATION - STOP 03:26 PM\n INTUBATION - At 03:45 PM\n INVASIVE VENTILATION - START 03:45 PM\n : admit to sicu, EVD placed, A-line placed; pt pancx'd for low\n grade temp; to Xray/MRI (requested by neurosurg)\n : extubated -> failed due to mucous plugging; reintubated; started\n on CIWA scale;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:11 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:28 AM\n Hydralazine - 03:30 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.1\nC (98.8\n HR: 86 (71 - 119) bpm\n BP: 133/57(81) {90/48(65) - 235/93(146)} mmHg\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n ICP: 6 (-8 - 15) mmHg\n Total In:\n 3,377 mL\n 747 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,997 mL\n 657 mL\n Blood products:\n Total out:\n 2,158 mL\n 454 mL\n Urine:\n 1,882 mL\n 380 mL\n NG:\n Stool:\n Drains:\n 276 mL\n 74 mL\n Balance:\n 1,219 mL\n 294 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 576 (398 - 576) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 98%\n ABG: 7.45/39/187/27/3\n Ve: 7.3 L/min\n PaO2 / FiO2: 374\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: @bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: :(PERRL) r sl. irreg. eyes open spont, follows commands, L\n side strong, RLE triple flex, RUE no movement with nox.\n Labs / Radiology\n 141 K/uL\n 13.0 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 98 mEq/L\n 134 mEq/L\n 36.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n WBC\n 8.4\n 10.0\n Hct\n 38.2\n 36.4\n Plt\n 152\n 141\n Creatinine\n 0.8\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n Glucose\n 120\n 116\n 139\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Neurologic: Dilantin started, follow levels; MRI read pending to help\n determine etiology of bleed; will have repeat CT head this morning; s/p\n EVD drain placement; neurosurg/neurology following - plan of action\n being decided; propofol for sedation; nimodipine\n Cardiovascular: Beta-blocker, SBP<140mmHg; lopressor10q6, labetalol\n prn, hydral 20q6h; nimotop 60q4\n Pulmonary: IS, failed extubation yesterday due to poor cough/gag, will\n need trach\n Gastrointestinal / Abdomen: NPO for now; TFs if not extubated\n Nutrition: Tube feeding, NPO for now; TFs if not extubated, will need\n peg\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: on ancef for EVD\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobbhoff\n Wounds: Dry dressings\n Imaging: none\n Fluids: NS\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:56 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 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:\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2156-12-29 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 650769, "text": "Subjective\n Reintub d/t plugged.\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 170 cm\n 67 kg\n 67 kg ( 03:00 PM)\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 67.1 kg\n 100%\n Diagnosis: stroke, ? TIA\n PMH : Nasal allergies, ? HTN\n Pertinent medications: dilantin, famotidine, colace, ssri, abx,\n thiamine, folic acid, mvi, enalaprilat, kcl, others noted\n Labs:\n Value\n Date\n Glucose\n 139 mg/dL\n 02:59 AM\n Glucose Finger Stick\n 165\n 11:00 AM\n BUN\n 10 mg/dL\n 02:59 AM\n Creatinine\n 0.6 mg/dL\n 02:59 AM\n Sodium\n 134 mEq/L\n 02:59 AM\n Potassium\n 3.6 mEq/L\n 02:59 AM\n Chloride\n 98 mEq/L\n 02:59 AM\n TCO2\n 27 mEq/L\n 02:59 AM\n PO2 (arterial)\n 187 mm Hg\n 11:57 AM\n PCO2 (arterial)\n 39 mm Hg\n 11:57 AM\n pH (arterial)\n 7.45 units\n 11:57 AM\n CO2 (Calc) arterial\n 28 mEq/L\n 11:57 AM\n Calcium non-ionized\n 8.5 mg/dL\n 02:59 AM\n Phosphorus\n 3.9 mg/dL\n 02:59 AM\n Ionized Calcium\n 1.09 mmol/L\n 04:15 AM\n Magnesium\n 2.1 mg/dL\n 02:59 AM\n Phenytoin (Dilantin)\n 16.2 ug/mL\n 02:59 AM\n WBC\n 10.0 K/uL\n 02:59 AM\n Hgb\n 13.0 g/dL\n 02:59 AM\n Hematocrit\n 36.4 %\n 02:59 AM\n Current diet order / nutrition support: 1000 mL NS Continuous at 75\n ml/hr\n GI: abd soft, nt +BS\n Assessment of Nutritional Status\n At risk for malnutrition\n Pt at risk due to: current illness\n Estimated Nutritional Needs\n Calories: 1500-1876 (BEE x or / 22-28 cal/kg)\n Protein: 87-101 (1.3-1.5 g/kg)\n Fluid: per team\n Estimation of current intake: inadequate\n Specifics:\n 53M presented to with complaint of left sided headache\n followed by right sided hemiparesis. CTA showing pontine SAH with IVH\n in left lateral ventricle. Pt intubated at OSH for airway protection,\n pt transferred to for cont care. Pt failed extubation yesterday,\n if unable to extub by Friday will need to start TF. If able to extub,\n pt will need S & S eval b/f any diet advancement.\n Medical Nutrition Therapy Plan - Recommend the Following\n Initiate TF if unable to extub: Replete with fiber at 10ml/hr, adv as\n tol to goal 65ml/hr (1560kcal/97g pro), monitor tol\n S & S eval b/f any diet adv\n Multivitamin / Mineral supplement: d/c MVI once on TF\n Check chemistry 10 panel daily, replete prn\n Cont bg management\n Other: f/u re poc, please page if has ?\n" }, { "category": "Physician ", "chartdate": "2156-12-30 00:00:00.000", "description": "Intensivist Note", "row_id": 650836, "text": "SICU\n HPI:\n 53M p/w pontine SAH with IVH in left lateral ventricle.\n Chief complaint:\n right sided hemiparesis\n PMHx:\n ?HTN\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 03:26 PM\n INVASIVE VENTILATION - STOP 03:26 PM\n INTUBATION - At 03:45 PM\n INVASIVE VENTILATION - START 03:45 PM\n Post operative day:\n HD4\n 24hr events: no gag. planning for trach/peg; TF started. repeat CT\n head stable. ween FiO2 to 40%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 07:48 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Labetalol - 09:08 AM\n Diazepam (Valium) - 11:26 PM\n Dilantin - 12:00 AM\n Metoprolol - 02:00 AM\n Hydralazine - 03:00 AM\n Other medications:\n Flowsheet Data as of 03:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.2\nC (100.7\n HR: 77 (76 - 109) bpm\n BP: 149/69(93) {87/50(63) - 178/76(111)} mmHg\n RR: 19 (12 - 31) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 5 (1 - 10) mmHg\n Total In:\n 2,763 mL\n 453 mL\n PO:\n Tube feeding:\n 102 mL\n 105 mL\n IV Fluid:\n 2,361 mL\n 288 mL\n Blood products:\n Total out:\n 1,765 mL\n 161 mL\n Urine:\n 1,500 mL\n 130 mL\n NG:\n Stool:\n Drains:\n 265 mL\n 31 mL\n Balance:\n 998 mL\n 292 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (372 - 576) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: ////\n Ve: 8.2 L/min\n Physical Examination\n General Appearance: No acute distress, Intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : though diminished b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli),\n spontaneous movement LUE and LLE and withdraws to noxious stimuli. No\n movement RUE and RLL\n Labs / Radiology\n 141 K/uL\n 13.0 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 98 mEq/L\n 134 mEq/L\n 36.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n WBC\n 8.4\n 10.0\n Hct\n 38.2\n 36.4\n Plt\n 152\n 141\n Creatinine\n 0.8\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n Glucose\n 120\n 116\n 139\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M p/w pontine SAH with IVH in left lateral\n ventricle.\n Neurologic: ICP monitor, Dilantin started; MRI and repeat head CTs done\n - no sig interval changes; s/p EVD drain placement; neurosurg/neurology\n following; diazepam for sedation; nimodipine\n Cardiovascular: SBP<140mmHg; lopressor10q6, labetalol prn, hydral\n 20q6h; nimotop 60q4; Intermittent use of nicardipine gtt overnight to\n meet goals.\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), No gag present.\n Cont CPAP/PS 5/5. Decr FiO2 to 40%. Potential Trach on if still\n no gag.\n Gastrointestinal / Abdomen: DHT. may need PEG\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: slow decline in HCT. No apparent source of bleeding.\n follow qday.\n Endocrine: RISS, low insulin requirement\n Infectious Disease: Ancef while EVD is in place\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS, Plan to KVO when TF at goal\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:48 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:55 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 22 Gauge - 02:03 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2156-12-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650576, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 0 None\n Ideal tidal volume: 0 / 0 / 0 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n 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 / Scant\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Icu -> ct scan ->icu\n 7:45pm\n None\n Icu->xray->mri->icu\n 12am to 2:30\n None\n Comments:\n No vent changes made overnight. RSBI=46 this am. See flowsheet for\n further pt data. Will follow.\n 05:47\n" }, { "category": "Physician ", "chartdate": "2156-12-29 00:00:00.000", "description": "Intensivist Note", "row_id": 650722, "text": "SICU\n HPI:\n 53M presented to this morning with complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Initial neuro exam on admission: able to follow basic commands.\n brainstem reflexes appear preserved. He squeezes his hands bilaterally,\n more strongly on the left, and is able to voluntarily bend his left\n knee, just lifting it off the bed. He is not moving the right\n voluntarily. He withdraws in all four extremities, left side more\n briskly than right\n Chief complaint:\n headache\n PMHx:\n PMH: ?HTN\n : Flonase\n Current medications:\n 1. 2. 1000 mL NS 3. Acetaminophen 4. Artificial Tear Ointment 5.\n Calcium Gluconate 6. CefazoLIN\n 7. Chlorhexidine Gluconate 0.12% Oral Rinse 8. Diazepam 9. Docusate\n Sodium (Liquid) 10. Enalaprilat\n 11. Famotidine 12. FoLIC Acid 13. HydrALAzine 14. HydrALAzine 15.\n Insulin 16. Influenza Virus Vaccine\n 17. Labetalol 18. Magnesium Sulfate 19. Metoprolol Tartrate 20.\n Multivitamins 21. Nimodipine 22. Nimodipine\n 23. NiCARdipine 24. Phenytoin 25. Potassium Chloride 26. Propofol 27.\n Sodium Chloride 0.9% Flush\n 28. Thiamine\n 24 Hour Events:\n EXTUBATION - At 03:26 PM\n INVASIVE VENTILATION - STOP 03:26 PM\n INTUBATION - At 03:45 PM\n INVASIVE VENTILATION - START 03:45 PM\n : admit to sicu, EVD placed, A-line placed; pt pancx'd for low\n grade temp; to Xray/MRI (requested by neurosurg)\n : extubated -> failed due to mucous plugging; reintubated; started\n on CIWA scale;\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:11 AM\n Infusions:\n Other ICU medications:\n Diazepam (Valium) - 12:28 AM\n Hydralazine - 03:30 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.1\nC (98.8\n HR: 86 (71 - 119) bpm\n BP: 133/57(81) {90/48(65) - 235/93(146)} mmHg\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n ICP: 6 (-8 - 15) mmHg\n Total In:\n 3,377 mL\n 747 mL\n PO:\n Tube feeding:\n IV Fluid:\n 2,997 mL\n 657 mL\n Blood products:\n Total out:\n 2,158 mL\n 454 mL\n Urine:\n 1,882 mL\n 380 mL\n NG:\n Stool:\n Drains:\n 276 mL\n 74 mL\n Balance:\n 1,219 mL\n 294 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 576 (398 - 576) mL\n PS : 5 cmH2O\n RR (Set): 14\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 50%\n RSBI: 56\n PIP: 11 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 98%\n ABG: 7.45/39/187/27/3\n Ve: 7.3 L/min\n PaO2 / FiO2: 374\n Physical Examination\n General Appearance: No acute distress, Well nourished\n HEENT: PERRL, EOMI\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: @bases)\n Abdominal: Soft, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: :(PERRL) r sl. irreg. eyes open spont, follows commands, L\n side strong, RLE triple flex, RUE no movement with nox.\n Labs / Radiology\n 141 K/uL\n 13.0 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 98 mEq/L\n 134 mEq/L\n 36.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n WBC\n 8.4\n 10.0\n Hct\n 38.2\n 36.4\n Plt\n 152\n 141\n Creatinine\n 0.8\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n Glucose\n 120\n 116\n 139\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M presented to this morning with\n complaint\n of left sided headache followed by right sided hemiparesis. CTA\n showing pontine SAH with IVH in left lateral ventricle. Incidental 2mm\n aneurysm of right basilar artery.\n Neurologic: Dilantin started, follow levels; MRI read pending to help\n determine etiology of bleed; will have repeat CT head this morning; s/p\n EVD drain placement; neurosurg/neurology following - plan of action\n being decided; propofol for sedation; nimodipine\n Cardiovascular: Beta-blocker, SBP<140mmHg; lopressor10q6, labetalol\n prn, hydral 20q6h; nimotop 60q4\n Pulmonary: IS, Extubate today, (Ventilator mode: CPAP + PS), CPAP+PS\n intubated/sedated, wean vent to extubation\n Gastrointestinal / Abdomen: NPO for now; TFs if not extubated\n Nutrition: Tube feeding, NPO for now; TFs if not extubated\n Renal: Foley, Adequate UO\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: on ancef for EVD\n Lines / Tubes / Drains: ETT, foley, a-line, EVD, dobbhoff\n Wounds: Dry dressings\n Imaging:\n Fluids: NS\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:56 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 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:\n Disposition: ICU\n Total time spent: 33 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2156-12-30 00:00:00.000", "description": "Intensivist Note", "row_id": 650898, "text": "SICU\n HPI:\n 53M p/w pontine SAH with IVH in left lateral ventricle.\n Chief complaint:\n right sided hemiparesis\n PMHx:\n ?HTN\n Current medications:\n 24 Hour Events:\n EXTUBATION - At 03:26 PM\n INVASIVE VENTILATION - STOP 03:26 PM\n INTUBATION - At 03:45 PM\n INVASIVE VENTILATION - START 03:45 PM\n Post operative day:\n HD4\n 24hr events: no gag. planning for trach/peg; TF started. repeat CT\n head stable. ween FiO2 to 40%\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 07:48 PM\n Infusions:\n Nicardipine - 1 mcg/Kg/min\n Other ICU medications:\n Labetalol - 09:08 AM\n Diazepam (Valium) - 11:26 PM\n Dilantin - 12:00 AM\n Metoprolol - 02:00 AM\n Hydralazine - 03:00 AM\n Other medications:\n Flowsheet Data as of 03:45 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.7\n T current: 38.2\nC (100.7\n HR: 77 (76 - 109) bpm\n BP: 149/69(93) {87/50(63) - 178/76(111)} mmHg\n RR: 19 (12 - 31) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 67 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 5 (1 - 10) mmHg\n Total In:\n 2,763 mL\n 453 mL\n PO:\n Tube feeding:\n 102 mL\n 105 mL\n IV Fluid:\n 2,361 mL\n 288 mL\n Blood products:\n Total out:\n 1,765 mL\n 161 mL\n Urine:\n 1,500 mL\n 130 mL\n NG:\n Stool:\n Drains:\n 265 mL\n 31 mL\n Balance:\n 998 mL\n 292 mL\n Respiratory support\n O2 Delivery Device: Endotracheal tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 372 (372 - 576) mL\n PS : 5 cmH2O\n RR (Spontaneous): 19\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 10 cmH2O\n SPO2: 98%\n ABG: ////\n Ve: 8.2 L/min\n Physical Examination\n General Appearance: No acute distress, Intubated\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : though diminished b/l), (Sternum: Stable )\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli),\n spontaneous movement LUE and LLE and withdraws to noxious stimuli. No\n movement RUE and RLL\n Labs / Radiology\n 141 K/uL\n 13.0 g/dL\n 139 mg/dL\n 0.6 mg/dL\n 27 mEq/L\n 3.6 mEq/L\n 10 mg/dL\n 98 mEq/L\n 134 mEq/L\n 36.4 %\n 10.0 K/uL\n [image002.jpg]\n 05:35 PM\n 04:01 AM\n 04:15 AM\n 11:57 AM\n 02:59 AM\n WBC\n 8.4\n 10.0\n Hct\n 38.2\n 36.4\n Plt\n 152\n 141\n Creatinine\n 0.8\n 0.6\n Troponin T\n <0.01\n <0.01\n TCO2\n 28\n 28\n Glucose\n 120\n 116\n 139\n Other labs: PT / PTT / INR:12.6/26.7/1.1, CK / CK-MB / Troponin\n T:169/4/<0.01, Ca:8.5 mg/dL, Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n .H/O AIRWAY, INABILITY TO PROTECT (RISK FOR ASPIRATION, ALTERED GAG,\n AIRWAY CLEARANCE, COUGH), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M p/w pontine SAH with IVH in left lateral\n ventricle.\n Neurologic: ICP monitor, Dilantin started; MRI and repeat head CTs done\n - no sig interval changes; s/p EVD drain placement; neurosurg/neurology\n following; diazepam for sedation; nimodipine\n Cardiovascular: SBP<140mmHg; lopressor10q6, labetalol prn, hydral\n 20q6h; nimotop 60q4; Intermittent use of nicardipine gtt overnight to\n meet goals.\n Pulmonary: Cont ETT, (Ventilator mode: CPAP + PS), No gag present.\n Cont CPAP/PS 5/5. Decr FiO2 to 40%. Potential Trach on if still\n no gag.\n Gastrointestinal / Abdomen: DHT. may need PEG\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO\n Hematology: slow decline in HCT. No apparent source of bleeding.\n follow qday.\n Endocrine: RISS, low insulin requirement\n Infectious Disease: Ancef while EVD is in place\n Lines / Tubes / Drains: Foley, Dobhoff, ETT\n Wounds: Dry dressings\n Imaging: CXR today\n Fluids: NS, Plan to KVO when TF at goal\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS), (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:48 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n 18 Gauge - 02:55 PM\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 22 Gauge - 02:03 PM\n Prophylaxis:\n DVT: Boots\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2156-12-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650518, "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: 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: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2156-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650572, "text": "53 yr old presented to Hosp. with c/o Lf sided Ha followed by Rt\n sided weakness head ct showed 3cm bleed involving 4th ventricle at area\n of pons..Intubated placed on propofol given versed & transferred to\n ed where he had repeat ct.was following some simple commands on\n lf no movement on rt.dilantin load given & transferred to sicu-b\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt was intubated from OSH for airway protection, cont on vent, on\n propofol gtt\n Action:\n Sxn prn white thick secretion, Good O2 sats,, ABG done in the morning,\n acceptable\n Response:\n LS clear and diminished at bases, O2 sats 98-99%, , FIO 2 down to 40%\n after morning ABG\n Plan:\n Cont monitoring, sxn prn, pulm hygiene. Wean as tolerates\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with H/o IVH and potine bleed with vent drain placed at bed side\n yesterday evening. Responding to voice by opening eyes at times, not\n following any commands\n Action:\n Taken to CT scan for post drain placement CT head with report in, Whole\n body X-ray done as check list for MRI was not complete .reached to pt\n mother through telephone and she was not able to complete it. Taken for\n MRI after x-rays were cleared by radiologist\n Response:\n Post drain CT head and MRI done, neuro checks q1h, SBP goal <140\n Plan:\n Neuro checks q1h, SBP <140, Ct head in the morning\n Hypertension, benign\n Assessment:\n Pt SBP >140 with stimulation, activities etc.\n Action:\n Pt on propofol gtt, titrated ppf to keep the pt sedated enough.\n hydralazine 10mg x1 for SBP >140\n Response:\n Maintained SBP <140.\n Plan:\n Goal SBP <140,PRN hydralazine, to start anti HT drugs gtt if\n persistently hypertensive\n" }, { "category": "Nursing", "chartdate": "2156-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650565, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt was intubated from OSH for airway protection, cont on vent, on\n propofol gtt\n Action:\n Sxn prn white thick secretion, Good O2 sats,, ABG done in the\n morning,acceptable\n Response:\n LS clear and diminished at bases, O2 sats 98-99%, , FIO 2 down to 40%\n after morning ABG\n Plan:\n Cont monitoring, sxn prn, pulm hygiene. Wean as tolerates\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with H/o IVH and potine bleed with vent drain placed at bed side\n yesterday evening.Responding to voice by opeing eyes ar\\t times\n Action:\n Taken to CT scan for post drain placement CT head with report in,\n Whole body Xray done as check list for MRI was not complete .eached to\n pt\ns mother through telephone and she was not able to complete it.\n Taken for MRI and xrays were cleared by radiologist\n Response:\n Post drain CT head and MRI done, neuro checks q1h, SBP goal <140\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2156-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650569, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt was intubated from OSH for airway protection, cont on vent, on\n propofol gtt\n Action:\n Sxn prn white thick secretion, Good O2 sats,, ABG done in the\n morning,acceptable\n Response:\n LS clear and diminished at bases, O2 sats 98-99%, , FIO 2 down to 40%\n after morning ABG\n Plan:\n Cont monitoring, sxn prn, pulm hygiene. Wean as tolerates\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt with H/o IVH and potine bleed with vent drain placed at bed side\n yesterday evening.Responding to voice by opeing eyes at times, nor\\t\n following any commands\n Action:\n Taken to CT scan for post drain placement CT head with report in,\n Whole body Xray done as check list for MRI was not complete .eached to\n pt\ns mother through telephone and she was not able to complete it.\n Taken for MRI and xrays were cleared by radiologist\n Response:\n Post drain CT head and MRI done, neuro checks q1h, SBP goal <140\n Plan:\n Neuro checks q1h, SBP <140, Ct head in the morning\n Hypertension, benign\n Assessment:\n Pt SBP >140 with stimulation, actvities etc.\n Action:\n Pt on propofol gtt, titrated ppf to keep the pt sedated enough.\n hydralazine 10mg x1 for SBP >140\n Response:\n Maintained SBP <140.\n Plan:\n Goal SBP <140,PRN hydralazine, to start anti HT drugs gtt if\n persistently hypertensive\n" }, { "category": "Respiratory ", "chartdate": "2156-12-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650648, "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: cm at teeth\n Route:\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Blood Tinged / Tenacious\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Not triggering\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: Pt was re-intubated\n for mucus plug after extubation. Will attempt to extubate in am\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2156-12-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 650819, "text": "TITLE:\n Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation:\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: 22 cm at teeth\n Route: Oral\n Type: Standard\n Size: 8mm\n Tracheostomy tube:\n Type:\n Manufacturer:\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: cmH2O\n Cuff volume: mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: 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 / 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: Not triggering\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: Cannot protect\n airway, Underlying illness not resolved; Comments: pt's cannot not\n protect airway due to mental staus... probable for trach and peg.\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Social Work", "chartdate": "2156-12-31 00:00:00.000", "description": "Social Work Admission Note", "row_id": 651104, "text": "Family Information\n Next of : (mother)\n Health Proxy appointed: Proxy\n Family Spokesperson designated:\n Communication or visitation restriction:\n Patient Information:\n Previous living situation:\n Previous level of functioning: Independent\n Previous or other hospital admissions: n/a\n Past psychiatric history: n/a\n Past addictions history: n/a\n Employment status: layed off\n Legal involvement: n/a\n Mandated Reporting Information:\n Additional Information:\n Patient / Family Assessment: Aunt h- w-\n \n Clergy Contact:\n Communication with Team:\n Plan / Follow up:\n 53 yr old divorced gentleman referred to this worker as he is the\n primary caretaker for his yr old mother. RN mother very upset\n and overwhelmed on the phone. Pt\ns aunt called the\n hospital on behalf of the mother to get medical update. Following hx\n taken from the aunt; Pt was once married and has been divorced for many\n years, he has no children. Pt currently living with mother to provide\n care and supervision, mother is yr\ns old and is described as frail\n but\nsharp as a tack\n. Pt recently layed off from his job at \n Financial.\n Pt has no siblings but does have a lifelong best friend \n h- cell . (friend) and (Aunt) are\n with pt\ns mother at this time trying to encourage her to go into\n respite care. police did contact elder services on behalf of\n the mother. Have mother\ns PCP to make her aware of the aunt\n need to speak with her re: mother\ns current med\ns and the potential\n need of a medical report for respite care.\n Will continue to follow pt\ns progress and plan with family for pt\n needs\n" }, { "category": "Nursing", "chartdate": "2156-12-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650875, "text": "Altered mental status (not Delirium)\n Assessment:\n Patient occasionally opening eyes to voice. Inconsistently follows\n commands. Discussed with nmed resident, exam similar to recent\n baseline. Able to move right arm & leg, no movement left side. Pupils\n ~ 2mm equal and brisk. ICP ranging , vent drain with moderate\n amount blood tinged drainage. Patient not sedated, does not appear in\n pain. Restless with stimulation, becoming tachycardic & tachypneic.\n No gag noted, but patient has strong cough.\n Action:\n Continued with neuro checks every 2 hours. Medicated with Valium as\n needed for CIWA.\n Response:\n Patient stable, see flowsheet for all details.\n Plan:\n ? Trach , will need consent. Continue to follow neuro exam.\n Hypertension, benign\n Assessment:\n Patient\ns sbp ranging 100-150\ns, nicardipine gtt on most of the shift.\n Patient also on hydralazine, enalapril, & lopressor.\n Action:\n Nicardipine gtt titrated for goal sbp < 140.\n Response:\n Patient\ns sbp now ranging 130-140\n Plan:\n ? change antihypertensives to PO (tolerating tube feeds). Continue to\n follow vitals.\n" }, { "category": "Nursing", "chartdate": "2156-12-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 650643, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt weaned to extubation, but plugged immediately, large mucous plug\n cleared by pt.\n Action:\n re intubated for airway protection\n Response:\n adequate oxygenation, good breathsounds.\n Plan:\n maintain overnight, ? extubate in am if stable.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pontine bleed, Ventriculostomy in place.\n Action:\n Sedation weaned to off this am.\n Response:\n moving left side well, minimal to right side (occasional weak hand\n grasp), nodding to yes/no q\ns appropriately. Blood tinged drainage\n from vent drain continues at 10-30cc/hr, transducer no longer working\n despite multiple attempts at troubleshooting.\n Plan:\n continue Q1hr neuro checks. BP 140-160\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656042, "text": "Tachycardia, Other\n Assessment:\n - pt became tachycardic with HR in the 120s\n -\n Action:\n - given labatelol 10mg\n - given Fentanyl 25mcg\n - repositioned\n Response:\n - pts HR decreased slightly with labetolol and slightly more\n with Fentanyl\n HR decreased to 100\n -\n Plan:\n - continue to assess and treat tachycardia\n -\n .H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n - Pt trached\n - pt became tachypneic with respiratory rate in the 50s-60s\n when turning and repositioning\n - Pt especially does not tolerate turning to his R side\n Action:\n - given 0.5mg versed\n -\n Response:\n - versed settled pt down to a normal RR X 2 episodes of\n tachypnea\n - 3^rd episode\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-02-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657960, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 6 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:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th yellow sput. Pt in\n NARD on current settings ; no vent changes required overnoc. Cont PSV.\n" }, { "category": "Nursing", "chartdate": "2157-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658086, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains on cpap with pressure support. Breath sounds are clear,\n occasionally rhonchorus and diminished in the bases.\n Action:\n Pt suctioned for small amts of thick yellow sputum. Able to cough and\n raise. Attempt made for CPAP 5/5 but pt tolerated poorly, dropping o2\n sat ~91% with tachypnea ~40 BPM. Placed back on CPAP . Pt OOb to\n chair and tolerated well.\n Response:\n Pt comfortable on cpap with pressure support .\n Plan:\n Monitor resp. status. Assess for readiness for trach collar or decrease\n in pressure support and wean as tol. ?Readiness for rehab when\n insurance provider available for pt.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655751, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 29\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 mL /\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 / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Physician ", "chartdate": "2157-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 656081, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12%\n Oral Rinse, ChlorproMAZINE, Ciprofloxacin HCl, Docusate Sodium\n (Liquid), Escitalopram Oxalate, Famotidine, Fentanyl Citrate, FoLIC\n Acid, Heparin, HydrALAzine, Insulin, Labetalol, Magnesium Sulfate,\n Metoclopramide, Midazolam, Multivitamins, Olanzapine,\n OxycoDONE-Acetaminophen Elixir, Thiamine\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Other ICU medications:\n Labetalol - 05:10 PM\n Fentanyl - 11:30 PM\n Heparin Sodium (Prophylaxis) - 11:55 PM\n Midazolam (Versed) - 05:04 AM\n Flowsheet Data as of 05:16 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: 36.6\nC (97.8\n HR: 104 (71 - 115) bpm\n BP: 149/77(94) {91/50(60) - 162/85(104)} mmHg\n RR: 20 (13 - 35) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.3 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,274 mL\n 389 mL\n PO:\n Tube feeding:\n 1,584 mL\n 339 mL\n IV Fluid:\n 111 mL\n Blood products:\n Total out:\n 2,153 mL\n 440 mL\n Urine:\n 2,153 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 121 mL\n -51 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (286 - 684) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ////\n Ve: 11.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 383 K/uL\n 7.8 g/dL\n 107 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.3 %\n 12.5 K/uL\n [image002.jpg]\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n WBC\n 14.5\n 13.3\n 11.8\n 12.5\n Hct\n 22.6\n 22.1\n 22.1\n 21.3\n Plt\n 83\n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n 1.4\n TCO2\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.0 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Serial Hct, Hct drifting down\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:45 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Transfer to rehab / long term facility\n Total time spent: 34 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656083, "text": "Demographics\n Day of mechanical ventilation: 31\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Known difficult intubation: Unknown\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Rhonchi\n LUL Lung Sounds: Rhonchi\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Irregular breathing pattern.\n Plan\n Next 24-48 hours: Continue with daily tests & SBT's as tolerated;\n Comments: No , pts RR> 35\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway\n" }, { "category": "Nutrition", "chartdate": "2157-02-07 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 657868, "text": "Current Wt: 65.8kg\n Adm Wt: 67kg\n Pertinent medications: Cipro, Mvit, RISS, Thiamine, others noted\n Labs:\n Value\n Date\n Glucose\n 101 mg/dL\n 04:35 AM\n Glucose Finger Stick\n 134\n 10:00 AM\n BUN\n 46 mg/dL\n 04:35 AM\n Creatinine\n 1.0 mg/dL\n 04:35 AM\n Sodium\n 143 mEq/L\n 04:35 AM\n Potassium\n 4.1 mEq/L\n 04:35 AM\n Chloride\n 108 mEq/L\n 04:35 AM\n TCO2\n 25 mEq/L\n 04:35 AM\n PO2 (arterial)\n 106 mm Hg\n 04:54 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:54 AM\n pH (arterial)\n 7.41 units\n 04:54 AM\n pH (urine)\n 5.0 units\n 09:41 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 04:19 AM\n Calcium non-ionized\n 9.8 mg/dL\n 04:35 AM\n Phosphorus\n 4.4 mg/dL\n 04:35 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:10 AM\n Magnesium\n 2.1 mg/dL\n 04:35 AM\n Phenytoin (Dilantin)\n 11.3 ug/mL\n 03:01 AM\n WBC\n 15.2 K/uL\n 04:35 AM\n Hgb\n 8.9 g/dL\n 04:35 AM\n Hematocrit\n 25.2 %\n 04:35 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 65cc/hr (1560kcal, 97g protein)\n GI: abd soft, +BS\n Assessment of Nutritional Status\n 53 y.o. M with trach & PEG, s/p VP shunt for ICH and IVH. Pt has been\n tolerating his tube feeding, which provides 23kcal/kg adm. However, pt\n has been slowly losing weight, and he may need increased kcals to\n achieve weight maintenance. Rec change to a lower protein formual\n Fibersource- in order to meet pt\ns kcal needs without providing excess\n protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec change TF goal to Fibersource @ 60cc/hr (1728kcals, 76g\n protein).\n 2) Monitor BG and hydration, as this TF formula is slightly more\n concentrated and is higher-carbohydrate than replete with Fiber.\n 3) Following\n please page with ?\ns #\n" }, { "category": "Rehab Services", "chartdate": "2157-02-07 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 657870, "text": "Subjective:\n intubated\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n N/A\n\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n Total Assist x2\n\n\n\n\n\n\n Transfer:\n N/A\n\n\n\n\n\n\n Sit to Stand:\n N/A\n\n\n\n\n\n\n Ambulation:\n N/A\n\n\n\n\n\n\n Stairs:\n\n\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 80\n 122/64\n 13\n 100%\n Activity\n Sit\n 96\n 131/91\n 18\n 100%\n Recovery\n 84\n /\n 13\n 100%\n Total distance walked:\n Minutes:\n Gait:\n Balance: sat EOB x 15 minutes-- able to use LUE to hold onto rail when\n placed-- varies from CGA to maxA to sit at edge of bed-- loses balance\n in all directions. head forward and down\n Education / Communication: communication with RN re: patient status\n Other: Pt on CPAP with PS 12, PEEP 8, 40% FiO2, TV 660mL\n Pt alerts to stim and looks toward voice, Pt following only about 5% of\n commands, mouthing words at some points\n Pt using LUE and LE in purposeful movements; very slight movement of R\n fingers noted, no other R sided movement\n suctioned through in-line and oral yankauer for large amounts thick\n secretions (yellow from in-line, clear from mouth)\n Assessment: 53m with L pontine-medullary hemorrhage tolerating edge of\n bed with assistance well with good level of arousal. Very minimal\n command following but is demonstrating purposeful movements on L side.\n Continue to recommend d/c to rehab.\n Anticipated Discharge: Rehab\n Plan: Continue balance, functional mob training, d/c planning.\n" }, { "category": "Rehab Services", "chartdate": "2157-02-07 00:00:00.000", "description": "PMV Follow-Up", "row_id": 657872, "text": "TITLE: PMV FOLLOW-UP\nWe returned to see how patient was tolerating trials of trach\ncollar with PMV. RN reported patient has remained on CPAP with\nPEEP throughout the weekend with increased difficulty weaning.\nTherefore PMV has not been trialed. Based on patient with\ncontinued difficulty with secretions, continued vent support, and\nRN report of patient not appropriate currently, PMV trials will\nbe deferred until patient is better able to tolerate trach collar\nas per medical goals. Please reconsult when patient is\nappropriate for repeat PMV evaluation when patient is tolerating\ntrach collar or Pressure Support or .\nThank you.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656940, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received on vent, CPAP/PSV 5/5 and 40%. VT and RR WNL.\n No vent changes made. RSBI 56 this morning\n" }, { "category": "Respiratory ", "chartdate": "2157-01-27 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656200, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 31\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Insp Wheeze\n LUL Lung Sounds: Insp Wheeze\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments: pt secretions more yellow this am sample sent to lab for\n culture\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 frequently tachypnic into the 50s at times IPS increased\n and decreased throughout the shift in attempt to maintain pt comfort.\n peep also slightly increased this afternoon\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: plan to contiinue to wean IPS as tolerated with a goal of TM\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2157-01-28 00:00:00.000", "description": "Intensivist Note", "row_id": 656259, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n CVA\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Alteplase (Catheter Clearance) 6.\n Artificial Tear Ointment\n 7. Bacitracin/Polymyxin B Sulfate Opht. Oint 8. Bisacodyl 9. Calcium\n Gluconate 10. Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. ChlorproMAZINE 12. Ciprofloxacin HCl 13. Docusate Sodium (Liquid)\n 14. Escitalopram Oxalate 15. Famotidine\n 16. Fentanyl Citrate 17. FoLIC Acid 18. Furosemide 19. Furosemide 20.\n Heparin 21. HydrALAzine 22. HydrALAzine\n 23. 24. Insulin 25. Influenza Virus Vaccine 26. Labetalol 27. Labetalol\n 28. Magnesium Sulfate\n 29. Metoclopramide 30. Midazolam 31. Multivitamins 32. Olanzapine 33.\n OxycoDONE-Acetaminophen Elixir\n 34. Potassium Chloride 35. Scopolamine Patch 36. Sodium Chloride 0.9%\n Flush 37. Sodium Chloride 0.9% Flush\n 38. Thiamine 39. Vancomycin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Vancomycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:27 PM\n Fentanyl - 03:15 PM\n Furosemide (Lasix) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.7\nC (98\n HR: 74 (74 - 109) bpm\n BP: 116/64(77) {113/62(68) - 162/82(105)} mmHg\n RR: 14 (6 - 40) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,108 mL\n 860 mL\n PO:\n Tube feeding:\n 1,578 mL\n 440 mL\n IV Fluid:\n 200 mL\n 200 mL\n Blood products:\n Total out:\n 2,205 mL\n 550 mL\n Urine:\n 2,205 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -97 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 924 (114 - 924) mL\n PS : 12 cmH2O\n RR (Spontaneous): 9\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities\n Labs / Radiology\n 472 K/uL\n 7.7 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 37 mg/dL\n 107 mEq/L\n 140 mEq/L\n 21.6 %\n 12.5 K/uL\n [image002.jpg]\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n Plt\n 48\n 472\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n TCO2\n 24\n 26\n Glucose\n 190\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.3 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach,sputum g+ cocci on vanco\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Hct drifting down\n Endocrine: RISS\n Infectious Disease: sputum from with Klebsiella pneumonia (no\n yeast cultured), cipro started for VAP, g + cocci 1+ in sputum, vanco 1\n g q 12\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: LENIS negative\n Fluids:\n Consults: Neuro surgery, Ophthalmology\n Billing Diagnosis: CVA, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:49 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656090, "text": " Problem - Tachypnea\n Assessment:\n Pt with periods of RR in the 30-40\ns. Mostly noted with any type of\n physical stimulation.\n Action:\n Fentanyl for decreasing discomfort with nursing activities, Vercid for\n decreasing ? of anxiety when patient spontaneously increased RR into\n the 40\n Response:\n Pt responding to pain and sedation medications.\n Plan:\n Continue use Fentanyl and Vercid as needed. ? increase standing dose\n of Zyprexia for better anxiety control.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-25 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 655838, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: ICH /\n Reason of referral: RE-EVAL\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , VP\n shunt and PICC line placed . PT has been following pt \n Past Medical / Surgical History: See initial evaluation\n Medications: HydrALAzine, Labetalol, ChlorproMAZINE,\n OxycoDONE-Acetaminophen Elixir\n Radiology: CXR : In comparison with the study of , the\n monitoring and support devices remain in place. Cardiomediastinal\n contours are stable. Patchy right upper lobe opacity is again seen,\n presumably related to infection as suggested on the recent CT scan.\n More symmetric bilateral perihilar and basilar opacities may reflect\n pulmonary edema with layering of bilateral pleural effusions\n Labs:\n 22.1\n 7.8\n 395\n 11.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: See initial eval\n Living Environment: See initial eval\n Prior Functional Status / Activity Level: See initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt eyes open t/o eval,\n Pt followed < 10% of 1 step command might have squeezed L hand however\n inconsistent.\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 90\n 125/65\n 98% CPAP\n Rest\n /\n Sit\n 82\n 90/50\n 99% CPAP\n Activity\n /\n Stand\n /\n Recovery\n 89\n 108/57\n 99% CPAP\n Total distance walked:\n Minutes:\n Pulmonary Status: CPAP PEEP 10 PSV 12 TV. 530-.850. Pt inline suctioned\n at EOB for scant amounts of thin white sputum, pt had large amounts of\n saliva at EOB.\n Integumentary / Vascular: Trach, PEG, L scalp incision intact, foley,\n PICC\n Sensory Integrity: No withdraw to pain R UE or LE, unable to accurately\n assess L UE and LE pt does responded however no localized response\n Pain / Limiting Symptoms: No signs of discomfort t/o eval\n Posture: Increased thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n Cervical L rotation and R lateral flexion limited\n Pt spontaneously moving L UE and LE in bed and against gravity, no\n movement of R UE or LE\n Motor Function: 1+ flexor tone L UE and L LE. Flaccid R UE/LE. Minimal\n visual tracking within R field, nystagmus with R gaze. Pt picking at\n objects with L UE.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was slide to stretcher chair with A x 3.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required Mod-Max A to maintain balance at EOB, poor head\n and neck control. Pt inconsistently using L UE on bed rail to assist\n with balance. Posterior L LOB when unsupported\n Education / Communication: Pt status discussed with RN, made aware of\n BP changes with OOB. Pt was seen with RN.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performance, Impaired\n Clinical impression / Prognosis: 53 yo m admitted with L pontine\n hemorrhage and IVH. Pt presents with above impairments c/w\n nonprogressive CNS dysfunction. Pt remains well below baseline. Today\n he demonstrated little change in cognition and activity tolerance. He\n requires total A for bed mobility and max A for balance. Pt will\n require skilled PT/OT/ Speech therapy in a rehab setting upon d/c to\n optimize safety and function.\n Goals\n Time frame:\n 1.\n Follow > 50% of 1 step commands\n 2.\n Tolerate trach collar trials\n 3.\n Max A for bed mobility\n 4.\n Sit at EOB > 10 mins c min A\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n F/u Balance training at EOB, bed mobility, cognitive stimulation.\n /xwk\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n No MS\n" }, { "category": "Respiratory ", "chartdate": "2157-01-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656019, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min);\n Comments: pt remains on PSV peep weaned down to 5 pt tolerated well\n sats remain >96% pt has periods of tachypnia >35 with stimulation. pt\n weaned to TM this afternoon pt tolerated <15 minutes due to increased\n rr into 40s\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 Comments: plan to continue to wean to TM 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": "Physician ", "chartdate": "2157-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 656368, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH, respiratory failure\n PMHx:\n Hypertension\n Current medications:\n Acetaminophen. Albuterol Inhaler. Artificial Tear Ointment.\n Bacitracin/Polymyxin B Sulfate Opht. Oint. Bisacodyl. Calcium\n Gluconate. Chlorhexidine Gluconate 0.12% Oral Rinse. ChlorproMAZINE.\n Ciprofloxacin HCl. Docusate Sodium (Liquid). Escitalopram Oxalate.\n Famotidine. Fentanyl Citrate. FoLIC Acid. Furosemide. Heparin.\n HydrALAzine. Insulin. Labetalol. Magnesium Sulfate. Metoclopramide.\n Midazolam. Midazolam. Multivitamins. Olanzapine.\n OxycoDONE-Acetaminophen Elixir. Potassium Chloride. Thiamine\n 24 Hour Events:\n BRONCHOSCOPY - At 10:05 AM\n Bronchoscopy with BAL (specimen lost)\n Small cuff leak\n 1L negative with diuresis\n Weaned to CPAP/PS of \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 04:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.5\nC (97.7\n HR: 88 (74 - 95) bpm\n BP: 125/60(84) {110/58(77) - 162/92(112)} mmHg\n RR: 15 (14 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,019 mL\n 275 mL\n PO:\n Tube feeding:\n 1,599 mL\n 275 mL\n IV Fluid:\n 200 mL\n Blood products:\n Total out:\n 3,125 mL\n 155 mL\n Urine:\n 3,125 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,106 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 503 (433 - 699) mL\n PS : 10 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, Left eyelids sutured closed\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 469 K/uL\n 7.9 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.7 mEq/L\n 35 mg/dL\n 104 mEq/L\n 139 mEq/L\n 22.1 %\n 12.1 K/uL\n [image002.jpg]\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n Plt\n 48\n 472\n 469\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n TCO2\n 26\n Glucose\n 190\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n Other labs: PT / PTT / INR:13.8/29.7/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:1.9 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neuro: stable cerebral hemorrhages, s/p VPS, cont zyprexa and SSRI, prn\n versed for agitation\n CV: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Resp: stable on CPAP/PS, try today, trach pressures adequate with\n small leak, bronch with BAL yesterday (BAL specimen lost), consult IP\n for possible stent for tracheomalacia\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix prn\n FEN: TFs\n Heme: Hct stable\n Endo: RISS\n ID: cipro started for VAP, continue Vanc\n TLD: trach, foley, PEG, rt PICC\n Wound: left corneal ulcer (optho following)\n Prophylaxis: H2B, SQH\n Imaging: CXR\n Dispo: start screening for vented rehab. no insurance and no health\n care proxy. social work following.\n Billing Diagnosis: SAH, respiratory failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:42 PM 65.\n mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: famotidine\n VAP bundle: +++\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-28 00:00:00.000", "description": "Intensivist Note", "row_id": 656277, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n CVA\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Alteplase (Catheter Clearance) 6.\n Artificial Tear Ointment\n 7. Bacitracin/Polymyxin B Sulfate Opht. Oint 8. Bisacodyl 9. Calcium\n Gluconate 10. Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. ChlorproMAZINE 12. Ciprofloxacin HCl 13. Docusate Sodium (Liquid)\n 14. Escitalopram Oxalate 15. Famotidine\n 16. Fentanyl Citrate 17. FoLIC Acid 18. Furosemide 19. Furosemide 20.\n Heparin 21. HydrALAzine 22. HydrALAzine\n 23. 24. Insulin 25. Influenza Virus Vaccine 26. Labetalol 27. Labetalol\n 28. Magnesium Sulfate\n 29. Metoclopramide 30. Midazolam 31. Multivitamins 32. Olanzapine 33.\n OxycoDONE-Acetaminophen Elixir\n 34. Potassium Chloride 35. Scopolamine Patch 36. Sodium Chloride 0.9%\n Flush 37. Sodium Chloride 0.9% Flush\n 38. Thiamine 39. Vancomycin\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Vancomycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Midazolam (Versed) - 12:27 PM\n Fentanyl - 03:15 PM\n Furosemide (Lasix) - 08:30 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Other medications:\n Flowsheet Data as of 06:44 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.6\nC (99.6\n T current: 36.7\nC (98\n HR: 74 (74 - 109) bpm\n BP: 116/64(77) {113/62(68) - 162/82(105)} mmHg\n RR: 14 (6 - 40) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,108 mL\n 860 mL\n PO:\n Tube feeding:\n 1,578 mL\n 440 mL\n IV Fluid:\n 200 mL\n 200 mL\n Blood products:\n Total out:\n 2,205 mL\n 550 mL\n Urine:\n 2,205 mL\n 550 mL\n NG:\n Stool:\n Drains:\n Balance:\n -97 mL\n 310 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 924 (114 - 924) mL\n PS : 12 cmH2O\n RR (Spontaneous): 9\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 5.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities\n Labs / Radiology\n 472 K/uL\n 7.7 g/dL\n 124 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.5 mEq/L\n 37 mg/dL\n 107 mEq/L\n 140 mEq/L\n 21.6 %\n 12.5 K/uL\n [image002.jpg]\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n Plt\n 48\n 472\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n TCO2\n 24\n 26\n Glucose\n 190\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.3 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach,sputum g+ cocci on vanco, bronch today\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Hct drifting down\n Endocrine: RISS\n Infectious Disease: sputum from with Klebsiella pneumonia (no\n yeast cultured), cipro started for VAP, g + cocci 1+ in sputum, vanco 1\n g q 12\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: LENIS negative\n Fluids:\n Consults: Neuro surgery, Ophthalmology\n Billing Diagnosis: CVA, (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 03:49 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 657863, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Respiratory failure\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Nystatin Oral Suspension\n 29. Olanzapine 30. Potassium Chloride 31. Sodium Chloride 0.9% Flush\n 32. Thiamine\n 24 Hour Events:\n : Trach collar trials for 45 min at a time\n : no trach trials\n Post operative day:\n VP shunt \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 12:09 AM\n Other medications:\n Flowsheet Data as of 08:11 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: 37.5\nC (99.5\n HR: 82 (82 - 98) bpm\n BP: 140/77(90) {113/63(78) - 171/88(106)} mmHg\n RR: 16 (9 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,100 mL\n 482 mL\n PO:\n Tube feeding:\n 1,570 mL\n 408 mL\n IV Fluid:\n 240 mL\n 74 mL\n Blood products:\n 290 mL\n Total out:\n 2,475 mL\n 965 mL\n Urine:\n 2,465 mL\n 965 mL\n NG:\n 10 mL\n Stool:\n Drains:\n Balance:\n -375 mL\n -483 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 709 (542 - 974) mL\n PS : 12 cmH2O\n RR (Spontaneous): 11\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 6.1 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bases bilat)\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, (Responds to: Verbal stimuli,\n Tactile stimuli), Moves all extremities\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 101 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 108 mEq/L\n 143 mEq/L\n 25.2 %\n 15.2 K/uL\n [image002.jpg]\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n Plt\n 58\n 350\n 337\n 340\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n Glucose\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: zyprexa, celexa\n Cardiovascular: CV: goal SBP < 160, labetolol decreased to 100 tid,\n hydral only prn\n Pulmonary: (Ventilator mode: CPAP + PS), Resp: stable on CPAP/PS, trach\n collar rest yesterday\n Gastrointestinal / Abdomen: GI: TFs at goal\n Nutrition: Tube feeding, GI: TFs at goal\n Renal: GU: adequate UOP, ARF resolved, lasix given after transfusion\n yesterday\n Hematology: s/p 1u PRBC yesterday for HCT 20\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course, wbc trending up\n with low grade temps\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following)\n Imaging: None\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 31 minutes\n" }, { "category": "Physician ", "chartdate": "2157-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 657864, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Respiratory failure\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Nystatin Oral Suspension\n 29. Olanzapine 30. Potassium Chloride 31. Sodium Chloride 0.9% Flush\n 32. Thiamine\n 24 Hour Events:\n : Trach collar trials for 45 min at a time\n : no trach trials\n Post operative day:\n VP shunt \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 12:09 AM\n Other medications:\n Flowsheet Data as of 08:11 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: 37.5\nC (99.5\n HR: 82 (82 - 98) bpm\n BP: 140/77(90) {113/63(78) - 171/88(106)} mmHg\n RR: 16 (9 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,100 mL\n 482 mL\n PO:\n Tube feeding:\n 1,570 mL\n 408 mL\n IV Fluid:\n 240 mL\n 74 mL\n Blood products:\n 290 mL\n Total out:\n 2,475 mL\n 965 mL\n Urine:\n 2,465 mL\n 965 mL\n NG:\n 10 mL\n Stool:\n Drains:\n Balance:\n -375 mL\n -483 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 709 (542 - 974) mL\n PS : 12 cmH2O\n RR (Spontaneous): 11\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 6.1 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bases bilat)\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, (Responds to: Verbal stimuli,\n Tactile stimuli), Moves all extremities\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 101 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 108 mEq/L\n 143 mEq/L\n 25.2 %\n 15.2 K/uL\n [image002.jpg]\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n Plt\n 58\n 350\n 337\n 340\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n Glucose\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: zyprexa, celexa\n Cardiovascular: CV: goal SBP < 160, labetolol decreased to 100 tid,\n hydral only prn\n Pulmonary: (Ventilator mode: CPAP + PS), Resp: stable on CPAP/PS, trach\n collar rest yesterday. Decrease PSV\n Gastrointestinal / Abdomen: GI: TFs at goal\n Nutrition: Tube feeding, GI: TFs at goal\n Renal: GU: adequate UOP, ARF resolved, lasix given after transfusion\n yesterday\n Hematology: s/p 1u PRBC yesterday for HCT 20\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course, wbc trending up\n with low grade temps\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following)\n Imaging: None\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655831, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 29\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / 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: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Tracheostomy tube change (15:00)\n Comments:\n Remains on PSV, PS titrated for RR<40, had bedside trach change for 8.0\n extra long fixed flange, due to high cuff pressures, positional\n leak and chronic aspirations\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655886, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. s/p VP shunt on . Pt is now\n trach/PEG on ventilator.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp and also rotating left foot in the bed ,but not on\n command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q4 hrs\n Response:\n No change in neuro assessment noted.\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Hypertension, benign\n Assessment:\n Patient SBP 110-140\ns with HR 80s while asleep and low 100 when awake/?\n Agitated- no ectopy noted.\n Action:\n PO Hydralazine 25 mg and labetolol 300 mg with SBP 120-145. goal to\n maintain systolic <160.\n Response:\n Patient SBP within parameters.\n Plan:\n Goal to keep SBP <160. prn orders available for IV hydralazine and IV\n labetolol.\n Rash\n Assessment:\n Scattered pink rash noted torso and all extremities, not raised or\n inflamed.\n Action:\n Monitored rash throughout the night., Lotion applied after bed bath.\n Frequent repositioning.\n Response:\n No change in rash noted.\n Plan:\n Continue to observe for changes rash. Skin care as needed. Reassess new\n medications or possible causes of rash. Continue repositioning.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupil or reaction\n to light. 2 sutures remain intact.\n Action:\n Bacitracin and artificial tears applied as ordered. Left eye shut\n overnight for sleep.\n Response:\n Pt opens eyes spontaneously as well as with stimulation. Appears to\n make eye contact, but tracking is intermittent.\n Plan:\n Continue eye treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse/diminished, moderate amount of yellow thick secretions\n from trach. Copious amount of oral secretion. Strong cough. Respiratory\n effort at times labored rr up to 40 with stimulation. CPAP settings\n unchanged O2 sats 98-100%. 1 episode small cuff leak with new trach in.\n Action:\n Intermittent suctioning, hob>30, Q 2hour oral care. RRT in to assess\n cuff leak and MD aware. No ABG collected. 1 mg IV versed given\n when RR increased.\n Response:\n Continues to have copious clear oral secretions and moderate amounts\n yellow secretions from trach. Versed reduced RR from 40s to low teens.\n Plan:\n Continue to provide frequent oral care and trach care as needed.\n Monitor cxray and ABG\ns as ordered by team. Monitor new trach for leak.\n Continue pain management as needed if RR increases.\n" }, { "category": "Nursing", "chartdate": "2157-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656545, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to simulation moves left side spontaneously and withdraws right\n side to deep nailbed pressure.\n Not following any commands.\n Pupils unequal, left pupil difficult to assess secondary to meds and\n corneal abrasion. Right pupil 2-3mm briskly reactive.\n Action:\n Cont Q4 neuro assessments\n Response:\n No changes\n Plan:\n Cont to monitor.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on Cpap+PS this am. Weaned to . Tolerated for a few\n hours then became tachypneic.\n Suctioned for copious clear thin oral secretions. Small amount thick\n yellow /green from ett.\n Sats 96-98%. LS Bilat rhonci.\n Cxray from am showed increased bilat pleural effusions.\n Action:\n Placed back on but remained tachy. PS increased to 10.\n Response:\n Sats unchanged. Tolerating PS 10.\n Occasional 15 second periods of apnea noted. MD, Sicu\n resident notified.\n Plan:\n Wean to trach collar as tolerated.\n Possible tracheal stent placement in am.\n Possible lung tap tomorrow if enough to tap\n" }, { "category": "Physician ", "chartdate": "2157-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 656465, "text": "SICU\n HPI:\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 Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 05:46 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: 83 (74 - 103) bpm\n BP: 121/71(83) {95/29(57) - 159/87(147)} mmHg\n RR: 17 (14 - 35) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,299 mL\n 607 mL\n PO:\n Tube feeding:\n 1,574 mL\n 370 mL\n IV Fluid:\n 540 mL\n 57 mL\n Blood products:\n Total out:\n 2,535 mL\n 730 mL\n Urine:\n 2,535 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -236 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (19 - 606) mL\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 13 cmH2O\n SPO2: 97%\n ABG: ///25/\n Ve: 10.3 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\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 Labs / Radiology\n 482 K/uL\n 7.9 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 140 mEq/L\n 22.1 %\n 12.7 K/uL\n [image002.jpg]\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n Plt\n 48\n 472\n 469\n 482\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n TCO2\n 26\n Glucose\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n Other labs: PT / PTT / INR:14.1/31.4/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.2 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, try trach collar today, trach pressures,\n adequate with small leak, ?tracheal stent on Monday\n Gastrointestinal / Abdomen: s/p renal transplant, f/u u/o, D5 1/2NS at\n 50 ml/hr\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: f/u Hct, keep it 30 or above\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging:\n Fluids:\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:07 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2157-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 658206, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Chief complaint:\n PMHx:\n PMH: ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Escitalopram Oxalate 12. Famotidine 13. Fentanyl Citrate 14. FoLIC\n Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol\n 22. Magnesium Sulfate\n 23. Metoclopramide 24. Midazolam 25. Miconazole Powder 2% 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n No events\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:14 PM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98.1\n HR: 88 (79 - 102) bpm\n BP: 133/75(90) {106/64(76) - 168/93(108)} mmHg\n RR: 19 (12 - 37) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,960 mL\n 633 mL\n PO:\n Tube feeding:\n 1,440 mL\n 491 mL\n IV Fluid:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 1,740 mL\n 400 mL\n Urine:\n 1,740 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 566 (386 - 566) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 17 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 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\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 334 K/uL\n 8.2 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.9 %\n 11.7 K/uL\n [image002.jpg]\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n Plt\n 58\n 350\n 337\n 340\n 334\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n Glucose\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol 100 tid, hydralazine prn\n Pulmonary: Resp: stable on CPAP/PS , continue to wean to \n Gastrointestinal / Abdomen: TFs at goal, changed to fibersource to\n increase Kcals. PEG.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, UOP adequate, no issues\n Hematology: Stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following. Follow up with\n MEEI regarding course of action.\n Imaging: CXR\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:43 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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 rehab / long term facility\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656546, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to simulation moves left side spontaneously and withdraws right\n side to deep nailbed pressure.\n Not following any commands.\n Pupils unequal left pupil difficult to assess secondary to meds and\n corneal abrasion. Right pupil 2-3mm briskly reactive.\n Action:\n Cont Q4 neuro assessments\n Response:\n No changes\n Plan:\n Cont to monitor.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on Cpap+PS this am. Weaned to . Tolerated for a few\n hours then became tachypneic.\n Suctioned for copious clear thin oral secretions. Small amount thick\n yellow /green from ett.\n Sats 96-98%. LS Bilat rhonci.\n Cxray from am showed increased bilat pleural effusions.\n Action:\n Placed back on but remained tachy. PS increased to 10.\n Response:\n Sats unchanged. Tolerating PS 10.\n Occasional 15 second periods of apnea noted. MD, Sicu\n resident notified.\n Plan:\n Wean to trach collar as tolerated.\n Continue pulm hygiene.\n Possible tracheal stent placement in am.\n Possible thoracentesis tomorrow.\n" }, { "category": "Physician ", "chartdate": "2157-01-31 00:00:00.000", "description": "Intensivist Note", "row_id": 656635, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Albuterol Inhaler, Artificial Tear Ointment,\n Bacitracin/Polymyxin B Sulfate Opht. Oint, Bisacodyl,Calcium\n Gluconate,Chlorhexidine Gluconate 0.12% Oral Rinse,Ciprofloxacin HCl,\n Docusate Sodium (Liquid),Escitalopram Oxalate, Famotidine ,Fentanyl\n Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol\n , Magnesium Sulfate, Metoclopramide, Midazolam, Multivitamins,\n Olanzapine, Potassium Chloride,Thiamine, Vancomycin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:14 PM\n Flowsheet Data as of 04:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.2\nC (98.9\n HR: 85 (73 - 105) bpm\n BP: 117/65(78) {90/43(54) - 154/77(96)} mmHg\n RR: 16 (10 - 46) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,416 mL\n 352 mL\n PO:\n Tube feeding:\n 1,576 mL\n 262 mL\n IV Fluid:\n 240 mL\n 40 mL\n Blood products:\n Total out:\n 2,850 mL\n 255 mL\n Urine:\n 2,850 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 409 (365 - 564) mL\n PS : 10 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 15 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 6.7 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 : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli)\n Labs / Radiology\n 438 K/uL\n 7.4 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 21.4 %\n 10.6 K/uL\n [image002.jpg]\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n Plt\n 48\n 472\n 469\n 482\n 438\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n TCO2\n 26\n Glucose\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n 136\n Other labs: PT / PTT / INR:14.1/31.4/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today, trach pressures adequate with small leak,\n call IP on Monday for ?tracheal stent and ultrasound pleural effusions\n for possible tap\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: vanc/cipro for VAP, will D/C/ vanco\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:20 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656547, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to simulation moves left side spontaneously and withdraws right\n side to deep nailbed pressure.\n Not following any commands.\n Pupils unequal left pupil difficult to assess secondary to meds and\n corneal abrasion. Right pupil 2-3mm briskly reactive.\n Action:\n Cont Q4 neuro assessments\n Response:\n Neuro status unchanged.\n Plan:\n Cont Q4hr neuro checks.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Comfortable on Cpap+PS this am. Weaned to . Tolerated for a few\n hours then became tachypneic.\n Sats 96-98%. LS Bilat rhonci.\n Cxray from am showed increased bilat pleural effusions.\n Action:\n Placed back on but remained tachy. PS increased to 10.\n Suctioned for copious clear thin oral secretions and small amount thick\n yellow /green from ett.\n Response:\n Sats unchanged. Tolerating PS 10.\n Occasional 15 second periods of apnea noted. MD, Sicu\n resident notified.\n Plan:\n Wean to trach collar as tolerated.\n Continue pulm hygiene.\n Possible tracheal stent placement in am.\n Possible thoracentesis tomorrow.\n" }, { "category": "Physician ", "chartdate": "2157-01-31 00:00:00.000", "description": "Intensivist Note", "row_id": 656568, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Albuterol Inhaler, Artificial Tear Ointment,\n Bacitracin/Polymyxin B Sulfate Opht. Oint, Bisacodyl,Calcium\n Gluconate,Chlorhexidine Gluconate 0.12% Oral Rinse,Ciprofloxacin HCl,\n Docusate Sodium (Liquid),Escitalopram Oxalate, Famotidine ,Fentanyl\n Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol\n , Magnesium Sulfate, Metoclopramide, Midazolam, Multivitamins,\n Olanzapine, Potassium Chloride,Thiamine, Vancomycin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 09:30 PM\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:14 PM\n Flowsheet Data as of 04:05 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.5\nC (99.5\n T current: 37.2\nC (98.9\n HR: 85 (73 - 105) bpm\n BP: 117/65(78) {90/43(54) - 154/77(96)} mmHg\n RR: 16 (10 - 46) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,416 mL\n 352 mL\n PO:\n Tube feeding:\n 1,576 mL\n 262 mL\n IV Fluid:\n 240 mL\n 40 mL\n Blood products:\n Total out:\n 2,850 mL\n 255 mL\n Urine:\n 2,850 mL\n 255 mL\n NG:\n Stool:\n Drains:\n Balance:\n -434 mL\n 97 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 409 (365 - 564) mL\n PS : 10 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 15 cmH2O\n SPO2: 99%\n ABG: ///26/\n Ve: 6.7 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 : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli)\n Labs / Radiology\n 438 K/uL\n 7.4 g/dL\n 136 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.7 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 21.4 %\n 10.6 K/uL\n [image002.jpg]\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n Plt\n 48\n 472\n 469\n 482\n 438\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n TCO2\n 26\n Glucose\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n 136\n Other labs: PT / PTT / INR:14.1/31.4/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today, trach pressures adequate with small leak,\n call IP on Monday for ?tracheal stent and ultrasound pleural effusions\n for possible tap\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: vanc/cipro for VAP, check vanc level with new dose\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:20 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: Transfer to rehab / long term facility\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2157-01-31 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 656645, "text": "Current Wt: 66.1kg\n Adm Wt: 67kg\n Pertinent medications: Mvit, RISS, Thiamine, Folic Acid, Reglan, others\n noted\n Labs:\n Value\n Date\n Glucose\n 168\n 04:00 AM\n Glucose Finger Stick\n 134\n 10:00 AM\n BUN\n 37 mg/dL\n 02:35 AM\n Creatinine\n 1.0 mg/dL\n 02:35 AM\n Sodium\n 140 mEq/L\n 02:35 AM\n Potassium\n 4.7 mEq/L\n 02:35 AM\n Chloride\n 105 mEq/L\n 02:35 AM\n TCO2\n 26 mEq/L\n 02:35 AM\n PO2 (arterial)\n 106 mm Hg\n 04:54 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:54 AM\n pH (arterial)\n 7.41 units\n 04:54 AM\n pH (urine)\n 5.0 units\n 09:41 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 04:19 AM\n Calcium non-ionized\n 9.5 mg/dL\n 02:35 AM\n Phosphorus\n 4.7 mg/dL\n 02:35 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:10 AM\n Magnesium\n 2.0 mg/dL\n 02:35 AM\n Phenytoin (Dilantin)\n 11.3 ug/mL\n 03:01 AM\n WBC\n 10.6 K/uL\n 02:35 AM\n Hgb\n 7.4 g/dL\n 02:35 AM\n Hematocrit\n 21.4 %\n 02:35 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 65cc/hr (1560kcal, 97g protein)\n GI: abd soft, +BS\n Assessment of Nutritional Status\n 53 y.o. M continues on enteral feeds at goal via PEG, also receiving\n H20 flushes of 50cc to maintain hydration. TF providing 23kcals/kg and\n 1.4g protein/kg, meeting 100% estimated needs. Pt\ns weight is ~1kg\n down from adm weight; will monitor daily weights and adjust TF to give\n more calories if needed. Noted Phos and K slightly elevated.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Continue with TF at goal.\n 2) Continue with H20 flushes 24hrs to maintain tube patency and\n hydration.\n 3) Monitor lytes.\n Following\n please page with ?\ns #\n" }, { "category": "Rehab Services", "chartdate": "2157-01-31 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 656649, "text": "Subjective:\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: Hct 21.4\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n Total A x 2\n\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 93\n 124/74\n 16\n 99% CPAP\n Activity\n Sit\n 101\n /\n 22\n 99% CPAP\n Recovery\n Supine\n 100\n 144/77\n 16\n 99% CPAP\n Total distance walked:\n Minutes:\n Gait: N/A\n Balance: Pt required total A x 2 to achieve sitting at . Pt\n tolerated sitting at for approx 10 mins, with mod to max A. Pt albe\n to use L UE to assist if placed in proper position by therapist, such\n as on bed rail, or on bed next to patient. Without A pt has L lateral\n and anterior LOB.\n Education / Communication: Pt status discussed with RN\n Other: Posture: At pt has significant forward head and rounded\n shoulder posture with R cervical rotation and L lateral flexion.\n Performed manual pec stretch and scalene stretch sitting at with\n good tolerance.\n Pulm: CPAP Peep 5 Psup 10 TV .450-.730 with RR 16-22 at . Pt has\n audible cuff leak in supine and sitting, which was discussed with RN,\n team aware\n Cognition: Fair eye contact in R field, Pt attempted nodding \"yes no\"\n inconsistently to 20% of questions. With max verbal, visual and tactile\n cues pt was able to squeeze L hand, perform modifieied \"high five\" and\n attempted \"thumbs up\"\n Assessment: 53 yo m admitted c L ponto-medullary hemorrhage with IVH\n with prolonged ICU admission and intubation. Today pt showed improved\n mentation. He demonstrated eye contact and more consistent purposeful\n movement with L UE. Pts still well below baseline, however today\n progress is positive towards patients rehab potential\n Anticipated Discharge: Rehab\n Plan: cont to work on balance, posture, strength, cognitive\n training\n REC: Pt should have R UE supported either with pillows or blue trough\n pillow due to flaccid UE and high risk for subluxation.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656663, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 35\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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: Rhonchi\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: Unassisted spontaneous breathing\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: Cannot protect\n airway, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient weaned to minimal ventilator support, PEEP 0cm, PSV 0cm. The\n patients spontaneous Vt decreased to less than 175cc and an increasing\n effort. Placed on 5cm PEEP and 5cm PSV, spontaneous VT in the upper\n 300\ns to lower 400\ns and spontaneous rate in the low 20\n" }, { "category": "Social Work", "chartdate": "2157-01-31 00:00:00.000", "description": "Social Work Progress Note", "row_id": 656668, "text": " pt\ns cousin re: guardianship paperwork that had\n been provided for her to take to the court. states that she has\n been overwhelmed with taking care of the business of the pt\ns mother ,\n the household and keeping in touch with the medical needs of the pt.\n also reports that pt\ns friend has been steadfast in his work\n with the pt\ns paperwork in his home trying to sort things out in terms\n of the pt\ns COBRA and keeping up with the household . Cousin \n has seen \ns commitment to the pt and to the mother over the last\n month and has now asked to be the guardian for the patient.\n Will outreach to re: COBRA and the guardianship paperwork.\n" }, { "category": "Nursing", "chartdate": "2157-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656669, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained on Pressure Support this morning.\n Action:\n Weaned to 5/0\n Response:\n Tidal volume between 100-200 and becoming increasingly tachypneic.\n Transitioned to CPAP 5/5 and has tolerated well all day.\n Plan:\n Continue to wean patient as tolerated. Anticipate Interventional\n Pulmonogist to consult for persistent leak, failure to wean problems.\n Anticipate further follow up re:plural effusions and whether they will\n be tapped or not.\n Aerobic Capacity / Endurance, Impaired\n Assessment:\n PT to bedside to exercise patient.\n Action:\n Dangled patient to bedside and encouraged some small exercising.\n Response:\n Able to raise hand and\ngive a high five\n. Lacked strength to sit up\n independently however, did well with physical therapists\n assistance.\n Plan:\n Continue to have PT consult patient and anticipate getting patient out\n of bed to a chair.\n" }, { "category": "Nursing", "chartdate": "2157-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658288, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt tolerating and continued on ventilator settings of . Continues\n with poor gag and moderate oral secretions.\n Action:\n Continue to turn and reposition Q2 hours, frequent oral suctioning and\n prn subglottal. Pt OOB with Pt with standing and dangling.\n Response:\n Per SICU Team, allow patient to rest on vent settings .\n Plan:\n ? attempt trach mask tomorrow if pt can maintain minimal settings on\n vent overnight.\n" }, { "category": "Nursing", "chartdate": "2157-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656165, "text": "HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt . Hx: HTN\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656237, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656238, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656246, "text": "Demographics\n Day of mechanical ventilation: 32\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Known difficult intubation: Unknown\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Insp Wheeze\n Comments: Lungs very wheezy in all lung fields at times tonight/MDI Alb\n given with good effect noted.\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Expectorated / Small\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: High flow demand\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. Pt more aawke this\n shift. Pressure support decreased due to drop in RR to <8/\n" }, { "category": "Respiratory ", "chartdate": "2157-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656354, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 33\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\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: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received intubated on PSV., now on and 40%. VT and RR\n WNL.\n ------ Protected Section ------\n Pt has a tracheostomy tube in place and not intubated.\n ------ Protected Section Addendum Entered By: , RRT\n on: 05:25 ------\n" }, { "category": "Nursing", "chartdate": "2157-01-31 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656609, "text": "Anemia, other\n Assessment:\n Hct 21.4 this am, it has been between 21 and 22 last few draws.\n Action:\n Dr notified\n Response:\n pending\n Plan:\n Continue to monitor HCT\n Address anemia on rounds this am.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt awake , alert, follows some commands, nods head to questions. Unable\n to check pupils due to corneal abrasions, no light to be shown in pt\n eyes. Hemipalegia right side.\n Action:\n No sedation or pain med overnoc.\n Complete care\n Response:\n Stable\n Plan:\n Continue NVS q2\n Continue complete care\n Respiratory failure, acute (not ARDS/)\n Assessment:\n No air leak from cuff overnoc. Vent settings unchanged Peep 5 PS 10, RR\n 20 with 30 sec periods of apnea. Pt suctioned q3-4 hrs for copious\n white thin secretions. Breath sounds clear.\n Action:\n VAP and tracheostomy suction PRN, Trach care.\n Response:\n Breath sounds remain clear.\n Plan:\n Continue plan of care.\n" }, { "category": "Nursing", "chartdate": "2157-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656240, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt with decreased respiration rate < 10 BPM. Continued with moderate\n to copious secretions in back of oral cavity. Remained positive for\n fluid balance.\n Action:\n RT alerted to RR and periods of apnea. Ventilator setting adjusted\n accordingly to 8 PEEP and 12 of PS (prior PS @ 16). Scopolamine Patch\n applied to decrease oral secretions. Furosemide 20 mg IVP for\n diuresing.\n Response:\n Pt RR and apneic periods improved. Oral secretions less, but ? of\n increased plugs. Lasix with positive output, but output remained even\n with input.\n Plan:\n Continue to monitor respiratory status with goal to wean off vent.\n Continue Lasix prn to keep pt -500?\n" }, { "category": "Respiratory ", "chartdate": "2157-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656351, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 33\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\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: Yellow / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt received intubated on PSV., now on and 40%. VT and RR\n WNL.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656540, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 34\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Frequent alarms (High rate)\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 Had hoped to wean to trach collar today but due to repeated periods of\n tachypnea, forced to increase PSV to 10cm. Will attempt to wean again\n in AM.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-27 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 656159, "text": "Subjective:\n pt non-verbal\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: CXR pending, US pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\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 90\n 139/62\n 26\n 100% on CPAP\n Activity\n Sit\n 102\n 164/85\n 52\n 97% on CPAP\n Recovery\n Sit\n 94\n 158/73\n 22\n 95% on CPAP\n Total distance walked:\n Minutes:\n Gait: patient total assist for all mobility, not able to assist.\n transfer to stretcher chair.\n Balance: Mod A to maintain static sitting at edge of bed, extends LUE\n with LOB L, pulls forward on bedrail with LOB backward. Max A to\n return to midline.\n Education / Communication: Patient following commands minimally <5%,\n squeezes hand, possible reaching for object.\n Communicated with nsg re: status\n Other: Respiratory:\n CPAP 5/10 PEEP/PS, needed to increased to during transfer \n increased RR.\n 40% FI02, TV 200-600\n Frequent coughing requiring suctioning- mod amt thick yellow secretions\n Assessment: 53 yo M s/p IVH making slow gains in PT with arousal and\n activity tolerance. He continues to follow minimal commands at this\n time, and his arousal level waxes and wanes. Pt is undergoing trach\n collar trials, anticipate improved rehab potential once patient is able\n to tolerate this for an extended period.\n Anticipated Discharge: Rehab\n Plan: Cont with POC\n" }, { "category": "Nursing", "chartdate": "2157-01-30 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656441, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Arouses to simulation, continues to move left side spontaneously and\n withdraws right side to deep nailbed pressure. Not following any\n commands. Movement purposeful at times. Pupils unequal, left pupil\n noted to be 2mm and unable to assess reaction to light d/t corneal\n abrasion. Right pupil 3-4mm briskly reactive. Both NMED HO and SICU HO\n notified and per NMED pupils have been unequal.\n Action:\n Cont Q4 neuro assessments\n Response:\n No changes\n Plan:\n Cont to monitor.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on CPAP\n Action:\n Pressure support decreased from 10 to 8\n Response:\n Tolerated well\n Plan:\n Wean to trach collar as tolerated.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656444, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 34\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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 / Small\n Comments:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt weaned down to 8 ips with good VT\nS.RSBI done on 0 peep/ 5\n ips 67. Temp 99.5.No response to commands.Will cont to monitor resp\n status. Cont to wean as tol.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656859, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 1\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL / Air\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:\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Cannot protect airway, Cannot manage secretions, Underlying illness not\n resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient\ns spontaneous efforts after returning to mechanical ventilation\n irregular, placed on 10cm PSV for several hours before returning to 5cm\n PEEP and 5 cm PSV.\n" }, { "category": "Nursing", "chartdate": "2157-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657404, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Neuro status waxes and wanes. Pt arousable to voice, following some\n commands to squeeze hand on left side. Left side moving spontaneously,\n right side only responding slightly to pain. Right pupil brisk and\n reactive, however left pupil unable to assess due to corneal injury.\n Nodding at times to simple questions, trying to mouth words\n unsuccessfully.\n Action:\n Neuro status checked Q4 hours, pt reminded of where he is and what day\n it is.\n Response:\n Neuro status remains unchanged\n Plan:\n Continue to monitor neuro exam Q 4 hours, reorient when necessary\n" }, { "category": "Nursing", "chartdate": "2157-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656339, "text": "Intracerebral hemorrhage (ICH) NEURO PT REMAINS MIN RESPONDSIVE\n MOVES LEFT SIDE ONLY WILL COMMUNICATE LIMITED PLEASE SEE NOTES ON\n DETAILS Q 2 HOUR EVALS IN PROGRESS PLEASEE KEEP SYS BP LESS THAN\n 160 MD ORDERS\n RESP ON VENT\n P/S OVER PEEP TOL WELL VIA TRACH LG CUFF LEAK NOTED SCANT SPUTUM CLEAR\n RHONCHI AT BASES TOL CPT WELL Q 4 HOUR SAT 99\n HEART SR PR\n .16 QRS .08 QT WNL FOR AGE AND GENDER VSS NO TEMP PULSES POS 3 THRU\n OUT\n ABD SOFT POS\n B/S NOTED TOL T/F MIN RESIDUAL LG SOFT NO STOOL AS OF YET\n Assessment:\n Action:\n Response:\n Plan:\n SUPPORTIVE SYS BP 160 OR LESS 500 CC PER DAY NEGATIVE\n PLEASE FAMILY/PT HELP WITH THIS LONG TERM HOSPITALZATION SKIN\n CARE\n" }, { "category": "Physician ", "chartdate": "2157-01-29 00:00:00.000", "description": "Intensivist Note", "row_id": 656342, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH, respiratory failure\n PMHx:\n Hypertension\n Current medications:\n Acetaminophen. Albuterol Inhaler. Artificial Tear Ointment.\n Bacitracin/Polymyxin B Sulfate Opht. Oint. Bisacodyl. Calcium\n Gluconate. Chlorhexidine Gluconate 0.12% Oral Rinse. ChlorproMAZINE.\n Ciprofloxacin HCl. Docusate Sodium (Liquid). Escitalopram Oxalate.\n Famotidine. Fentanyl Citrate. FoLIC Acid. Furosemide. Heparin.\n HydrALAzine. Insulin. Labetalol. Magnesium Sulfate. Metoclopramide.\n Midazolam. Midazolam. Multivitamins. Olanzapine.\n OxycoDONE-Acetaminophen Elixir. Potassium Chloride. Thiamine\n 24 Hour Events:\n BRONCHOSCOPY - At 10:05 AM\n Bronchoscopy with BAL (specimen lost)\n Small cuff leak\n 1L negative with diuresis\n Weaned to CPAP/PS of \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 04:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 04:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37\nC (98.6\n T current: 36.5\nC (97.7\n HR: 88 (74 - 95) bpm\n BP: 125/60(84) {110/58(77) - 162/92(112)} mmHg\n RR: 15 (14 - 26) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,019 mL\n 275 mL\n PO:\n Tube feeding:\n 1,599 mL\n 275 mL\n IV Fluid:\n 200 mL\n Blood products:\n Total out:\n 3,125 mL\n 155 mL\n Urine:\n 3,125 mL\n 155 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,106 mL\n 120 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 503 (433 - 699) mL\n PS : 10 cmH2O\n RR (Spontaneous): 17\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 18 cmH2O\n SPO2: 98%\n ABG: ///27/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, EOMI, Left eyelids sutured closed\n Cardiovascular: (Rhythm: Regular), (Murmur: No(t) Systolic)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Wheezes : )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, Moves all extremities, Sedated\n Labs / Radiology\n 469 K/uL\n 7.9 g/dL\n 125 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.7 mEq/L\n 35 mg/dL\n 104 mEq/L\n 139 mEq/L\n 22.1 %\n 12.1 K/uL\n [image002.jpg]\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n Plt\n 48\n 472\n 469\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n TCO2\n 26\n Glucose\n 190\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n Other labs: PT / PTT / INR:13.8/29.7/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:1.9 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS, cont\n zyprexa and SSRI, prn versed for agitation\n CV: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Resp: stable on CPAP/PS, try today, trach pressures adequate with\n small leak, bronch with BAL yesterday (BAL specimen lost)\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix prn\n FEN: TFs\n Heme: Hct stable\n Endo: RISS\n ID: cipro started for VAP, oropharyngeal flora in latest sputum so Vanc\n discontinued\n TLD: trach, foley, PEG, rt PICC\n Wound: left corneal ulcer (optho following)\n Prophylaxis: H2B, SQH\n Imaging: CXR\n Dispo: start screening for vented rehab. no insurance and no health\n care proxy. social work following.\n Billing Diagnosis: SAH, respiratory failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 06:42 PM 65.\n mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: famotidine\n VAP bundle: +++\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-30 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656539, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 34\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern: Accessory muscle use\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Abnormal trigger efforts (efforts during\n inspiratory)\n Dysynchrony assessment: Possible air trapping, Frequent alarms (High\n rate)\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656954, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro assessment unchanged\n Remains on ventilator overnight\n Sleeping well\n Action:\n Neuro assessments as ordered\n No vent changes indicated\n Promoted rest\n Response:\n No changes in condition\n Plan:\n Cont to monitor and provide supportive care.\n" }, { "category": "Nursing", "chartdate": "2157-02-04 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657515, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt placed on trach mask q 3 hours\n planned to keep on for at least 45\n minutes each time\n Action:\n Pt tolerated trach mask for over one hour at 0900. When placed on at\n 1300 and 1600 pt only tolerated mask for approx 10 minutes.\n Response:\n Pt became tachypneic, tachycardic and very agitated last two tries on\n trach mask. Does have mod amt cl thin secretions.\n Plan:\n Continue on CPAP 5/5 and continue to attempt longer periods on the\n trach mask as tolerated.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp slowly increasing to max of 100.7 PO at 1600\n Action:\n No action taken at this time\n Response:\n none\n Plan:\n It femp continues to rise\n team may want to re culture pt since his\n last culture was the 23^rd.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655766, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Rash\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 656974, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n head bleed\n PMHx:\n HTN\n Current medications:\n . 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. HydrALAzine 20. 21.\n Insulin 22. Influenza Virus Vaccine\n 23. Labetalol 24. Labetalol 25. Magnesium Sulfate 26. Metoclopramide\n 27. Midazolam 28. Multivitamins\n 29. Nystatin Oral Suspension 30. Olanzapine 31. Potassium Chloride 32.\n Sodium Chloride 0.9% Flush\n 33. Thiamine\n 24 Hour Events:\n attempted Trach collar trials\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:55 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: 35.7\nC (96.3\n HR: 91 (65 - 99) bpm\n BP: 159/81(99) {86/50(58) - 163/97(112)} mmHg\n RR: 16 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,390 mL\n 454 mL\n PO:\n Tube feeding:\n 1,580 mL\n 336 mL\n IV Fluid:\n 240 mL\n 69 mL\n Blood products:\n Total out:\n 1,815 mL\n 560 mL\n Urine:\n 1,815 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 575 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 591 (340 - 591) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///26/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 408 K/uL\n 8.1 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 39 mg/dL\n 104 mEq/L\n 138 mEq/L\n 22.6 %\n 11.9 K/uL\n [image002.jpg]\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n WBC\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n Hct\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n Plt\n 448\n 472\n 469\n 482\n 438\n 404\n 408\n Creatinine\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n Glucose\n 124\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n Other labs: PT / PTT / INR:14.1/37.7/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.7 mg/dL,\n Mg:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today, trach pressures adequate with small leak,\n IP no tracheal stent no thoracentesis\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2157-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656735, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 36\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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 / Small\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n detailsNot responding to commands.RSBI done on 0 peep/ 5 ips 68.MDI\n given . Will cont to monitor resp status.\n" }, { "category": "Rehab Services", "chartdate": "2157-02-01 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 656829, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: 431 /\n Reason of referral: Re-evaluation\n History of Present Illness / Subjective Complaint: 53 y/o male adm to\n OSH with HA and R sided weakness. Fount to have L ponto-medullary\n hemorrhage with IVH. Intubated and transferred to . EVD placed.\n Course compounded by failure to wean. s/p trach and PEG on . s/p\n VP shunt placement. Course c/b LLL pna.\n Past Medical / Surgical History: see eval\n Medications: Insulin, Fentanyl, Labetalol, HydrALAzine, Olanzapine,\n Midazolam, Albuterol, Furosemide\n Radiology: CXR : small B pleural effusions and retrocardiac\n atelectasis\n Labs:\n 21.5\n 7.7\n 404\n 9.5\n [image002.jpg]\n Other labs:\n Activity Orders: OOB with assist\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, eyes open\n throughout treatment, nodding yes/no 50% of the time, attempting to\n mouth words but difficult to understand, following 50% of simple\n commands, gave \"thumbs up\" to command 2x, copied number of fingers\n therapist showed him 4x, unable to show fingers to command only\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n 88\n 132/66\n 20\n 99%\n Rest\n /\n Sit\n 93\n 144/76\n 37\n 98%\n Activity\n /\n Stand\n /\n Recovery\n 90\n 116/69\n 25\n 99%\n Total distance walked: n/a\n Minutes:\n Pulmonary Status: NARD, intubated and trached. Vent settings: CPAP,\n FiO2 40%, PEEP 5, PS 5, copious clear oral secretions, + drooling when\n head upright, patient able to use yankauer with min A to suction oral\n secretions\n Integumentary / Vascular: foley, pIV, VP shunt incision\n Sensory Integrity: withdraws to noxious stimuli in L UE/LE > R LE > R\n UE, only minimal muscle contraction for withdrawal noted on R UE\n Pain / Limiting Symptoms: no c/o pain\n Posture: severe forward head, rounded shoulders, increased kyphosis,\n posterior pelvic tilt\n Range of Motion\n Muscle Performance\n WFL\n Unable to formally MMT, but noted to have strong L grasp, L elbow\n flexors lift against gravity > 50% ROM, L shoulder flexors at least\n trace, no movement noted in R UE, L LE: patient able to assist with\n flexing L knee, able to hold knee in a flexed position, able to extend\n L knee against gravity through 30% of ROM, no movement noted in R LE\n Motor Function: Moves L UE and LE in isolation, minimal increase in\n tone in R elbow extensors, otherwise flaccid in R UE, hypotonic in R\n LE, normal tone in L UE and LE, (-) clonus B, tracks midline to R,\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Clarification:\n Rolling to R: Patient required assist to flex L knee and to grasp\n therapist's hand with his L hand, then able to assist in pulling self\n onto side.\n Rolling to L: Patient unable to assist, requires total assist x 1\n Sidelying to sit: requires total assist x 2 as patient was unable to\n assist with moving B LE off bed or pushing up to sitting\n Rolling:\n\n\n\n\n\n T\n Supine /\n Sidelying to Sit:\n Total assist x 2\n\n\n\n\n\n T\n Transfer:\n Bed to stretcher chair with total assist x 4\n\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: Seated: sat EOB x 15 minutes, required min to mod A to\n maintain balance, using L UE for support intermittently, positioned\n patient with R shoulder supported with pillow under forearm; initiating\n cervical extension with min A and max VC x 2 reps, fatigues quickly and\n is unable to maintain neutral c-spine; reached for Yankauer suction and\n brought to mouth with min A; able to kick L LE while at EOB, weight\n shifting L to/from R requires total A x 1\n Education / Communication: Educated patient as to role of PT, progress\n with PT.\n Communicated with RN.\n Intervention: n/a\n Other: n/a\n Diagnosis:\n 1.\n Knowledge, Impaired\n 2.\n Respiration / Gas Exchange, Impaired\n 3.\n Aerobic Capacity / Endurance, Impaired\n 4.\n Arousal, Attention, and Cognition, Impaired\n 5.\n Balance, Impaired\n 6.\n Muscle Performance, Impaired\n Clinical impression / Prognosis: 53 y/o male adm with cerebral\n hemorrhage and IVH. Patient presents with above deficits c/w\n non-progressive CNS dysfunction. Patient has made slow progress over\n past several weeks, but mental status has improved dramatically over\n past few days. Patient is now able to follow some commands and\n participate more fully with physical therapy. Additionally, patient is\n tolerating more therapy without tachypnea. Patient would now benefit\n from aggressive PT/OT to maximize gains and function. With extensive\n therapy, patient has potential to be independent with wheelchair\n mobility.\n Goals\n Time frame: 1 week\n 1.\n Roll to R with mod A x 1, reaching across body with L UE and\n positioning L knee in flexion\n 2.\n Sup to sit with max A x 1 with patient pushing through L UE to right\n self\n 3.\n Sit EOB with min A x 1 x 15 minutes with L UE support\n 4.\n Follow 75% of simple commands\n 5.\n Perform AAROM throughout L UE and L LE with mod verbal cues\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 3-5x/week x 1 week\n Transfer training, balance training at EOB including weight shifting,\n attaining and maintaining balance at EOB, reaching with L UE, kicking\n with L LE; cervical exercises to encourage extensor activation,\n postural stretches for pecs and abdominal muscles, postural ther-ex for\n inter-scapular muscles, patient education, positioning\n T Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n RN recommendations: OOB to stretcher chair daily for 1 hour\n Face Time: 10:45\n 11:45\n" }, { "category": "Nursing", "chartdate": "2157-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656890, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt improving neurologically. Mouthing words, gesturing and nodding head\n appropriately.\n Action:\n OOB to chair with PT and nursing. Appropriate with commands while\n dangling on bedside and with self suctioning. Requested Speech Therapy\n Consult to assist patient with communication with staff.\n Response:\n Speech Therapy to return to unit.\n Plan:\n OOB Q Day. Encourage patient to communicate with gestures, mouthing\n words, nodding, letter board, etc.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655769, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n However patient continues to have impaired gag and cough. Suctioned\n moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Patient to have a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow commands. Right ue/le no\n movement to command. Right le withdraws to stimuli. Left strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm, and\n patient had ctscan of head this am.\n Response:\n No change in neuron checks remains off sedation. Iv diazepam mgs\n given for etoh withdrawls\n Plan:\n To continue with current plan, monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Iv hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n Patient unable to protect airway, so will have trach and peg placed.\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655770, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n However patient continues to have impaired gag and cough. Suctioned\n moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Patient to have a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow commands. Right ue/le no\n movement to command. Right le withdraws to stimuli. Left strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm, and\n patient had ctscan of head this am.\n Response:\n No change in neuron checks remains off sedation. Iv diazepam mgs\n given for etoh withdrawls\n Plan:\n To continue with current plan, monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Iv hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n Patient unable to protect airway, so will have trach and peg placed.\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient occasionally opening eyes to voice. Inconsistently follows\n commands. Discussed with nmed resident, exam similar to recent\n baseline. Able to move right arm & leg, no movement left side. Pupils\n ~ 2mm equal and brisk. ICP ranging , vent drain with moderate\n amount blood tinged drainage. Patient not sedated, does not appear in\n pain. Restless with stimulation, becoming tachycardic & tachypneic.\n No gag noted, but patient has strong cough.\n Action:\n Continued with neuro checks every 2 hours. Medicated with Valium as\n needed for CIWA.\n Response:\n Patient stable, see flowsheet for all details.\n Plan:\n ? Trach , will need consent. Continue to follow neuro exam.\n Hypertension, benign\n Assessment:\n Patient\ns sbp ranging 100-150\ns, nicardipine gtt on most of the shift.\n Patient also on hydralazine, enalapril, & lopressor.\n Action:\n Nicardipine gtt titrated for goal sbp < 140.\n Response:\n Patient\ns sbp now ranging 130-140\n Plan:\n ? change antihypertensives to PO (tolerating tube feeds). Continue to\n follow vitals.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655771, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n However patient continues to have impaired gag and cough. Suctioned\n moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Patient to have a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Perrla. Patient will follow commands. Right ue/le no\n movement to command. Right le withdraws to stimuli. Left strong ue/le.\n Action:\n Neuro checks monitored Q2 hrly, ventric remains open at 10cm, and\n patient had ctscan of head this am.\n Response:\n No change in neuron checks remains off sedation. Iv diazepam mgs\n given for etoh withdrawls\n Plan:\n To continue with current plan, monitor and treat accordingly\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Iv hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n Patient unable to protect airway, so will have trach and peg placed.\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient occasionally opening eyes to voice. Inconsistently follows\n commands. Discussed with nmed resident, exam similar to recent\n baseline. Able to move right arm & leg, no movement left side. Pupils\n ~ 2mm equal and brisk. ICP ranging , vent drain with moderate\n amount blood tinged drainage. Patient not sedated, does not appear in\n pain. Restless with stimulation, becoming tachycardic & tachypneic.\n No gag noted, but patient has strong cough.\n Action:\n Continued with neuro checks every 2 hours. Medicated with Valium as\n needed for CIWA.\n Response:\n Patient stable, see flowsheet for all details.\n Plan:\n ? Trach , will need consent. Continue to follow neuro exam.\n Hypertension, benign\n Assessment:\n Patient\ns sbp ranging 100-150\ns, nicardipine gtt on most of the shift.\n Patient also on hydralazine, enalapril, & lopressor.\n Action:\n Nicardipine gtt titrated for goal sbp < 140.\n Response:\n Patient\ns sbp now ranging 130-140\n Plan:\n ? change antihypertensives to PO (tolerating tube feeds). Continue to\n follow vitals.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt does open his eyes when you call his name\n At times will look toward you when you call his name\n Right pupil 3mm and briskly reactive to light\n Left pupil with corneal abrasion unable to assess\n Pt will intermittently follow commands\n Action:\n Neuro assessment every 2 hours as ordered\n Response:\n Unchanged neuro exam\n Plan:\n Continue to monitor\n Notify team if any neuro changed\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy\n Action:\n Bacitracin and artifical tears applied as ordered\n Attempt to put steri-strips to keep left eye closed\n Response:\n Pt keeping eyes open spontanously\n Plan:\n Continue with current plan.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657789, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 6\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: 6 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 / 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 continues on CSV with trach collar trials on hold. Still evaluating\n for neurologic improvement.\n" }, { "category": "Nursing", "chartdate": "2157-02-01 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656734, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Neuro status waxes and wanes. Pt arousable to voice, following some\n commands to squeeze hand on left side. Left side moving spontaneously,\n right side only responding slightly to pain. Right pupil brisk and\n reactive, however left pupil unable to assess due to corneal injury.\n Nodding at times to simple questions, trying to mouth words\n unsuccessfully.\n Action:\n Neuro status checked Q4 hours, pt reminded of where he is and what day\n it is.\n Response:\n Neuro status remains unchanged\n Plan:\n Continue to monitor neuro exam Q 4 hours, reorient when necessary\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655911, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. s/p VP shunt on . Pt is now\n trach/PEG on ventilator.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp and also rotating left foot in the bed ,but not on\n command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q4 hrs\n Response:\n No change in neuro assessment noted.\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Hypertension, benign\n Assessment:\n Patient SBP 110-140\ns with HR 80s while asleep and low 100 when awake/?\n Agitated- no ectopy noted.\n Action:\n PO Hydralazine 25 mg and labetolol 300 mg with SBP 120-145. goal to\n maintain systolic <160.\n Response:\n Patient SBP within parameters.\n Plan:\n Goal to keep SBP <160. prn orders available for IV hydralazine and IV\n labetolol.\n Rash\n Assessment:\n Scattered pink rash noted torso and all extremities, not raised or\n inflamed.\n Action:\n Monitored rash throughout the night., Lotion applied after bed bath.\n Frequent repositioning.\n Response:\n No change in rash noted.\n Plan:\n Continue to observe for changes rash. Skin care as needed. Reassess new\n medications or possible causes of rash. Continue repositioning.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupil or reaction\n to light. 2 sutures remain intact.\n Action:\n Bacitracin and artificial tears applied as ordered. Left eye shut\n overnight for sleep.\n Response:\n Pt opens eyes spontaneously as well as with stimulation. Appears to\n make eye contact, but tracking is intermittent.\n Plan:\n Continue eye treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse/diminished, moderate amount of yellow thick secretions\n from trach. Copious amount of oral secretion. Strong cough. Respiratory\n effort at times labored rr up to 40 with stimulation. CPAP settings\n unchanged O2 sats 98-100%. 1 episode small cuff leak with new trach\n in.\n Action:\n Intermittent suctioning, hob>30, Q 2hour oral care. RRT in to assess\n cuff leak and MD aware. No ABG collected. 1 mg IV versed given\n when RR increased.\n Response:\n Continues to have copious clear oral secretions and moderate amounts\n yellow secretions from trach. Versed reduced RR from 40s to low teens.\n Plan:\n Continue to provide frequent oral care and trach care as needed.\n Monitor cxray and ABG\ns as ordered by team. Monitor new trach for leak.\n Continue pain management as needed if RR increases.\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655912, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. s/p VP shunt on . Pt is now\n trach/PEG on ventilator.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp and also rotating left foot in the bed ,but not on\n command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q4 hrs\n Response:\n No change in neuro assessment noted.\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Hypertension, benign\n Assessment:\n Patient SBP 110-140\ns with HR 80s while asleep and low 100 when awake/?\n Agitated- no ectopy noted.\n Action:\n PO Hydralazine 25 mg and labetolol 300 mg with SBP 120-145. goal to\n maintain systolic <160.\n Response:\n Patient SBP within parameters.\n Plan:\n Goal to keep SBP <160. prn orders available for IV hydralazine and IV\n labetolol.\n Rash\n Assessment:\n Scattered pink rash noted torso and all extremities, not raised or\n inflamed.\n Action:\n Monitored rash throughout the night., Lotion applied after bed bath.\n Frequent repositioning.\n Response:\n No change in rash noted.\n Plan:\n Continue to observe for changes rash. Skin care as needed. Reassess new\n medications or possible causes of rash. Continue repositioning.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupil or reaction\n to light. 2 sutures remain intact.\n Action:\n Bacitracin and artificial tears applied as ordered. Left eye shut\n overnight for sleep.\n Response:\n Pt opens eyes spontaneously as well as with stimulation. Appears to\n make eye contact, but tracking is intermittent.\n Plan:\n Continue eye treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse/diminished, moderate amount of yellow thick secretions\n from trach. Copious amount of oral secretion. Strong cough. Respiratory\n effort at times labored rr up to 40 with stimulation. CPAP settings\n unchanged O2 sats 98-100%. 1 episode small cuff leak with new trach\n in.\n Action:\n Intermittent suctioning, hob>30, Q 2hour oral care. RRT in to assess\n cuff leak and MD aware. No ABG collected. 1 mg IV versed given\n when RR increased.\n Response:\n Continues to have copious clear oral secretions and moderate amounts\n yellow secretions from trach. Versed reduced RR from 40s to low teens.\n Plan:\n Continue to provide frequent oral care and trach care as needed.\n Monitor cxray and ABG\ns as ordered by team. Monitor new trach for leak.\n Continue pain management as needed if RR increases.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-26 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655915, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 30\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Extra Length\n Manufacturer: \n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 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: Yellow / Thin\n Sputum source/amount: Suctioned / Copious\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n" }, { "category": "Physician ", "chartdate": "2157-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 657625, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n IVH in left lateral ventricle\n PMHx:\n ?HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment 6.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. HydrALAzine 20. 21.\n Insulin 22. Influenza Virus Vaccine\n 23. Labetalol 24. Labetalol 25. Magnesium Sulfate 26. Metoclopramide\n 27. Midazolam 28. Multivitamins\n 29. Nystatin Oral Suspension 30. Olanzapine 31. Potassium Chloride 32.\n Sodium Chloride 0.9% Flush\n 33. Thiamine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.8\nC (100.1\n HR: 105 (84 - 109) bpm\n BP: 115/69(93) {86/46(57) - 140/71(93)} mmHg\n RR: 29 (11 - 44) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.9 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,004 mL\n 487 mL\n PO:\n Tube feeding:\n 1,564 mL\n 426 mL\n IV Fluid:\n 290 mL\n 61 mL\n Blood products:\n Total out:\n 1,605 mL\n 355 mL\n Urine:\n 1,605 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 399 mL\n 132 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 570 (199 - 610) mL\n PS : 12 cmH2O\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 131\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 11.1 L/min\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 350 K/uL\n 7.4 g/dL\n 109 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 48 mg/dL\n 107 mEq/L\n 142 mEq/L\n 21.2 %\n 19.0 K/uL\n [image002.jpg]\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n WBC\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n Hct\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n Plt\n 482\n 438\n 404\n \n 350\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n Glucose\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.5 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan:\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, D/C hydral\n Pulmonary: stable on CPAP/PS, Tol trach collar 30min Q3H,\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: TFs at goal\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:17 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657786, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657787, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt alert. Inconsistently following commands. Does not move right\n side, moves left side on bed. Pupils equal and reactive. Difficult to\n assess left pupil secondary to protective lense. Sbp w/in ordered\n parameters.\n Action:\n Cont Q4hr neuro checks, maintain sbp per ordered parameters.\n Response:\n Unchanged.\n Plan:\n Discharge planning.\n" }, { "category": "Nursing", "chartdate": "2157-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657895, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Unchanged neurological exam in pt with long standing Pontine bleed.\n Tube feeds changed to Fibersource HN at 60cc/hr per dietitian.\n Action:\n Q4hr neuro checks, PT daily.\n Response:\n Pt follows simple commands at times with left hand, no movement to\n right limbs.\n Plan:\n Continue current POC.\n" }, { "category": "Physician ", "chartdate": "2157-01-26 00:00:00.000", "description": "Intensivist Note", "row_id": 655925, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Metoprolol - 04:05 PM\n Heparin Sodium (Prophylaxis) - 04:06 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 98 (87 - 109) bpm\n BP: 156/84(101) {97/52(65) - 169/88(109)} mmHg\n RR: 18 (13 - 45) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,458 mL\n 627 mL\n PO:\n Tube feeding:\n 1,574 mL\n 405 mL\n IV Fluid:\n 423 mL\n 62 mL\n Blood products:\n Total out:\n 1,050 mL\n 655 mL\n Urine:\n 1,050 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,408 mL\n -28 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 571 (549 - 682) mL\n PS : 10 cmH2O\n RR (Spontaneous): 14\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 99%\n ABG: ///23/\n Ve: 10.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 383 K/uL\n 7.8 g/dL\n 107 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.3 %\n 12.5 K/uL\n [image002.jpg]\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n WBC\n 14.5\n 13.3\n 11.8\n 12.5\n Hct\n 22.6\n 22.1\n 22.1\n 21.3\n Plt\n 83\n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n 1.4\n TCO2\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.0 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach\n Gastrointestinal / Abdomen: NPO, TF\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Hct 21\n Endocrine: RISS\n Infectious Disease: sputum from with Klebsiella pneumonia (no\n yeast cultured), cipro started for VAP\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:11 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657690, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n pt put on trach collar\n suctioning pt for thick yellow secretions\n Action:\n pt only on trach collar ~15min, pt became tacypenic\n Response:\n pt put back on cpap with ps 12,peep 8\n Plan:\n continue to monitor\n monitor 02 sats\n suction as needed\n send sputum for culture\n Intracerebral hemorrhage (ICH)\n Assessment:\n Right pupil 3 mm and briskly reactive to light\n Left pupil 3mm and cloudy\n Pt will intermittently will follow commands\n Pt does move left arm and left leg on bed, pt slightly withdraw right\n and right leg to painful stimuli\n Action:\n Monitor neuro signs every four hours\n Response:\n Plan:\n Continue to monitor, neuro assessment as ordered\n Keep sbp less than 160\n Opthamology into assess, try tape eye shut when pt is sleeping per\n opthamology.\n" }, { "category": "Nursing", "chartdate": "2157-02-08 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657965, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Pt remains on cpap with pressure support. Breath sounds are clear to\n rhonchi and diminished in the bases.\n Pt suctioned for small amts of thick yellow sputum. Much less sputum\n than Saturday night.\n Action:\n Wean pressure support as tolerated. ? attempt trache collar trial\n today.\n Response:\n Pt comfortable on cpap with pressure support less secretions than over\n the weekend.\n Plan:\n Monitor resp. status. Assess for readiness for trache collar or\n decrease in pressure support.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro assessment is unchanged. Left pupil remains unable to assess due\n to corneal abrasion and lens for protection. Right pupil reacts\n briskly. Pt will inconsistently follow commands. Sbp remains less than\n 160.\n Action:\n Goal sbp less than 160. monitor neuro exam\n Response:\n Neuro is unchanged.\n Plan:\n Await plan per team. Continue to assess for readiness to wean from vent\n and attempt trache collar. ? rehab soon.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-01 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656825, "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 placed on 40% trach collar at 11:55am. Spontaneous inspiratory\n efforts at the outset 24 bpm, slowly increasing. At the 20 minute mark\n the spontaneous rate approached 40 bpm. Placed back on CPAP/PSV.\n" }, { "category": "Nursing", "chartdate": "2157-02-09 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658141, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro assessment unchanged\n Remains mechanically ventilated\n VS and labs have been stable\n Action:\n Cont on Q4 neuro assessments, reoriented and rest promoted\n No vent changes overnight\n No labs this am per Dr \n Response:\n Tolerating current vent settings\n Plan:\n Cont to work with PT/OT and speech therapy. Awaiting acceptance to\n rehab pending insurance. F/u with team re: next lab draw.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 658144, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 9\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 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:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for sm th yellow sput. Pt in\n NARD on current settings ; no vent changes required overnoc. Cont PSV.\n" }, { "category": "Respiratory ", "chartdate": "2157-02-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657136, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 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 / 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: Frequent alarms (Low min. ventilation)\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657331, "text": "Respiration / Gas Exchange, Impaired\n Assessment:\n pt on ps ventilation, s/p trach,\n Action:\n pt given trach mask trial x 2, fair-becomes hypertensive, occas\n periods of apnea, 02 sat stable at 97%, suctioned for moder-thick white\n secretions via trach,\n Response:\n pt able to expectorate moder thick secretions on his own, 02 sats\n stable\n Plan:\n trach mask trials as tolerated, pulmonary toileting\n Hypotension (not Shock)\n Assessment:\n occas transient sys bsp of 80\n Action:\n pt stimulated, repositioned\n Response:\n sys presently 116, pt mae,\n Plan:\n continue to keep sys 90 or >,\n Intracerebral hemorrhage (ICH)\n Assessment:\n pt is s/p vp shunt for ICH\n Action:\n frequent neuro assessments,\n Response:\n pt occas tracks speaker, mouthes words although not comprehensible,\n moves toes to command but does not give , , pulls at tubing\n with left hand, appears anxious at times,\n Plan:\n continue with frequent neuro checks, keep sys > 90\n" }, { "category": "Respiratory ", "chartdate": "2157-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657380, "text": "Demographics\n Day of intubation: 4\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Procedure location: Percutaneous trach tube placed at bedside.\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 mL / Air\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No 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: Initiating short trach mask trials.\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2157-02-09 00:00:00.000", "description": "Intensivist Note", "row_id": 658236, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Chief complaint:\n PMHx:\n PMH: ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Escitalopram Oxalate 12. Famotidine 13. Fentanyl Citrate 14. FoLIC\n Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol\n 22. Magnesium Sulfate\n 23. Metoclopramide 24. Midazolam 25. Miconazole Powder 2% 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n On currently and tolerating well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:14 PM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98.1\n HR: 88 (79 - 102) bpm\n BP: 133/75(90) {106/64(76) - 168/93(108)} mmHg\n RR: 19 (12 - 37) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,960 mL\n 633 mL\n PO:\n Tube feeding:\n 1,440 mL\n 491 mL\n IV Fluid:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 1,740 mL\n 400 mL\n Urine:\n 1,740 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 566 (386 - 566) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 17 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 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\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 334 K/uL\n 8.2 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.9 %\n 11.7 K/uL\n [image002.jpg]\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n Plt\n 58\n 350\n 337\n 340\n 334\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n Glucose\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol 100 tid, hydralazine prn\n Pulmonary: Resp: stable on CPAP/PS , continue to wean to today,\n possible trach trial today although in past pt has taken time to\n recover after failing trach trial; some secretions noted but afebrile\n Gastrointestinal / Abdomen: TFs at goal, changed to fibersource to\n increase Kcals. PEG.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, UOP adequate, no issues\n Hematology: Stable, QOD labs\n Endocrine: RISS\n Infectious Disease: completed VAP 14 day course of treatment\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following. Follow up with\n MEEI regarding course of action.\n Imaging: CXR\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:43 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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 rehab / long term facility\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 657229, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Respiratory failure\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Nystatin Oral Suspension\n 29. Olanzapine 30. Potassium Chloride 31. Sodium Chloride 0.9% Flush\n 32. Thiamine\n 24 Hour Events:\n Trach mask 30min Q4H\n Post operative day:\n VP shunt \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.3\nC (97.4\n HR: 90 (74 - 99) bpm\n BP: 151/78(95) {89/55(63) - 183/95(114)} mmHg\n RR: 23 (14 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,164 mL\n 533 mL\n PO:\n Tube feeding:\n 1,574 mL\n 462 mL\n IV Fluid:\n 210 mL\n 70 mL\n Blood products:\n Total out:\n 1,640 mL\n 470 mL\n Urine:\n 1,640 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 524 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (299 - 472) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 6 cmH2O\n SPO2: 98%\n ABG: ///28/\n Ve: 10.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Neurologic: No(t) Moves all extremities, (RUE: Weakness, No(t) No\n movement), (LUE: No(t) Weakness, No(t) No movement), (RLE: Weakness,\n No(t) No movement), (LLE: No(t) Weakness, No(t) No movement), tries to\n mouth words moves L spontaneously R weakly\n Labs / Radiology\n 397 K/uL\n 8.1 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 22.7 %\n 10.9 K/uL\n [image002.jpg]\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n WBC\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n Hct\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n Plt\n 472\n 469\n 482\n \n 397\n Creatinine\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n Glucose\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n Other labs: PT / PTT / INR:14.0/29.6/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: Neuro checks Q: 2 hr, zyprexa, celexa More alert\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: Resp: stable on CPAP/PS, Tol trach collar 30minQ4H; try\n 30min Q3H,\n Gastrointestinal / Abdomen: GI: TFs at goal\n Nutrition: FEN: TFs\n Renal: Foley, Adequate UO, GU: adequate UOP, ARF resolved, lasix prn\n Hematology: Heme: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course Tmax 101\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following\n Imaging: None\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:22 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: 31 minutes\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2157-02-03 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657134, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 3\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 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 / Scant\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: On TM 40% every 3hrs for 30 min. as tolerated.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Physician ", "chartdate": "2157-02-03 00:00:00.000", "description": "Intensivist Note", "row_id": 657206, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Respiratory failure\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Nystatin Oral Suspension\n 29. Olanzapine 30. Potassium Chloride 31. Sodium Chloride 0.9% Flush\n 32. Thiamine\n 24 Hour Events:\n Trach mask 30min Q4H\n Post operative day:\n VP shunt \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Flowsheet Data as of 07:10 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 36.5\nC (97.7\n T current: 36.3\nC (97.4\n HR: 90 (74 - 99) bpm\n BP: 151/78(95) {89/55(63) - 183/95(114)} mmHg\n RR: 23 (14 - 29) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,164 mL\n 533 mL\n PO:\n Tube feeding:\n 1,574 mL\n 462 mL\n IV Fluid:\n 210 mL\n 70 mL\n Blood products:\n Total out:\n 1,640 mL\n 470 mL\n Urine:\n 1,640 mL\n 470 mL\n NG:\n Stool:\n Drains:\n Balance:\n 524 mL\n 63 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 445 (299 - 472) mL\n PS : 5 cmH2O\n RR (Spontaneous): 24\n PEEP: 0 cmH2O\n FiO2: 40%\n RSBI: 45\n PIP: 6 cmH2O\n SPO2: 98%\n ABG: ///28/\n Ve: 10.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Neurologic: No(t) Moves all extremities, (RUE: Weakness, No(t) No\n movement), (LUE: No(t) Weakness, No(t) No movement), (RLE: Weakness,\n No(t) No movement), (LLE: No(t) Weakness, No(t) No movement), tries to\n mouth words moves L spontaneously R weakly\n Labs / Radiology\n 397 K/uL\n 8.1 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 22.7 %\n 10.9 K/uL\n [image002.jpg]\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n WBC\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n Hct\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n Plt\n 472\n 469\n 482\n \n 397\n Creatinine\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n Glucose\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n Other labs: PT / PTT / INR:14.0/29.6/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: Neuro checks Q: 2 hr, zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: Resp: stable on CPAP/PS, Tol trach collar 30minQ4H; try\n 30min Q3H,\n Gastrointestinal / Abdomen: GI: TFs at goal\n Nutrition: FEN: TFs\n Renal: Foley, Adequate UO, GU: adequate UOP, ARF resolved, lasix prn\n Hematology: Heme: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course Tmax 101\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following\n Imaging: None\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 08:22 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-02-05 00:00:00.000", "description": "Intensivist Note", "row_id": 657589, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n IVH in left lateral ventricle\n PMHx:\n ?HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment 6.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. HydrALAzine 20. 21.\n Insulin 22. Influenza Virus Vaccine\n 23. Labetalol 24. Labetalol 25. Magnesium Sulfate 26. Metoclopramide\n 27. Midazolam 28. Multivitamins\n 29. Nystatin Oral Suspension 30. Olanzapine 31. Potassium Chloride 32.\n Sodium Chloride 0.9% Flush\n 33. Thiamine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 11:00 AM\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.3\nC (100.9\n T current: 37.8\nC (100.1\n HR: 105 (84 - 109) bpm\n BP: 115/69(93) {86/46(57) - 140/71(93)} mmHg\n RR: 29 (11 - 44) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.9 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,004 mL\n 487 mL\n PO:\n Tube feeding:\n 1,564 mL\n 426 mL\n IV Fluid:\n 290 mL\n 61 mL\n Blood products:\n Total out:\n 1,605 mL\n 355 mL\n Urine:\n 1,605 mL\n 355 mL\n NG:\n Stool:\n Drains:\n Balance:\n 399 mL\n 132 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 570 (199 - 610) mL\n PS : 12 cmH2O\n RR (Spontaneous): 18\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 131\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 11.1 L/min\n Physical Examination\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: 2+), (Temperature: Warm)\n Right Extremities: (Edema: 2+), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 350 K/uL\n 7.4 g/dL\n 109 mg/dL\n 1.2 mg/dL\n 24 mEq/L\n 4.5 mEq/L\n 48 mg/dL\n 107 mEq/L\n 142 mEq/L\n 21.2 %\n 19.0 K/uL\n [image002.jpg]\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n WBC\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n Hct\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n Plt\n 482\n 438\n 404\n \n 350\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n Glucose\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.5 mg/dL, PO4:4.9 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan:\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, Tol trach collar 45min Q3H,\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: TFs at goal\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds:\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 05:17 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658349, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n aneurysm of right basilar artery. Ventilator dependent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient trached and vented on PS 40% 5/5. Sats at high 90\n-100% RR\n 14-18. Bil LS clear w/transient rhonchi which clear after being\n suctioned for med amnt of white thick secretions.\n Action:\n Mechanical ventilation -> will attempt trach mask in am, mouth care\n q4hr and as needed, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent if tolerates.\n Neuro: alert, unable to communicate because of trach/SAH+IVH.\n Inconsistently follows commands. Moves Left upper extr purposefully, no\n movement noted @ RT upper extr. Some movement of the lower extr. Bil\n pupils are equal and reactive. Eyes tape shut 12am-6am as ordered. Eye\n care done ASDIR.\n Cardio: B/P at 100-120\ns/60\ns (elevated to 160\ns during care or\n repositioning) HR at 80\ns no ectopy noted. No peripheral edema noted.\n Peripheral pulses present.\n GI: abd soft distended, non tender. Positive for BS. Small BM during\n the shift. PEG w/TF at goal. No residuals.\n GU: clear yellow urine via foley. Adequate amnt.\n IV access: RT PICC double lumen.\n Social: patient is a FULL CODE. Awaiting placement.\n" }, { "category": "Physician ", "chartdate": "2157-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 657447, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Albuterol Inhaler, Artificial Tear Ointment,\n Bacitracin/Polymyxin B Sulfate Opht. Oint, Bisacodyl, Calcium\n Gluconate, Chlorhexidine Gluconate 0.12% Oral Rinse, Ciprofloxacin HCl,\n Docusate Sodium (Liquid), Escitalopram Oxalate, Famotidine, Fentanyl\n Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol,\n Magnesium Sulfate, Metoclopramide, Midazolam, Multivitamins ,Nystatin\n Oral Suspension, Olanzapine,Thiamine\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 87 (77 - 109) bpm\n BP: 97/52(63) {80/42(55) - 169/95(111)} mmHg\n RR: 19 (15 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,807 mL\n 220 mL\n PO:\n Tube feeding:\n 1,567 mL\n 178 mL\n IV Fluid:\n 240 mL\n 42 mL\n Blood products:\n Total out:\n 1,390 mL\n 180 mL\n Urine:\n 1,390 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 417 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 462 (234 - 581) mL\n PS : 5 cmH2O\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 11.9 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 : , No(t)\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli)\n Labs / Radiology\n 358 K/uL\n 7.7 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 21.2 %\n 16.1 K/uL\n [image002.jpg]\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n WBC\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n Hct\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n Plt\n 472\n 469\n 482\n 58\n Creatinine\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n Glucose\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n Other labs: PT / PTT / INR:14.9/30.1/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan:\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, Tol trach collar 30min Q3H, try 45min\n today\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: TFs at goal\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative. Will give 10mg this am\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: none\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Transfer to rehab / long term facility\n Total time spent: 31 min\n" }, { "category": "Physician ", "chartdate": "2157-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 657756, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n head bleed\n PMHx:\n HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine\n 21. Labetalol 22. Labetalol\n 23. Magnesium Sulfate 24. Metoclopramide 25. Midazolam 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n Trach collar trials for 45 min at a time, but failed, only lasted 10\n min\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 PM\n Heparin Sodium (Prophylaxis) - 12:51 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.3\nC (99.2\n HR: 89 (86 - 105) bpm\n BP: 126/74(85) {96/54(65) - 142/83(97)} mmHg\n RR: 12 (10 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.9 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,910 mL\n 294 mL\n PO:\n Tube feeding:\n 1,575 mL\n 254 mL\n IV Fluid:\n 236 mL\n 39 mL\n Blood products:\n Total out:\n 1,580 mL\n 400 mL\n Urine:\n 1,580 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 745 (435 - 842) mL\n PS : 12 cmH2O\n RR (Spontaneous): 9\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 6.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 337 K/uL\n 6.9 g/dL\n 110 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 48 mg/dL\n 108 mEq/L\n 142 mEq/L\n 20.1 %\n 13.3 K/uL\n [image002.jpg]\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n WBC\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n Hct\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n Plt\n 97\n 358\n 350\n 337\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n Glucose\n 136\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53yM with pontine hemorrhage and continued\n respiratory failure with inability to wean from the ventilator\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol decreased to 100 tid, hydral\n only prn\n Pulmonary: stable on CPAP/PS, Tol trach collar for less than 10 min\n yesterday. Hold trach collar trials\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course, wbc trending up\n with low grade temps\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: left corneal ulcer\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:41 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-02-07 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657850, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuros unchanged. No movement R side. Left eye open all the time. Taped\n shut overnight 12 -6 am. Moves left hand to command and moves left leg\n on bed to command but inconsistent. R eye pupil 2 and reacts briskly.\n Left eye is open and red and difficult to evaluate pupil reaction\n because eye is cloudy from ointment and lens\n Action:\n Pt on q 4 hour neuro checks, maintain sbp< 160. received 1 unit prbcs\n for hct of 20.1. Lasix 20 mg iv after tx.\n Response:\n Hct increased to 25\n Plan:\n Monitor neuro status and hct. Discharge plans\n" }, { "category": "Physician ", "chartdate": "2157-02-07 00:00:00.000", "description": "Intensivist Note", "row_id": 657852, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Respiratory failure\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Nystatin Oral Suspension\n 29. Olanzapine 30. Potassium Chloride 31. Sodium Chloride 0.9% Flush\n 32. Thiamine\n 24 Hour Events:\n : Trach collar trials for 45 min at a time\n : no trach trials\n Post operative day:\n VP shunt \n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 08:00 AM\n Furosemide (Lasix) - 12:09 AM\n Other medications:\n Flowsheet Data as of 08:11 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: 37.5\nC (99.5\n HR: 82 (82 - 98) bpm\n BP: 140/77(90) {113/63(78) - 171/88(106)} mmHg\n RR: 16 (9 - 22) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.8 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,100 mL\n 482 mL\n PO:\n Tube feeding:\n 1,570 mL\n 408 mL\n IV Fluid:\n 240 mL\n 74 mL\n Blood products:\n 290 mL\n Total out:\n 2,475 mL\n 965 mL\n Urine:\n 2,465 mL\n 965 mL\n NG:\n 10 mL\n Stool:\n Drains:\n Balance:\n -375 mL\n -483 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 709 (542 - 974) mL\n PS : 12 cmH2O\n RR (Spontaneous): 11\n PEEP: 8 cmH2O\n FiO2: 40%\n RSBI: 102\n PIP: 21 cmH2O\n SPO2: 100%\n ABG: ///25/\n Ve: 6.1 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : , Diminished: bases bilat)\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, (Responds to: Verbal stimuli,\n Tactile stimuli), Moves all extremities\n Labs / Radiology\n 340 K/uL\n 8.9 g/dL\n 101 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 4.1 mEq/L\n 46 mg/dL\n 108 mEq/L\n 143 mEq/L\n 25.2 %\n 15.2 K/uL\n [image002.jpg]\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n Plt\n 58\n 350\n 337\n 340\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n Glucose\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.1 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: zyprexa, celexa\n Cardiovascular: CV: goal SBP < 160, labetolol decreased to 100 tid,\n hydral only prn\n Pulmonary: (Ventilator mode: CPAP + PS), Resp: stable on CPAP/PS, trach\n collar rest yesterday\n Gastrointestinal / Abdomen: GI: TFs at goal\n Nutrition: Tube feeding, GI: TFs at goal\n Renal: GU: adequate UOP, ARF resolved, lasix given after transfusion\n yesterday\n Hematology: s/p 1u PRBC yesterday for HCT 20\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course, wbc trending up\n with low grade temps\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following)\n Imaging: None\n Fluids:\n Consults: Neuro surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 31 minutes\n" }, { "category": "Nursing", "chartdate": "2157-02-06 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657728, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro status is unchanged. Pt inconsistently follows commands. Moves\n left arm spontaneously and moves left leg on bed right pupil is 3 and\n reactive to light. Left pupil difficult to assess due to corneal\n ulceration and lens.\n Action:\n Continue with neuro checks.\n Response:\n No change in neuro status.\n Plan:\n Continue to monitor . await rehab placement.\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658441, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt. alert, responsive, following commands. Very minimal movements with\n right side, but able to weakly squeeze and move leg slightly. Left\n side active. Mouthing words and nodding appropriately.\n Action:\n Neuro exam Q4hr.\n Response:\n No changes noted.\n Plan:\n Continue to monitor\n discharge planning in progress with primary\n team. Pt. has bed in vented rehab and plan is to transfer today; teams\n aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished bibasilar. Pt. overall weak, deconditioned.\n Action:\n Placed on trach mask this a.m. at approximately 1115. Suctioned once\n for moderate yellow secretions.\n Response:\n Pt. remains on TM in NAD.\n Plan:\n Pulmonary hygiene, TM as tolerated, rehab planning as above.\n Left eye abrasion vs. infection.\n Assessment:\n Left eye with whitish film, sutured at corner to\nfoam\n. Pt. states he\n has visual disturbance (via nodding.)\n Action:\n Lubricant placed Q2hrs. unless due for Q6hr warm bacitracin ointment.\n Eye steri\nd close while napping this afternoon.\n Response:\n No change.\n Plan:\n Continue present regimen per Optho. Rehab planning as above.\n ------ Protected Section ------\n Pt. transferred to Rehab vent weaning unit this afternoon,\n ambulance left at approximately 1630. Pt. with stable VS\ns and placed\n on paramedic ventilator in NAD.\n ------ Protected Section Addendum Entered By: , RN\n on: 17:41 ------\n" }, { "category": "Respiratory ", "chartdate": "2157-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657665, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 5\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 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:\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 Attempted TC trial and PSV wean did not tol RR>45\n" }, { "category": "Respiratory ", "chartdate": "2157-02-04 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657528, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 4\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 8 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: Tachypneic (RR> 35 b/min)\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Tolerated Trach Collar trial for approx 1hr, failed attempts later in\n shift RR>45\n" }, { "category": "Nursing", "chartdate": "2157-02-05 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657575, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Low grade temps TMAX 100.9, WBC now 19\n Action:\n Discuss need for c/s on rounds\n Response:\n pending\n Plan:\n Discuss plan on rounds ? c/s.\n Anemia, other\n Assessment:\n HCT 21, SBP 93/50 -100/50s.\n Action:\n Notify h.o on rounds/correlate with failure to wean\n Response:\n pending\n Plan:\n Discuss on rounds ? need for PRBCs\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n Pt nods head intermittently to questions. Pt always squeezes ones hand\n but does not let go to command.Eye open looking about room ? tracking.\n Pts coworker in to visit and stated other friends and coworkers \n like to come see pt but it is busy time at wotk (tax season)\n Action:\n Stimulated pt by talking to him, (he likes baseball) and putting his TV\n on for him.\n Response:\n More wakeful\n Plan:\n Continue to stimulate pt during day and evs.\n" }, { "category": "Physician ", "chartdate": "2157-02-08 00:00:00.000", "description": "Intensivist Note", "row_id": 658035, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n SAH, weakness\n PMHx:\n HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine\n 21. Labetalol 22. Labetalol\n 23. Magnesium Sulfate 24. Metoclopramide 25. Midazolam 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\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) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.1\nC (97\n HR: 86 (78 - 100) bpm\n BP: 124/72(84) {117/63(77) - 167/91(103)} mmHg\n RR: 17 (10 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,936 mL\n 521 mL\n PO:\n Tube feeding:\n 1,506 mL\n 361 mL\n IV Fluid:\n 240 mL\n 60 mL\n Blood products:\n Total out:\n 2,170 mL\n 670 mL\n Urine:\n 2,170 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -234 mL\n -149 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 635 (405 - 644) mL\n PS : 8 cmH2O\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: ///27/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, on ventilator\n Labs / Radiology\n 334 K/uL\n 8.2 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.9 %\n 11.7 K/uL\n [image002.jpg]\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n Plt\n 58\n 350\n 337\n 340\n 334\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n Glucose\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery, failure to\n wean from vent\n Neurologic: Neuro checks Q: 2 hr, zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol 100 tid, hydralazine prn\n Pulmonary: Trach Decrease PSV/ CPAP to 5 if possible\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, TFs at goal, changed to fibersource to\n increase Kcals\n Renal: Foley\n Hematology: hct 22.9 today from 25.2, continue to monitor closely hx\n transfusion 1 unit PRBC \n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:45 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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:\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2157-02-05 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657578, "text": "Demographics\n Day of intubation: 5\n Day of mechanical ventilation: 5\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 25 cmH2O\n Cuff volume: 6 mL / Air\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: 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: Wean to trach mask as tolerated.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Respiratory ", "chartdate": "2157-02-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657815, "text": "Demographics\n Day of intubation: 7\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: 6 mL / Air\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: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Comments: Occasionally goes into apnea ventilation.\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Respiratory ", "chartdate": "2157-02-09 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 658282, "text": "Demographics\n Day of mechanical ventilation: 9\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Rhonchi\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: 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 Periodic SBT's for conditioning; Comments: attempt trach collar\n tomorrow if pt stays on IPS 5 over noc.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, underlying illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2157-02-10 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 658336, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 10\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 9.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 20 cmH2O\n Cuff volume: 6 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: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort:\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, Increase ventilatory support at\n night\n Reason for continuing current ventilatory support: Cannot protect\n airway, Cannot manage secretions; Comments: Pt remains stable on\n minimal vent settings, no changes this shift. Good RSBI performed.\n Trach collar to be used today.\n BEDSIDE RSBI- 66\n" }, { "category": "Respiratory ", "chartdate": "2157-02-06 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657713, "text": "Demographics\n Day of intubation: 6\n Day of mechanical ventilation: 6\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: 6 mL / Air\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: 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 completed on PS 5=163.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Cannot protect airway\n" }, { "category": "Physician ", "chartdate": "2157-02-08 00:00:00.000", "description": "Intensivist Note", "row_id": 657987, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n SAH, weakness\n PMHx:\n HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine\n 21. Labetalol 22. Labetalol\n 23. Magnesium Sulfate 24. Metoclopramide 25. Midazolam 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\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) - 08:07 PM\n Heparin Sodium (Prophylaxis) - 12:07 AM\n Other medications:\n Flowsheet Data as of 06:13 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.3\n T current: 36.1\nC (97\n HR: 86 (78 - 100) bpm\n BP: 124/72(84) {117/63(77) - 167/91(103)} mmHg\n RR: 17 (10 - 23) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,936 mL\n 521 mL\n PO:\n Tube feeding:\n 1,506 mL\n 361 mL\n IV Fluid:\n 240 mL\n 60 mL\n Blood products:\n Total out:\n 2,170 mL\n 670 mL\n Urine:\n 2,170 mL\n 670 mL\n NG:\n Stool:\n Drains:\n Balance:\n -234 mL\n -149 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 635 (405 - 644) mL\n PS : 8 cmH2O\n RR (Spontaneous): 13\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 16 cmH2O\n SPO2: 100%\n ABG: ///27/\n Ve: 7 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: CTA\n bilateral : )\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Absent)\n Right Extremities: (Edema: Absent)\n Neurologic: Follows simple commands, on ventilator\n Labs / Radiology\n 334 K/uL\n 8.2 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.9 %\n 11.7 K/uL\n [image002.jpg]\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n Plt\n 58\n 350\n 337\n 340\n 334\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n Glucose\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery, failure to\n wean from vent\n Neurologic: Neuro checks Q: 2 hr, zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol 100 tid, hydralazine prn\n Pulmonary: Trach\n Gastrointestinal / Abdomen:\n Nutrition: Tube feeding, TFs at goal, changed to fibersource to\n increase Kcals\n Renal: Foley\n Hematology: hct 22.9 today from 25.2, continue to monitor closely hx\n transfusion 1 unit PRBC \n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: Foley, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:45 PM 60 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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:\n Total time spent:\n" }, { "category": "Physician ", "chartdate": "2157-02-06 00:00:00.000", "description": "Intensivist Note", "row_id": 657706, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n head bleed\n PMHx:\n HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine\n 21. Labetalol 22. Labetalol\n 23. Magnesium Sulfate 24. Metoclopramide 25. Midazolam 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n Trach collar trials for 45 min at a time, but failed, only lasted 10\n min\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:10 PM\n Heparin Sodium (Prophylaxis) - 12:51 AM\n Other medications:\n Flowsheet Data as of 04:03 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 37.3\nC (99.2\n HR: 89 (86 - 105) bpm\n BP: 126/74(85) {96/54(65) - 142/83(97)} mmHg\n RR: 12 (10 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.9 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,910 mL\n 294 mL\n PO:\n Tube feeding:\n 1,575 mL\n 254 mL\n IV Fluid:\n 236 mL\n 39 mL\n Blood products:\n Total out:\n 1,580 mL\n 400 mL\n Urine:\n 1,580 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 330 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 745 (435 - 842) mL\n PS : 12 cmH2O\n RR (Spontaneous): 9\n PEEP: 8 cmH2O\n FiO2: 40%\n PIP: 20 cmH2O\n SPO2: 100%\n ABG: ///24/\n Ve: 6.2 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 337 K/uL\n 6.9 g/dL\n 110 mg/dL\n 1.0 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 48 mg/dL\n 108 mEq/L\n 142 mEq/L\n 20.1 %\n 13.3 K/uL\n [image002.jpg]\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n WBC\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n Hct\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n Plt\n 97\n 358\n 350\n 337\n Creatinine\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n Glucose\n 136\n 168\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.2 mg/dL, PO4:4.1 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53yM with pontine hemorrhage and continued\n respiratory failure with inability to wean from the ventilator\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol decreased to 100 tid, hydral\n only prn\n Pulmonary: stable on CPAP/PS, Tol trach collar for less than 10 min\n yesterday. Cont trach collar trials\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course, wbc trending up\n with low grade temps\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds: left corneal ulcer\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 11:41 PM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle: HOB elevation\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2157-02-07 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657909, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 7\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 7.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 23 cmH2O\n Cuff volume: 6 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:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Respiratory ", "chartdate": "2157-02-08 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 658107, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 8\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Cuffed\n Manufacturer: Portex\n Size: 9.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 6 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Attempt to wean PEEP from 8 to 5 cmH20.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Dysynchrony assessment: Frequent alarms (High rate)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Reduce PEEP as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n" }, { "category": "Rehab Services", "chartdate": "2157-02-09 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 658262, "text": "Subjective:\n Pt mouthing, but unable to understand\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 Max A x 2\n\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n Max A x 2\n\n\n\n\n\n T\n Transfer:\n\n\n\n\n\n Sit to Stand:\n Max A x 2\n\n\n\n\n\n T\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 /\n Activity\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait:\n Balance: Pt required max A x 2 to achieve sitting at EOB, once upright\n required min A to max A to maintain balance in midline with LOB in all\n directions. Pt inconsistently using L UE to assist with posture when\n positioned by therapist. Pt was able to achieve standing with Max A\n x 2 for 2 reps, with significant B LE knee buckling, and with patient\n attempting to lift L LE off of ground. Pt tolerated for <10 sec each\n rep.\n Education / Communication: Pt status discussed with RN\n Other: Pt followed approx 25% of 1 step commands with L UE and LE.\n Thick and copious amounts of oral secretions when sitting at EOB used\n yankaur to clear.\n Performed pec stretch and scalene stretch at EOB\n CPAP PEEP 5 PSup 5\n Assessment: 53 yo m c prolonged ICU stay after pontine hemorrhage\n continues to be functioning below baseline, however he has been making\n gains with balance and following commands. Pt will require rehab upon\n d/c to optimize function.\n Anticipated Discharge: Rehab\n Plan: cont balance training at EOB, progress to standing training.\n Cognitive training, ROM and postural re-education\n" }, { "category": "Nursing", "chartdate": "2157-02-03 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657142, "text": "Arousal, Attention, and Cognition, Impaired\n Assessment:\n Neuro status waxes and wanes. Pt arousable to voice, following some\n commands to squeeze hand on left side. Left side moving spontaneously,\n right side only responding slightly to pain. Right pupil brisk and\n reactive, however left pupil unable to assess due to corneal injury.\n Nodding at times to simple questions, trying to mouth words\n unsuccessfully.\n Action:\n Neuro status checked Q4 hours, pt reminded of where he is and what day\n it is.\n Response:\n Neuro status remains unchanged\n Plan:\n Continue to monitor neuro exam Q 4 hours, reorient when necessary\n" }, { "category": "Nursing", "chartdate": "2157-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657080, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient continues on CPAP 5/5. Sating 99-100%, breath sounds clear\n diminished at bases. Suctioned for small amount of thin yellow\n secretions. Suctioned for copious amounts of oral secretions.\n Action:\n Trach mask FiO2 40% on for 30 mins this am and 50 mins in afternoon.\n Turned and suctioned frequently. OOB to chair.\n Response:\n Patient tolerated trach mask well RR 20\ns-30\ns, sating 98-100%.\n Plan:\n Continue to try trach mask q 4 hours as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Patient able to follow commands inconsistently. Lifts and holds right\n side, able to move left leg. Pupils 3-4mm equal and reactive.\n Action:\n Speech and swallow eval, passy muir vale tried for speaking\n Response:\n Patient able to say name with PMV on. Neuro status unchanged.\n Plan:\n Continue to try using valve twice daily during small periods of time\n with supervision.\n" }, { "category": "Nursing", "chartdate": "2157-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657081, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient continues on CPAP 5/5. Sating 99-100%, breath sounds clear\n diminished at bases. Suctioned for small amount of thin yellow\n secretions. Suctioned for copious amounts of oral secretions.\n Action:\n Trach mask FiO2 40% on for 30 mins this am and 50 mins in afternoon.\n Turned and suctioned frequently. OOB to chair.\n Response:\n Patient tolerated trach mask well RR 20\ns-30\ns, sating 98-100%.\n Plan:\n Continue to try trach mask q 4 hours for 30 mins as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Patient able to follow commands inconsistently. Lifts and holds right\n side, able to move left leg. Pupils 3-4mm equal and reactive.\n Action:\n Speech and swallow eval, passy muir vale tried for speaking\n Response:\n Patient able to say name with PMV on. Neuro status unchanged.\n Plan:\n Continue to try using valve twice daily during small periods of time\n with supervision.\n" }, { "category": "General", "chartdate": "2157-02-03 00:00:00.000", "description": "Generic Note", "row_id": 657337, "text": "TITLE:\n Respiratory Care Service: Pt remains on a PS 5/5 .40 as tolerated and\n for rest between Trach Collar .50 trials for 30 minutes to 1 hour today\n x 2. Will c/w current plan and gradually extend the length of the Trach\n Collar trials as tolerated.\n" }, { "category": "Physician ", "chartdate": "2157-02-04 00:00:00.000", "description": "Intensivist Note", "row_id": 657390, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Albuterol Inhaler, Artificial Tear Ointment,\n Bacitracin/Polymyxin B Sulfate Opht. Oint, Bisacodyl, Calcium\n Gluconate, Chlorhexidine Gluconate 0.12% Oral Rinse, Ciprofloxacin HCl,\n Docusate Sodium (Liquid), Escitalopram Oxalate, Famotidine, Fentanyl\n Citrate, FoLIC Acid, Heparin, HydrALAzine, Insulin, Labetalol,\n Magnesium Sulfate, Metoclopramide, Midazolam, Multivitamins ,Nystatin\n Oral Suspension, Olanzapine,Thiamine\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:15 AM\n Flowsheet Data as of 04:20 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.1\nC (98.8\n T current: 37.1\nC (98.8\n HR: 87 (77 - 109) bpm\n BP: 97/52(63) {80/42(55) - 169/95(111)} mmHg\n RR: 19 (15 - 33) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,807 mL\n 220 mL\n PO:\n Tube feeding:\n 1,567 mL\n 178 mL\n IV Fluid:\n 240 mL\n 42 mL\n Blood products:\n Total out:\n 1,390 mL\n 180 mL\n Urine:\n 1,390 mL\n 180 mL\n NG:\n Stool:\n Drains:\n Balance:\n 417 mL\n 40 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 462 (234 - 581) mL\n PS : 5 cmH2O\n RR (Spontaneous): 32\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 89\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ////\n Ve: 11.9 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 : , No(t)\n Rhonchorous : , Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli)\n Labs / Radiology\n 358 K/uL\n 7.7 g/dL\n 119 mg/dL\n 0.9 mg/dL\n 28 mEq/L\n 4.0 mEq/L\n 37 mg/dL\n 105 mEq/L\n 140 mEq/L\n 21.2 %\n 16.1 K/uL\n [image002.jpg]\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n WBC\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n 10.9\n 16.1\n Hct\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n 22.7\n 21.2\n Plt\n 472\n 469\n 482\n 58\n Creatinine\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n 0.9\n Glucose\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n 119\n Other labs: PT / PTT / INR:14.9/30.1/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.8 mg/dL,\n Mg:2.0 mg/dL, PO4:4.3 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan:\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, Tol trach collar 30min Q3H, try 45min\n today\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: TFs at goal\n Renal: adequate UOP, ARF resolved, consider restarting Lasix to keep\n even/negative\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging: none\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Transfer to rehab / long term facility\n Total time spent:\n" }, { "category": "Respiratory ", "chartdate": "2157-02-02 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 657071, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 2\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: Yellow / Thin\n Sputum source/amount: Suctioned / Small\n Comments: when placed on PMV and cuff deflated caused pt to cough and\n sxned out a moderate amnt of secretions,\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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: pt will have 15-30 min TM trials every 3 hrs per doctors\n . Pt's first trial included PMV trial, pt was able to say name.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n" }, { "category": "Nursing", "chartdate": "2157-02-02 00:00:00.000", "description": "Nursing Progress Note", "row_id": 657074, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient continues on CPAP 5/5. Sating 99-100%, breath sounds clear\n diminished at bases. Suctioned for small amount of thin yellow\n secretions. Suctioned for copious amounts of oral secretions.\n Action:\n Trach mask FiO2 40% on for 30 mins this am and 30 mins in afternoon.\n Response:\n Patient tolerated trach mask well RR 20\ns-30\ns, sating 98-100%.\n Plan:\n Continue to try trach mask q 4 hours as tolerated.\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654883, "text": "Hypertension, benign/ Anxiety\n Assessment:\n Pt continues to have episodes of sustained SBP above 160 especially\n with any type of stimulation.\n Action:\n Increased PO Labetalol to 300 mg TID. Started on Zyprexia to\n alleviate ? of anxiety.\n Response:\n Pt remains with SBP above 160 with bedside care and exams.\n Plan:\n Continue to adjust antihypertensives as needed. PRN IVP Labetalol and\n Hydralazine.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt remains inconsistent with obeying of commands and with purposeful\n mvts.\n Action:\n Continue to attempt to engage and encourage patient to attempt\n communication etc. PT at bedside dangling patient encouraging patient\n to use left hand for interactions.\n Response:\n Pt appropriately nodding head and shrugging shoulders intermittingly.\n Plan:\n Per Neuro Medicine, ? of sending pt to MRI for further study s/p staple\n removal from head.\n" }, { "category": "Physician ", "chartdate": "2157-01-30 00:00:00.000", "description": "Intensivist Note", "row_id": 656489, "text": "SICU\n HPI:\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 Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Other medications:\n Flowsheet Data as of 05:46 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: 83 (74 - 103) bpm\n BP: 121/71(83) {95/29(57) - 159/87(147)} mmHg\n RR: 17 (14 - 35) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,299 mL\n 607 mL\n PO:\n Tube feeding:\n 1,574 mL\n 370 mL\n IV Fluid:\n 540 mL\n 57 mL\n Blood products:\n Total out:\n 2,535 mL\n 730 mL\n Urine:\n 2,535 mL\n 730 mL\n NG:\n Stool:\n Drains:\n Balance:\n -236 mL\n -123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 530 (19 - 606) mL\n PS : 8 cmH2O\n RR (Spontaneous): 25\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 67\n PIP: 13 cmH2O\n SPO2: 97%\n ABG: ///25/\n Ve: 10.3 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\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 Labs / Radiology\n 482 K/uL\n 7.9 g/dL\n 106 mg/dL\n 1.0 mg/dL\n 25 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 140 mEq/L\n 22.1 %\n 12.7 K/uL\n [image002.jpg]\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n WBC\n 13.3\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n Hct\n 22.1\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n Plt\n 48\n 472\n 469\n 482\n Creatinine\n 1.1\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n TCO2\n 26\n Glucose\n 137\n 133\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n Other labs: PT / PTT / INR:14.1/31.4/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:2.2 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, try trach collar today, trach pressures,\n adequate with small leak, ?tracheal stent on Monday\n Gastrointestinal / Abdomen: s/p renal transplant, f/u u/o, D5 1/2NS at\n 50 ml/hr\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: f/u Hct, keep it 30 or above\n Endocrine: RISS\n Infectious Disease: Anti-Thymocyte\n Globulin/mmf/valcyte/bactrim/prednisone\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging:\n Fluids:\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:07 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-19 00:00:00.000", "description": "Intensivist Note", "row_id": 654773, "text": "SICU\n HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:15 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:45 AM\n Labetalol - 05:30 AM\n Hydralazine - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:46 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: 36.6\nC (97.9\n HR: 83 (72 - 100) bpm\n BP: 166/73(109) {120/58(81) - 195/88(129)} mmHg\n RR: 16 (14 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,405 mL\n 661 mL\n PO:\n Tube feeding:\n 720 mL\n 233 mL\n IV Fluid:\n 295 mL\n 128 mL\n Blood products:\n Total out:\n 2,195 mL\n 880 mL\n Urine:\n 2,195 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -790 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 633 (410 - 633) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\n Physical Examination\n Labs / Radiology\n 307 K/uL\n 9.3 g/dL\n 100 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 113 mEq/L\n 145 mEq/L\n 27.1 %\n 8.8 K/uL\n [image002.jpg]\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n WBC\n 8.6\n 7.5\n 7.4\n 8.8\n Hct\n 27.1\n 25.0\n 25.7\n 27.1\n Plt\n 300\n 297\n 314\n 307\n Creatinine\n 1.0\n 1.3\n 1.1\n 1.0\n TCO2\n 22\n 23\n 21\n 21\n 22\n 26\n Glucose\n 112\n 110\n 110\n 100\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\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 Nutren 2.0 (Full) - 02:36 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\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 RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\n" }, { "category": "Physician ", "chartdate": "2157-01-19 00:00:00.000", "description": "Intensivist Note", "row_id": 654808, "text": "SICU\n HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:15 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:45 AM\n Labetalol - 05:30 AM\n Hydralazine - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:46 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: 36.6\nC (97.9\n HR: 83 (72 - 100) bpm\n BP: 166/73(109) {120/58(81) - 195/88(129)} mmHg\n RR: 16 (14 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,405 mL\n 661 mL\n PO:\n Tube feeding:\n 720 mL\n 233 mL\n IV Fluid:\n 295 mL\n 128 mL\n Blood products:\n Total out:\n 2,195 mL\n 880 mL\n Urine:\n 2,195 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -790 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 633 (410 - 633) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\n Physical Examination\n Labs / Radiology\n 307 K/uL\n 9.3 g/dL\n 100 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 113 mEq/L\n 145 mEq/L\n 27.1 %\n 8.8 K/uL\n [image002.jpg]\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n WBC\n 8.6\n 7.5\n 7.4\n 8.8\n Hct\n 27.1\n 25.0\n 25.7\n 27.1\n Plt\n 300\n 297\n 314\n 307\n Creatinine\n 1.0\n 1.3\n 1.1\n 1.0\n TCO2\n 22\n 23\n 21\n 21\n 22\n 26\n Glucose\n 112\n 110\n 110\n 100\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\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: left corneal ulcer, improving\n Imaging: none\n Fluids: NS 75\n Consults: neurosurgery, neurology\n Billing Diagnosis: ICH\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:36 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SCH\n Stress ulcer: H2\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\n" }, { "category": "Physician ", "chartdate": "2157-01-19 00:00:00.000", "description": "Intensivist Note", "row_id": 654811, "text": "SICU\n HPI:\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n BRONCHOSCOPY - At 12:15 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 01:45 AM\n Labetalol - 05:30 AM\n Hydralazine - 06:00 AM\n Other medications:\n Flowsheet Data as of 07:46 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: 36.6\nC (97.9\n HR: 83 (72 - 100) bpm\n BP: 166/73(109) {120/58(81) - 195/88(129)} mmHg\n RR: 16 (14 - 22) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,405 mL\n 661 mL\n PO:\n Tube feeding:\n 720 mL\n 233 mL\n IV Fluid:\n 295 mL\n 128 mL\n Blood products:\n Total out:\n 2,195 mL\n 880 mL\n Urine:\n 2,195 mL\n 880 mL\n NG:\n Stool:\n Drains:\n Balance:\n -790 mL\n -219 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 633 (410 - 633) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\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 Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 307 K/uL\n 9.3 g/dL\n 100 mg/dL\n 1.0 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 25 mg/dL\n 113 mEq/L\n 145 mEq/L\n 27.1 %\n 8.8 K/uL\n [image002.jpg]\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n WBC\n 8.6\n 7.5\n 7.4\n 8.8\n Hct\n 27.1\n 25.0\n 25.7\n 27.1\n Plt\n 300\n 297\n 314\n 307\n Creatinine\n 1.0\n 1.3\n 1.1\n 1.0\n TCO2\n 22\n 23\n 21\n 21\n 22\n 26\n Glucose\n 112\n 110\n 110\n 100\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.1 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, dilantin stopped\n Cardiovascular: goal SBP < 160, started on labetolol 200 po TID for\n hypertension, prn Hydralazine and IV labetolol\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs\n Nutrition: adequate UOP, ARF resolved\n Renal: TFs, hypernatremic, increase free water flushes, NS at 75\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures\n Lines / Tubes / Drains: trach, foley, ?d/c a-line, VPS, PEG, rt PICC,\n VPS\n Wounds: left corneal ulcer, improving\n Imaging: none\n Fluids: NS 75\n Consults: neurosurgery, neurology\n Billing Diagnosis: ICH\n Dispo: start screening for vented rehab. no insurance or health care\n proxy. social work following\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:36 PM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SCH\n Stress ulcer: H2\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 min\n RSBI Deferred: RR >35\n PIP: 17 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 96%\n ABG: 7.43/38/99./22/0\n Ve: 10.6 L/min\n PaO2 / FiO2: 248\n" }, { "category": "Rehab Services", "chartdate": "2157-01-19 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 654813, "text": "Subjective:\n pt non-verbal\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: pt tolerated 30 min on CPAP this am\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\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 95\n 145/68\n 16\n 96% on AC\n Activity\n Sit\n 111\n 170/73\n 20\n 97% on AC\n Recovery\n 99\n 149/70\n 14\n 98% on AC\n Total distance walked:\n Minutes:\n Gait: patient requires total assist for rolling and supine-to-sit, pt\n not participating actively in any mobilty\n Balance: Patient able to maintain static sitting at edge of bed with\n min A, LOB to left. Dynamic acitivities with mod A, extends LLE\n minimally with LOB to left\n Education / Communication: Communicated with nsg re: status\n Other: Pt is alert, inconsistently following some simple commands:\n thumbs up, smiles, waves, wiggles L foot and extends left knee.\n Moderate delay to follow commands\n Spontaneous movement of RLE, hypotonic RUE\n Visually tracks with saccadic eye movements, nystagmus\n Assessment: 53 yo M s/p pontine CVA making good progress in PT with\n arousal and cognition, today able to follow <20% of simple commands and\n is tolerating increased sitting time at edge of bed. Rehab potential\n still remains guarded given his vent dependency and significance of\n injury, will cont to follow and re-assess.\n Anticipated Discharge: Rehab\n Plan: Cont with POC.\n" }, { "category": "Nutrition", "chartdate": "2157-01-19 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 654824, "text": "Current Wt: 72.4kg\n Pertinent medications: RISS, Famotidine, Folic Acid, Mvit, others noted\n Labs:\n Value\n Date\n Glucose\n 100 mg/dL\n 02:48 AM\n Glucose Finger Stick\n 155\n 10:00 AM\n BUN\n 25 mg/dL\n 02:48 AM\n Creatinine\n 1.0 mg/dL\n 02:48 AM\n Sodium\n 145 mEq/L\n 02:48 AM\n Potassium\n 4.2 mEq/L\n 02:48 AM\n Chloride\n 113 mEq/L\n 02:48 AM\n TCO2\n 22 mEq/L\n 02:48 AM\n PO2 (arterial)\n 99. mm Hg\n 02:58 AM\n PCO2 (arterial)\n 38 mm Hg\n 02:58 AM\n pH (arterial)\n 7.43 units\n 02:58 AM\n pH (urine)\n 5.0 units\n 05:00 PM\n CO2 (Calc) arterial\n 26 mEq/L\n 02:58 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 8.4 mg/dL\n 02:48 AM\n Phosphorus\n 3.4 mg/dL\n 02:48 AM\n Ionized Calcium\n 1.21 mmol/L\n 02:58 AM\n Magnesium\n 2.1 mg/dL\n 02:48 AM\n Phenytoin (Dilantin)\n 11.3 ug/mL\n 03:01 AM\n WBC\n 8.8 K/uL\n 02:48 AM\n Hgb\n 9.3 g/dL\n 02:48 AM\n Hematocrit\n 27.1 %\n 02:48 AM\n Current diet order / nutrition support: TF: Nutren 2.0 @ 30cchr + 30g\n protein (1547kcal, 84g protein)\n GI: +BS, +brown stool\n Assessment of Nutritional Status\n 53 y.o. M adm with SAH and IVH in left lateral ventricle. Pt continues\n on vent support via trach and is receiving TF via PEG. Pt\ns TF goal is\n meeting 100% of pt\ns needs, and was originally recommended because of\n pt\ns Hyponatremia. This is now improved, and pt will likely be able to\n tolerate a more standard formula (1kcal/mL). Will provide recs below.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec change TF to Replete with Fiber @ 65cc/hr (1560kcal, 97g\n protein).\n 2) Monitor lytes and hydration.\n 3) Monitor TF tolerance; check residuals q4hrs, hold only if\n >150cc.\n Following\n please page with ?\ns #\n" }, { "category": "Respiratory ", "chartdate": "2157-01-31 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656581, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 35\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt remains on current vent settings. See vent flow sheet for\n details. RSBI done on 0 peep/ 5 ips 48.Possible thoracentesis today fro\n bilat pleural effusions.Will cont to monitor rresp status.\n" }, { "category": "Physician ", "chartdate": "2157-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 656809, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH with IVH in left lateral ventricle\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment 6.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Olanzapine\n 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush 31. Thiamine\n 24 Hour Events:\n BRONCHOSCOPY - At 05:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.3\n HR: 86 (79 - 102) bpm\n BP: 131/69(85) {99/56(67) - 162/87(99)} mmHg\n RR: 23 (14 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,615 mL\n 723 mL\n PO:\n Tube feeding:\n 1,575 mL\n 489 mL\n IV Fluid:\n 440 mL\n 75 mL\n Blood products:\n Total out:\n 1,840 mL\n 405 mL\n Urine:\n 1,840 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 775 mL\n 318 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 449 (381 - 449) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ///27/\n Ve: 11 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities\n Labs / Radiology\n 404 K/uL\n 7.7 g/dL\n 117 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.5 %\n 9.5 K/uL\n [image002.jpg]\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n WBC\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n Hct\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n Plt\n 395\n 383\n 448\n 472\n 04\n Creatinine\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n Glucose\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n Other labs: PT / PTT / INR:13.6/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today, trach pressures adequate with small leak,\n IP bronched- no TBM. Pleural effusions too small to tap\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro for VAP 14 d course.\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery, CT surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:43 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: 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": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655584, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-02-01 00:00:00.000", "description": "Intensivist Note", "row_id": 656784, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH with IVH in left lateral ventricle\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment 6.\n Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Heparin 17. HydrALAzine 18. HydrALAzine 19. 20. Insulin 21.\n Influenza Virus Vaccine 22. Labetalol\n 23. Labetalol 24. Magnesium Sulfate 25. Metoclopramide 26. Midazolam\n 27. Multivitamins 28. Olanzapine\n 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush 31. Thiamine\n 24 Hour Events:\n BRONCHOSCOPY - At 05:10 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 07:48 AM\n Other medications:\n Flowsheet Data as of 07:31 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.2\nC (98.9\n T current: 36.8\nC (98.3\n HR: 86 (79 - 102) bpm\n BP: 131/69(85) {99/56(67) - 162/87(99)} mmHg\n RR: 23 (14 - 26) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,615 mL\n 723 mL\n PO:\n Tube feeding:\n 1,575 mL\n 489 mL\n IV Fluid:\n 440 mL\n 75 mL\n Blood products:\n Total out:\n 1,840 mL\n 405 mL\n Urine:\n 1,840 mL\n 405 mL\n NG:\n Stool:\n Drains:\n Balance:\n 775 mL\n 318 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 449 (381 - 449) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 68\n PIP: 10 cmH2O\n SPO2: 99%\n ABG: ///27/\n Ve: 11 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli, Noxious stimuli), Moves all\n extremities\n Labs / Radiology\n 404 K/uL\n 7.7 g/dL\n 117 mg/dL\n 1.0 mg/dL\n 27 mEq/L\n 4.2 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.5 %\n 9.5 K/uL\n [image002.jpg]\n 05:18 AM\n 02:12 AM\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n WBC\n 11.8\n 12.5\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n Hct\n 22.1\n 21.3\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n Plt\n 395\n 383\n 448\n 472\n 04\n Creatinine\n 1.4\n 1.4\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n Glucose\n 120\n 107\n 124\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n Other labs: PT / PTT / INR:13.6/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.5 mg/dL,\n Mg:1.9 mg/dL, PO4:4.6 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/)\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today, trach pressures adequate with small leak,\n IP to c/s for ?tracheal stent and ultrasound pleural effusions for\n possible tap\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro for VAP\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds:\n Imaging:\n Fluids:\n Consults: Neuro surgery, CT surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 10:43 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: 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": "2157-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654671, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Continues to have moderate to copious thick, white, secretions in oral\n and trach. Per SICU Team, Chest xray on LLL slightly worsened.\n Action:\n Brochoscopy at bedside. Sputum sample sent.\n Response:\n Pt continues to need subglottal and oral suctioning. Continues to have\n low-grade temps.\n Plan:\n Await for pending sputum cult. ? Antibiotic tx. Continue to\n administer pulmonary toileting.\n" }, { "category": "Physician ", "chartdate": "2157-01-18 00:00:00.000", "description": "Intensivist Note", "row_id": 654570, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \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 Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:35 PM\n Famotidine (Pepcid) - 08:23 PM\n Hydralazine - 12:19 AM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100.1\n HR: 100 (89 - 103) bpm\n BP: 150/66(95) {128/59(84) - 173/78(112)} mmHg\n RR: 19 (15 - 68) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,460 mL\n 371 mL\n PO:\n Tube feeding:\n 720 mL\n 196 mL\n IV Fluid:\n 340 mL\n 115 mL\n Blood products:\n Total out:\n 2,055 mL\n 905 mL\n Urine:\n 1,905 mL\n 905 mL\n NG:\n Stool:\n Drains:\n Balance:\n -595 mL\n -534 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 239 (203 - 374) mL\n PS : 14 cmH2O\n RR (Set): 12\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 27 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 96%\n ABG: 7.36/37/81./23/-3\n Ve: 6.9 L/min\n PaO2 / FiO2: 205\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 Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 314 K/uL\n 9.1 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 116 mEq/L\n 147 mEq/L\n 25.7 %\n 7.4 K/uL\n [image002.jpg]\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n WBC\n 8.5\n 8.6\n 7.5\n 7.4\n Hct\n 27.7\n 27.1\n 25.0\n 25.7\n Plt\n 398\n 300\n 297\n 314\n Creatinine\n 1.1\n 1.0\n 1.3\n 1.1\n TCO2\n 22\n 22\n 23\n 21\n 21\n 22\n Glucose\n 91\n 112\n 110\n 110\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: stable cerebral hemorrhages, s/p VPS, dilantin stopped\n Cardiovascular: goal SBP < 180, started on labetolol po for\n hypertension, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 20mg daily started\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds:\n Imaging:\n Fluids: NS, 75cc/h\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:17 AM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 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 rehab / long term facility\n Total time spent: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655052, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 mL /\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: Blood Tinged / Thick\n Sputum source/amount: Expectorated / Moderate\n Ventilation Assessment\n Level of breathing assistance: Intermittent invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing,\n Tachypneic (RR> 35 b/min); Comments: tried TM for 5 min pt became\n tachypnic RR 45\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: keep trying TM on pt, might be easier for pt after his\n effusions are tapped.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1:30 pm\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655062, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Balance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655064, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Balance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655065, "text": " Problem - Description In Comments\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Balance, Impaired\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-01-22 00:00:00.000", "description": "Intensivist Note", "row_id": 655286, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:45 AM\n Midazolam (Versed) - 05:01 AM\n Fentanyl - 05:01 AM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.3\nC (99.1\n HR: 87 (76 - 108) bpm\n BP: 105/50(70) {72/37(50) - 178/80(116)} mmHg\n RR: 24 (11 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,321 mL\n 558 mL\n PO:\n Tube feeding:\n 1,621 mL\n 163 mL\n IV Fluid:\n 541 mL\n 396 mL\n Blood products:\n Total out:\n 2,705 mL\n 200 mL\n Urine:\n 2,705 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -384 mL\n 358 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 498 (396 - 774) mL\n PS : 10 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 104\n PIP: 19 cmH2O\n SPO2: 96%\n ABG: 7.40/42/104/25/0\n Ve: 7.5 L/min\n PaO2 / FiO2: 260\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Wheezes : bilaterally)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 309 K/uL\n 8.5 g/dL\n 141 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 104 mEq/L\n 139 mEq/L\n 23.3 %\n 10.8 K/uL\n [image002.jpg]\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n 02:02 PM\n 02:14 PM\n 02:46 AM\n 02:56 AM\n WBC\n 10.6\n 11.0\n 12.2\n 10.8\n Hct\n 26.3\n 25.2\n 25.9\n 23.3\n Plt\n 326\n 290\n 318\n 309\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.2\n TCO2\n 27\n 26\n 25\n 28\n 28\n 27\n Glucose\n 107\n 87\n 121\n 141\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI\n Cardiovascular: goal SBP < 160, labetolol 400 tid, prn Hydral and IV\n labetolol, hypotensive requred fluid bolus o/n\n Pulmonary: Trach collar trials, bilat pleural effusions\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, PRN lasix, goal 1L negative\n Hematology: f/u Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures.\n repeat CBC, WBC increasing, vanc/zosyn started for presumed VAP\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655391, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt with eposides of tacypenic rr 60\ns, respiratory therapy\n into assess patient,\n Pt put on cpap with ps 10 with minimal effect, pt placed on cmv by\n resp. therapy, 02 sat dropped to 90% abg done p02 72 , resp therapy\n gave pt a recruitment breathe, sbp dropped to 77\n Action:\n Dr. into assess patient\n Pt received 250cc ns bolus\n Pt placed on 80% fio2\n Response:\n Sbp back up to 110-150 range\n 02 sat up to 97%\n Fi02 weaned back down to 40%\n Plan:\n Continue to monitor\n Keep sbp under 160\n Attempt to wean back to cpap with ps when pt can tolerate\n Hypertension, benign\n Assessment:\n This evening sbp up to 170-180\n Action:\n Dr. \n Pt received 10mg labetalol\n Response:\n Sbp dropped down to 170\ns pt received another 10mg of iv\n labetatol with effect.\n Plan:\n Continue to monitor\n To keep sbp less than 160\n" }, { "category": "Respiratory ", "chartdate": "2157-01-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655392, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 mL /\n Airway problems: Positional leak around cuff\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\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, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Recruitment Maneuvers Done\n CPAP pressure used: 15 cm H2O\n Duration: 30 sec\n Times per shift: 1\n Comments: Did not tolerate RM, significant drop in HR and BP\n Pt currently on CMV, had tachypnic episode with drop in sats, attempted\n recruitment did not tol. Required to switch to CMV ^fio2 and ^peep.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-25 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655729, "text": "Demographics\n Day of intubation: \n Day of mechanical ventilation: 29\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tube Type\n Tracheostomy tube:\n Type: Standard\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 mL /\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 / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655220, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens his eyes when you call his name\n Right pupil 3mm and briskly reactive to light, left pupil\n unable to access secondary to corneal ulcer\n Pt will intermittently follow commands\n Pt does spontaneously move left leg , left arm on bed,\n pt slightly withdraws right leg to painful stimuli\n Action:\n Response:\n Neuro signs unchanged\n Plan:\n Continue to monitor, check nuero signs as ordered, keep sbp\n less than 160\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt placed on trach collar\n prior to pt being placed on trach collar,suctioned for thick\n yellow secretions\n Action:\n within 5min , hr elevated, pt dropping 02 sats, pt became\n hypertensive, pt tacypenic\n Response:\n pt placed back on cpap with ps 10,peep 5\n Plan:\n continue to monitor, attempt to wean ps down to 5, pt\n started on vancomycin and zosyn.\n" }, { "category": "Physician ", "chartdate": "2157-01-18 00:00:00.000", "description": "Intensivist Note", "row_id": 654544, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \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 Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Fentanyl - 03:35 PM\n Famotidine (Pepcid) - 08:23 PM\n Hydralazine - 12:19 AM\n Heparin Sodium (Prophylaxis) - 12:30 AM\n Other medications:\n Flowsheet Data as of 06:36 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 37.8\nC (100.1\n HR: 100 (89 - 103) bpm\n BP: 150/66(95) {128/59(84) - 173/78(112)} mmHg\n RR: 19 (15 - 68) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,460 mL\n 371 mL\n PO:\n Tube feeding:\n 720 mL\n 196 mL\n IV Fluid:\n 340 mL\n 115 mL\n Blood products:\n Total out:\n 2,055 mL\n 905 mL\n Urine:\n 1,905 mL\n 905 mL\n NG:\n Stool:\n Drains:\n Balance:\n -595 mL\n -534 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 239 (203 - 374) mL\n PS : 14 cmH2O\n RR (Set): 12\n RR (Spontaneous): 2\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 27 cmH2O\n Plateau: 17 cmH2O\n Compliance: 50 cmH2O/mL\n SPO2: 96%\n ABG: 7.36/37/81./23/-3\n Ve: 6.9 L/min\n PaO2 / FiO2: 205\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 Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 314 K/uL\n 9.1 g/dL\n 110 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.1 mEq/L\n 22 mg/dL\n 116 mEq/L\n 147 mEq/L\n 25.7 %\n 7.4 K/uL\n [image002.jpg]\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n WBC\n 8.5\n 8.6\n 7.5\n 7.4\n Hct\n 27.7\n 27.1\n 25.0\n 25.7\n Plt\n 398\n 300\n 297\n 314\n Creatinine\n 1.1\n 1.0\n 1.3\n 1.1\n TCO2\n 22\n 22\n 23\n 21\n 21\n 22\n Glucose\n 91\n 112\n 110\n 110\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:1.9 mg/dL, PO4:3.4 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: stable cerebral hemorrhages, s/p VPS, dilantin stopped\n Cardiovascular: goal SBP < 180, started on labetolol po for\n hypertension, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 20mg daily started\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds:\n Imaging:\n Fluids: NS, 75cc/h\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:17 AM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 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 rehab / long term facility\n Total time spent: 35 minutes\n" }, { "category": "Rehab Services", "chartdate": "2157-01-20 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 655047, "text": "Subjective:\n pt non-verbal\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: s/p CT and CXR- pending\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\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 98\n 166/80\n 13\n 98% on CPAP\n Activity\n see below\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait: Pt requires total assist for rolling and supine-to-sit, unable to\n participate in mobility. transfer from bed to stretcher\n chair\n Balance: Maintains static sitting at EOB with mod-max A, uses LUE\n extension to prevent LOB to left. Improved head control in sitting\n initially, then limited by fatigue\n Education / Communication: Communicated with nsg re: status\n Other: CPAP 5/12 PEEP/PS\n at EOB BP 170/76, HR 90, 96%\n in stretcher chair: BP 94/49, HR 94, O2 98%\n Patient inconsistently squeezing hand on command, shaking head no,\n using yankauer to mouth\n Assessment: 53 yo M with ICH making good progress today in that he is\n able to tolerate sitting OOB in stretcher chair. Still inconsistent\n with level of arousal and responsiveness, as well as hypotension today\n when up to chair. Rehab potential still guarded at this time but would\n continue to recommend rehab upon d/c.\n Anticipated Discharge: Rehab\n Plan: Cont with POC\n" }, { "category": "Nursing", "chartdate": "2157-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655221, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt opens his eyes when you call his name\n Right pupil 3mm and briskly reactive to light, left pupil\n unable to access secondary to corneal ulcer\n Pt will intermittently follow commands\n Pt does spontaneously move left leg , left arm on bed,\n pt slightly withdraws right leg to painful stimuli\n Action:\n Response:\n Neuro signs unchanged\n Plan:\n Continue to monitor, check nuero signs as ordered, keep sbp\n less than 160\n Respiratory failure, acute (not ARDS/)\n Assessment:\n pt placed on trach collar\n prior to pt being placed on trach collar,suctioned for thick\n yellow secretions\n Action:\n within 5min , hr elevated, pt dropping 02 sats, pt became\n hypertensive, pt tacypenic\n Response:\n pt placed back on cpap with ps 10,peep 5\n Plan:\n continue to monitor, attempt to wean ps down to 5, pt\n started on vancomycin and zosyn.\n Goal is to have a liter negative\n" }, { "category": "Respiratory ", "chartdate": "2157-01-22 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655273, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 26\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 50 cmH2O\n Cuff volume: 8 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:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th bld tinged yellow\n sput. Pt in NARD on current settings able to wean PSV slightly ; no\n other vent changes required overnoc. Cont PSV/trach mask as tol.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655226, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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: Rhonchi\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 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: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Failed Trach Collar trial after 10min, ^rr with desat\n" }, { "category": "Physician ", "chartdate": "2157-02-02 00:00:00.000", "description": "Intensivist Note", "row_id": 657038, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n head bleed\n PMHx:\n HTN\n Current medications:\n . 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Ciprofloxacin HCl\n 11. Docusate Sodium (Liquid) 12. Escitalopram Oxalate 13. Famotidine\n 14. Fentanyl Citrate 15. FoLIC Acid\n 16. Furosemide 17. Heparin 18. HydrALAzine 19. HydrALAzine 20. 21.\n Insulin 22. Influenza Virus Vaccine\n 23. Labetalol 24. Labetalol 25. Magnesium Sulfate 26. Metoclopramide\n 27. Midazolam 28. Multivitamins\n 29. Nystatin Oral Suspension 30. Olanzapine 31. Potassium Chloride 32.\n Sodium Chloride 0.9% Flush\n 33. Thiamine\n 24 Hour Events:\n attempted Trach collar trials\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 07:48 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 01:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 04:00 AM\n Other medications:\n Flowsheet Data as of 06:55 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: 35.7\nC (96.3\n HR: 91 (65 - 99) bpm\n BP: 159/81(99) {86/50(58) - 163/97(112)} mmHg\n RR: 16 (12 - 29) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 69.6 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,390 mL\n 454 mL\n PO:\n Tube feeding:\n 1,580 mL\n 336 mL\n IV Fluid:\n 240 mL\n 69 mL\n Blood products:\n Total out:\n 1,815 mL\n 560 mL\n Urine:\n 1,815 mL\n 560 mL\n NG:\n Stool:\n Drains:\n Balance:\n 575 mL\n -106 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 591 (340 - 591) mL\n PS : 5 cmH2O\n RR (Spontaneous): 20\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 56\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///26/\n Ve: 10.6 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:\n Diminished: bases)\n Abdominal: Soft, Non-distended, Non-tender\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 408 K/uL\n 8.1 g/dL\n 118 mg/dL\n 1.0 mg/dL\n 26 mEq/L\n 4.1 mEq/L\n 39 mg/dL\n 104 mEq/L\n 138 mEq/L\n 22.6 %\n 11.9 K/uL\n [image002.jpg]\n 04:22 AM\n 03:31 PM\n 03:45 AM\n 01:47 AM\n 03:06 AM\n 02:35 AM\n 04:00 AM\n 02:37 AM\n 06:06 PM\n 02:54 AM\n WBC\n 17.0\n 12.5\n 12.1\n 12.7\n 10.6\n 9.5\n 11.9\n Hct\n 21.9\n 21.6\n 22.1\n 22.1\n 21.4\n 21.5\n 22.6\n Plt\n 448\n 472\n 469\n 482\n 438\n 404\n 408\n Creatinine\n 1.1\n 1.1\n 1.0\n 0.9\n 1.0\n 1.0\n 1.0\n 1.0\n 1.0\n Glucose\n 124\n 130\n 124\n 125\n 106\n 136\n 168\n 117\n 108\n 118\n Other labs: PT / PTT / INR:14.1/37.7/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.7 mg/dL,\n Mg:2.0 mg/dL, PO4:4.7 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, has periods of apnea for 15 seconds on\n CPAP, try trach collar today for 30 min periods, trach pressures\n adequate with small leak, IP no tracheal stent no thoracentesis\n Gastrointestinal / Abdomen: TFs at goal\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix prn\n Hematology: Hct stable\n Endocrine: RISS\n Infectious Disease: cipro() for VAP 14 day course\n Lines / Tubes / Drains: Foley, G-tube, Trach\n Wounds:\n Imaging:\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31\n Patient is critically ill\n" }, { "category": "Respiratory ", "chartdate": "2157-01-21 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655099, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 25\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments: Pt cont trached and on mech vent as per Metavision. Lung\n sounds rhonchi improve somewhat with suct for mod th bld tinged yellow\n sput. Pt in NARD on current settings able to wean PSV slightly ; no\n other vent changes required overnoc. Cont PSV/trach mask as tol.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655779, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. Pt now trach/PEG.\n H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n On PSimpaired gag and cough. Suctioned moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp but not on command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q2 hrs\n Response:\n No change in neuro checks\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Reconsider changing frequency of neuro checks.\n Hypertension, benign\n Assessment:\n Patient SBP 100-150\ns with HR 100 ST with out ectopy\n Action:\n Started gastric meds; Hydralazine and labetolol with SBP 120-145\n Response:\n Patient SBP within parameters\n Plan:\n Goal to keep SBP <160\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupils\n Action:\n Bacitracin and artificial tears applied, 2 sutures noted at end of eye\n Response:\n Pt keeping eyes open spontaneously with stimulation.\n Plan:\n Continue treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse, moderate-copious amount of yellow thick secretions.\n Strong cough effort Respiratory effort at times labored rr up to 40.\n CPAP settings unchanged\n Action:\n Intermittent suctioning, hob>30, prn diuresis.\n Response:\n Bilateral pleural effusion Pt tolerates suctioning and vent changes\n well.\n Plan:\n Continue diuresis with daily goal net neg 1l, Continue vent wean with\n goal of transition to trach mask as tolerated.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655781, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. s/p shunt Pt is now trach/PEG.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp but not on command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q2 hrs\n Response:\n No change in neuro checks\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Reconsider changing frequency of neuro checks.\n Hypertension, benign\n Assessment:\n Patient SBP 100-150\ns with HR 100 ST with out ectopy\n Action:\n Started gastric meds; Hydralazine and labetolol with SBP 120-145\n Response:\n Patient SBP within parameters\n Plan:\n Goal to keep SBP <160\n Rash\n Assessment:\n Scattered pink rash noted torso and all extremities, not raised or\n inflamed.\n Action:\n No treatment at this time.\n Response:\n Plan:\n Reassess new medications or possible causes of rash.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupils\n Action:\n Bacitracin and artificial tears applied, 2 sutures noted at end of eye\n Response:\n Pt keeping eyes open spontaneously with stimulation.\n Plan:\n Continue treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse, moderate-copious amount of yellow thick secretions.\n Strong cough. Respiratory effort at times labored rr up to 40. CPAP\n settings unchanged O2 sats 97-100% moderate cuff leak\n Action:\n Intermittent suctioning, hob>30, prn diuresis. ABG checked per order\n and CXR obtained\n Response:\n Bilateral pleural effusion Pt not tolerating suctioning\n Plan:\n Continue with current plan with possible increase in chest PT, decrease\n frequency of daily CXR.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655782, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. s/p VP shunt on . Pt is now\n trach/PEG on ventilator.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n with hand grasp but not on command. Soft wrist restraint on.\n Action:\n Neuro checks monitored Q2 hrs\n Response:\n No change in neuro checks\n Plan:\n Notify team of any decline in assessment; continue to reorient prn.\n Reconsider changing frequency of neuro checks.\n Hypertension, benign\n Assessment:\n Patient SBP 100-150\ns with HR 100 ST with out ectopy\n Action:\n Started gastric meds; Hydralazine and labetolol with SBP 120-145\n Response:\n Patient SBP within parameters\n Plan:\n Goal to keep SBP <160\n Rash\n Assessment:\n Scattered pink rash noted torso and all extremities, not raised or\n inflamed.\n Action:\n Observation of rash throughout the night.\n Response:\n No treatment at this time.\n Plan:\n Continue to observe changes rash, Reassess new medications or possible\n causes of rash.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy unable to assess pupils\n Action:\n Bacitracin and artificial tears applied, 2 sutures noted at end of eye\n Response:\n Pt keeping eyes open spontaneously with stimulation.\n Plan:\n Continue treatments as ordered, notify team of any change\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse, moderate-copious amount of yellow thick secretions.\n Strong cough. Respiratory effort at times labored rr up to 40. CPAP\n settings unchanged O2 sats 97-100% moderate cuff leak\n Action:\n Intermittent suctioning, hob>30, prn diuresis. ABG checked per order\n and CXR obtained\n Response:\n Bilateral pleural effusion Pt not tolerating suctioning\n Plan:\n Continue with current plan with possible increase in chest PT, decrease\n frequency of daily CXR.\n" }, { "category": "Physician ", "chartdate": "2157-01-25 00:00:00.000", "description": "Intensivist Note", "row_id": 655783, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine hemorrhage, vent dependent respiratory failure\n PMHx:\n hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. Caspofungin. Chlorhexidine\n Gluconate 0.12% Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid).\n Escitalopram Oxalate. Famotidine. Fentanyl Citrate. FoLIC Acid.\n Furosemide. Heparin. HydrALAzine. Insulin. Labetalol. Magnesium\n Sulfate. Midazolam. Multivitamins. Olanzapine. OxycoDONE-Acetaminophen\n Elixir. Piperacillin-Tazobactam Na. Potassium Chloride. Thiamine\n 24 Hour Events:\n tolerating CPAP/PSV, given lasix x 2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 07:54 AM\n Heparin Sodium (Prophylaxis) - 03:44 PM\n Other medications:\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.4\nC (99.4\n HR: 87 (68 - 103) bpm\n BP: 114/65(78) {74/50(55) - 165/88(109)} mmHg\n RR: 20 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,699 mL\n 732 mL\n PO:\n Tube feeding:\n 1,579 mL\n 444 mL\n IV Fluid:\n 790 mL\n 168 mL\n Blood products:\n Total out:\n 2,195 mL\n 135 mL\n Urine:\n 2,195 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 504 mL\n 598 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (316 - 536) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/40/106/24/0\n Ve: 11.7 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, left eye sutured\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: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished), (Pulse - Posterior tibial:\n Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), No(t) Moves all extremities, (RUE:\n No movement), (LUE: Weakness), (RLE: No movement), (LLE: Weakness),\n intermittently follows commands\n Labs / Radiology\n 395 K/uL\n 7.8 g/dL\n 120 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 31 mg/dL\n 105 mEq/L\n 137 mEq/L\n 22.1 %\n 11.8 K/uL\n [image002.jpg]\n 02:56 AM\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n WBC\n 14.5\n 13.3\n 11.8\n Hct\n 22.6\n 22.1\n 22.1\n Plt\n \n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n TCO2\n 27\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.7 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN\n (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL\n HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS, cont\n zyprexa and SSRI, prn versed for agitation\n CV: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Resp: stable on CPAP/PS, trach collar trials, bilat pleural effusions\n improved with diuresis, Klebsiella PNA, change to bovona trach\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n FEN: TFs\n Heme: Hct stable at 22\n Endo: RISS\n ID: sputum from with Klebsiella pneumonia (no yeast cultured),\n zosyn started for VAP, caspofungin started for in sputum, f/u\n cultures\n TLD: trach, foley, a-line, VPS, PEG, rt PICC\n Wound: left corneal ulcer (optho following)\n Prophylaxis: H2B, SQH\n Imaging: CXR\n Dispo: start screening for vented rehab. no insurance or health care\n proxy. social work following.\n Billing Diagnosis: pontine hemorrhage, vent dependent respiratory\n failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:07 AM 65.\n mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: famotidine\n VAP bundle: ++\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 minutes\n" }, { "category": "General", "chartdate": "2157-02-02 00:00:00.000", "description": "Generic Note", "row_id": 657017, "text": "TITLE: Evaluation\n Pt seen for evaluation. He is safe to trial the valve for short\n periods of time, but cuff should not be deflated for extended periods\n of time given aspiration of oral secretions. Pt must be supervised by\n SLP, RT or RN with the valve in place. Please see Web OMR for\n additional details.\n , MS, CCC-SLP\n Pager#\n 10:24\n" }, { "category": "Rehab Services", "chartdate": "2157-01-25 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 655819, "text": "Attending Physician: \n Referral date: \n Medical Diagnosis / ICD 9: ICH /\n Reason of referral: RE-EVAL\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , VP\n shunt and PICC line placed . PT has been following pt \n Past Medical / Surgical History: See intial evaluatoin\n Medications: HydrALAzine, Labetalol, ChlorproMAZINE,\n OxycoDONE-Acetaminophen Elixir\n Radiology: CXR : In comparison with the study of , the\n monitoring and support devices remain in place. Cardiomediastinal\n contours are stable. Patchy right upper lobe opacity is again seen,\n presumably related to infection as suggested on the recent CT scan.\n More symmetric bilateral perihilar and basilar opacities may reflect\n pulmonary edema with layering of bilateral pleural effusions\n Labs:\n 22.1\n 7.8\n 395\n 11.8\n [image002.jpg]\n Other labs:\n Activity Orders: OOB c A\n Social / Occupational History: See intial eval\n Living Environment: See intial eval\n Prior Functional Status / Activity Level: See intial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: Pt eyes open t/o eval,\n Pt followed < 10% of 1 step command might have sqeezed L hand however\n inconsistant.\n Hemodynamic Response\n Aerobic Capacity\n HR\n BP\n RR\n O[2 ]sat\n HR\n BP\n RR\n O[2] sat\n RPE\n Supine\n /\n Rest\n /\n Sit\n /\n Activity\n /\n Stand\n /\n Recovery\n /\n Total distance walked:\n Minutes:\n Pulmonary Status: CPAP PEEP 10 PSV 12 TV. 530-.850. Pt inline suctioned\n at EOB for scant amounts of thin white sputum, pt had large amounts of\n saliva at EOB.\n Integumentary / Vascular: Trach, PEG, L scalp incision intact, foley,\n PICC\n Sensory Integrity: No withdraw to pain R UE or LE, unable to accurately\n assess L UE and LE pt does responde however no locilized response\n Pain / Limiting Symptoms: No signs of discomfort t/o eval\n Posture: Increased thoracic kyphosis\n Range of Motion\n Muscle Performance\n B UE and LE WFL\n Cervical L rotatoin and R lateral flexion limited\n Pt spontaneously moving L UE and LE in bed and against gravity, no\n movement of R UE or LE\n Motor Function: 1+ flexor tone L UE and L LE. Flaccid R UE/LE. Minimal\n visual tracking within R field, nystagmus with R gaze. Pt picking at\n objects with L UE.\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: Pt was slide to stretcher chair with A x 3.\n Rolling:\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\n\n Ambulation:\n\n\n\n\n\n Stairs:\n\n\n\n\n\n Balance: Pt required Mod-Max A to maintain balance at EOB, poor head\n and neck control. Pt inconsistanly using L UE on bed rail to assist\n with balance. Posterior L LOB when unsupported\n Education / Communication: Pt status discussed with RN, made aware of\n BP changes with OOB. Pt was seen with RN.\n Intervention:\n Other:\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performace, Impaired\n Clinical impression / Prognosis:\n Goals\n Time frame:\n 1.\n 2.\n 3.\n 4.\n 5.\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration:\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655618, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 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/ Plan\n Pt remains trached, vent supported. No changes made overnight. No\n RSBI secondary to peep 10. See flowsheet for further pt data. Will\n follow.\n AM\n" }, { "category": "Physician ", "chartdate": "2157-01-25 00:00:00.000", "description": "Intensivist Note", "row_id": 655801, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine hemorrhage, vent dependent respiratory failure\n PMHx:\n hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. Caspofungin. Chlorhexidine\n Gluconate 0.12% Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid).\n Escitalopram Oxalate. Famotidine. Fentanyl Citrate. FoLIC Acid.\n Furosemide. Heparin. HydrALAzine. Insulin. Labetalol. Magnesium\n Sulfate. Midazolam. Multivitamins. Olanzapine. OxycoDONE-Acetaminophen\n Elixir. Piperacillin-Tazobactam Na. Potassium Chloride. Thiamine\n 24 Hour Events:\n tolerating CPAP/PSV, given lasix x 2\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Other ICU medications:\n Famotidine (Pepcid) - 07:54 AM\n Heparin Sodium (Prophylaxis) - 03:44 PM\n Flowsheet Data as of 06:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.4\nC (99.4\n T current: 37.4\nC (99.4\n HR: 87 (68 - 103) bpm\n BP: 114/65(78) {74/50(55) - 165/88(109)} mmHg\n RR: 20 (11 - 30) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,699 mL\n 732 mL\n PO:\n Tube feeding:\n 1,579 mL\n 444 mL\n IV Fluid:\n 790 mL\n 168 mL\n Blood products:\n Total out:\n 2,195 mL\n 135 mL\n Urine:\n 2,195 mL\n 135 mL\n NG:\n Stool:\n Drains:\n Balance:\n 504 mL\n 598 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 519 (316 - 536) mL\n PS : 10 cmH2O\n RR (Spontaneous): 24\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 20 cmH2O\n SPO2: 98%\n ABG: 7.41/40/106/24/0\n Ve: 11.7 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, left eye sutured\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: No(t) Absent, Trace), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished), (Pulse - Posterior tibial:\n Diminished)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli, Noxious stimuli), No(t) Moves all extremities, (RUE:\n No movement), (LUE: Weakness), (RLE: No movement), (LLE: Weakness),\n intermittently follows commands\n Labs / Radiology\n 395 K/uL\n 7.8 g/dL\n 120 mg/dL\n 1.4 mg/dL\n 24 mEq/L\n 4.3 mEq/L\n 31 mg/dL\n 105 mEq/L\n 137 mEq/L\n 22.1 %\n 11.8 K/uL\n [image002.jpg]\n 02:56 AM\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n WBC\n 14.5\n 13.3\n 11.8\n Hct\n 22.6\n 22.1\n 22.1\n Plt\n \n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n TCO2\n 27\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.7 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN\n (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL STATUS (NOT\n DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL\n HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS, cont\n zyprexa and SSRI, prn versed for agitation\n CV: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Resp: stable on CPAP/PS, trach collar trials, bilat pleural effusions\n improved with diuresis, Klebsiella PNA, change to bovona trach\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n FEN: TFs\n Heme: Hct stable at 22\n Endo: RISS\n ID: sputum from with Klebsiella pneumonia (no yeast cultured),\n zosyn started for VAP, stopped caspofungin, f/u cultures\n TLD: trach, foley, a-line, VPS, PEG, rt PICC\n Wound: left corneal ulcer (optho following)\n Prophylaxis: H2B, SQH\n Imaging: CXR\n Dispo: start screening for vented rehab. no insurance or health care\n proxy. social work following.\n Billing Diagnosis: pontine hemorrhage, vent dependent respiratory\n failure\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 01:07 AM 65.\n mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: famotidine\n VAP bundle: ++\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: SICU\n Total time spent: 31 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-20 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654919, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 24\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tracheostomy tube:\n Type: Standard, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: 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: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: Pt cannot tolerate RSBI at this time, rate goes to above 55\n Breaths per mintute in under 20 sec.\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2157-01-23 00:00:00.000", "description": "Intensivist Note", "row_id": 655432, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12%\n Oral Rinse, ChlorproMAZINE, Docusate Sodium (Liquid), Escitalopram\n Oxalate, Famotidine, Fentanyl Citrate, FoLIC Acid, Heparin,\n HydrALAzine, Insulin, Labetalol, Magnesium Sulfate, Multivitamins,\n Olanzapine, OxycoDONE-Acetaminophen Elixir, Piperacillin-Tazobactam Na,\n Potassium Chloride,Thiamine, Vancomycin\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n : pan cultured, required multiple fluid bolus, decreased antiHTN\n meds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:08 AM\n Flowsheet Data as of 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.4\n T current: 38\nC (100.4\n HR: 72 (72 - 111) bpm\n BP: 94/48(64) {78/41(53) - 187/80(117)} mmHg\n RR: 19 (13 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 3,467 mL\n 338 mL\n PO:\n Tube feeding:\n 1,597 mL\n 206 mL\n IV Fluid:\n 1,690 mL\n 132 mL\n Blood products:\n Total out:\n 2,075 mL\n 270 mL\n Urine:\n 2,075 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,392 mL\n 68 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 501 (501 - 664) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 160\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/36/72/25/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: No(t) Rhonchorous : , Diminished:\n )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli)\n Labs / Radiology\n 309 K/uL\n 8.5 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 23.3 %\n 10.8 K/uL\n [image002.jpg]\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n 02:02 PM\n 02:14 PM\n 02:46 AM\n 02:56 AM\n 01:22 PM\n 01:50 PM\n WBC\n 11.0\n 12.2\n 10.8\n Hct\n 25.2\n 25.9\n 23.3\n Plt\n 290\n 318\n 309\n Creatinine\n 1.1\n 1.0\n 1.2\n 1.3\n TCO2\n 26\n 25\n 28\n 28\n 27\n 25\n Glucose\n 87\n 121\n 141\n 108\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.4 mg/dL,\n Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI\n Cardiovascular: goal SBP < 160, hypotensive requred fluid bolus and\n albumin. Decreased labetolol to 300'''/hydral 25'''. With increased\n PEEP and dropped BP. Gave 500 ml NS bolus\n Pulmonary: Trach collar trials, bilat pleural effusions IP does not\n want to tap. Dropped sats (likely to atelectasis) after tachypnic\n episode and placed back on CMV. f/u CXR. will wean in AM\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, PRN lasix, euvolemic today\n Hematology: f/u Hct, checking B12, folte, retic count\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date including BAL\n with oropharyngeal flora believed to be from microaspiration.\n vanc/zosyn started for presumed VAP. vanc level 12, considering\n increasing dosage for levels closer to 15 for better lung penetration.\n temp spike and pan cx'd\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: multiple fluid bolus\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:16 AM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 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: Transfer to rehab / long term facility\n Total time spent: 32 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655776, "text": "53M with pontine SAH with IVH in left lateral ventricle with Incidental\n 2mm aneurysm of right basilar artery. Pt is trached/PEG.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Patient failed extubation , Reintubated on CPAP. Tolerating well.\n However patient continues to have impaired gag and cough. Suctioned\n moderated amount of secretions.\n Action:\n Patient to remain intubated, on current settings as tolerated\n Response:\n Patient is tolerating current vent settings, on no sedation.\n Plan:\n Patient to have a trach placed for airway protection.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Patient will open eyes to speech and on occasion will open eyes\n spontaneously. Right pupil 3cm/brisk reaction to light and left pupil\n unable to assess. Patient not following commands. Moving left arm/hand\n non purposely soft wrist restraint on.\n Action:\n Neuro checks monitored Q2 hrs\n Response:\n No change in neuro checks\n Plan:\n Hypertension, benign\n Assessment:\n Patient SBP >140\n Action:\n Iv hydralazine enalapril and lopressor given. also iv nicardipine\n started to maintain SBP<140\n Response:\n Patient SBP within parameters\n Plan:\n To keep SBP within parameters. Wean off iv nicardipine.\n Patient unable to protect airway, so will have trach and peg placed.\n Rash\n Assessment:\n Action:\n Response:\n Plan:\n Altered mental status (not Delirium)\n Assessment:\n Patient occasionally opening eyes to voice. Inconsistently follows\n commands. Discussed with nmed resident, exam similar to recent\n baseline. Able to move right arm & leg, no movement left side. Pupils\n ~ 2mm equal and brisk. ICP ranging , vent drain with moderate\n amount blood tinged drainage. Patient not sedated, does not appear in\n pain. Restless with stimulation, becoming tachycardic & tachypneic.\n No gag noted, but patient has strong cough.\n Action:\n Continued with neuro checks every 2 hours.\n Response:\n Plan:\n ? Trach , will need consent. Continue to follow neuro exam.\n Hypertension, benign\n Assessment:\n Patient\ns sbp ranging 100-150\ns, nicardipine gtt on most of the shift.\n Patient also on hydralazine, enalapril, & lopressor.\n Action:\n Nicardipine gtt titrated for goal sbp < 140.\n Response:\n Patient\ns sbp now ranging 130-140\n Plan:\n ? change antihypertensives to PO (tolerating tube feeds). Continue to\n follow vitals.\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy\n Action:\n Bacitracin and artifical tears applied as ordered\n Attempt to put steri-strips to keep left eye closed\n Response:\n Pt keeping eyes open spontanously\n Plan:\n Continue with current plan.\n 53yr old male s/p SAH with IVH in left lateral ventricle. Now s/p trach\n and peg and VP shunt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse, secretions blood tinged in moderate amount. Respiratory\n effort unlabored.\n Action:\n Chest CT, intermittent suctioning, hob>30, diuresed with 20mg lasix\n IVP. Placed on Cpap/ps\n Response:\n Bilateral pleural effusion by CT to small to tap per IP. Pt tolerates\n suctioning and vent changes well.\n Plan:\n Continue diuresis with daily goal net neg 1l, Continue vent wean with\n goal of transition to trach mask as tolerated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Right pupil briskly reactive to light, 2mm. Unable to assess left pupil\n corneal abrasion. Nods head to yes/no questions with response\n delayed. Unable to follow commands, moves left arm purposefully.\n Action:\n Neuro assessment q4yrs, reoriented pt to course of events, day/day and\n time and surroundings.\n Response:\n Neuro assessment unchanged.\n Plan:\n Notify team of any decline in assessment, continue to reorient prn.\n Problem\n Corneal abrasion O.S.\n Assessment:\n Left eye sclera Injected, cornea opaque\n Action:\n Aqua tear and bacitracin ointments as ordered.\n Response:\n No change noted in assessment\n Plan:\n Continue treatments as ordered, notify team of any change,\n Ophthalmology service following.\n" }, { "category": "Nursing", "chartdate": "2157-01-25 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655858, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt opens eyes spontaneously, R pupil is 3mm equal and\n reactive, L pupil is unable to assess\n - pt moves L arm and leg spontaneously, will reach for his\n trach, inconsistently following commands\n - flexes R leg to nail bed, and no response from RUE\n Action:\n - neuro checks changed to q4h\n - eye ointment and artifical tears applied as ordered\n Response:\n - neuro status unchanged throughout shift\n Plan:\n - continue q4h neuro checks\n - continue with eye care\n Rash\n Assessment:\n - rash covering pts chest, torso, arms, legs, and buttocks\n - rash consists of tiny red pinpoint spots, not raised\n Action:\n - notified team\n team assessed pts rash on rounds\n - Zosyn stopped ? drug rash ?\n Response:\n - no response noted at this time\n Plan:\n - continue frequent turning, repositioning and skin care\n Hypertension, benign\n Assessment:\n - SBP elevated to 180s\n Action:\n - hydralazine IV 10mg given\n Response:\n - SBP decreased to 130s\n Plan:\n - continue to monitor BP\n - goal SBP < 60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - ? slight leak in trach\n - Pt has copious amts of oral secretions\n Action:\n - trach inserted to take place of reg trach\n - ventilator settings changed to CPAP 10 and 10\n - frequent suctioning and mouth care\n Response:\n - pt has moderate amts of thick yellow secretions suctioned\n out\n - pt has copious thin, clear oral secretions\n Plan:\n - continue with frequent suctioning and mouth care\n - continue with frequent turning and repositioning\n - monitor pt with changes in vent settings\n Tachycardia, Other\n Assessment:\n - pt tachycardic to 120s\n Action:\n - lopressor 2.5mg IV given\n Response:\n - HR decreased to reg rate\n Plan:\n - continue to monitor and treat tachycardia\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656051, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough), Tachycardia, and Tachypnea\n Assessment:\n - Pt is trached, vent settings have been decreased all day,\n PEEP down to 5 from 10, with pressure support at 10.\n - Pt became tachycardic when tried on trach mask this\n afternoon\n - Pt also became tachypneic to 50s-60s when turned onto R side\n Action:\n - given labatelol 10mg for HR control\n - given Fentanyl 25mcg for ? of pain and discomfort\n - given versed 0.5mg for ? anxiety\n - Pt repositioned to supine\n - Suctioned pt multiple times throughout tachypneic episode\n Response:\n - HR decreased to 98-100 after actions performed in the order\n stated above\n Plan:\n - continue to assess and treat tachycardia and tachypnea\n - continue to turn and reposition\n" }, { "category": "Respiratory ", "chartdate": "2157-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654850, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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: 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: Intolerant of\n weaning attempts\n" }, { "category": "Social Work", "chartdate": "2157-01-20 00:00:00.000", "description": "Social Work Progress Note", "row_id": 655029, "text": "Continuing to work with patients and friend with re: to\n guardianship for pt who remains minimally responsive and vent\n dependent. and friend have started to go through the pt\n paperwork and have found documentation that pt\ns insurance is termed,\n with it was a request form for pt to elect COBRA. At this moment the\n mother the only person who the insurance company may work with to\n enroll pt in COBRA.\n Mother is currently in rehab, received a call from rehab social worker\n who got permission from pt\ns mother for us to discuss\n planning for both pt and mother. Social worker from facility states\n that she is willing to work with the pt\ns mother to contact \n Insurance co. Worker felt that it may be therapeutic for the mother to\n feel that she can do something to help her son.\n and friend have enlisted the help of a elder planning service to\n assist them in organizing the legal and health matters for the family.\n" }, { "category": "Nursing", "chartdate": "2157-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655434, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on q2h neuro checks, following commands inconsistently, rt pupil 2mm\n & sluggish reaction, lt pupil unable to assess d/o corneal abration.rt\n side not moving.\n Action:\n Neuro checks q2h, SBP goal <160, t max 103.6, urine c/s sent, Tylenol\n prn given\n Response:\n Unchanged neuro status, fever down to 100.4 after Tylenol and bath.\n Plan:\n Cont monitoring, neuron checks, SBP goal <160, fluid boluses for\n hypotension\n Hypotension (not Shock)\n Assessment:\n Noted pt\ns SBP 86-89 after po anti HT meds\n Action:\n SICU MD informed, fluid bolus of NS 250ml per order.\n Response:\n SBP to 120-130\ns after fluid bolus\n Plan:\n Cont monitoring, fluid boluses prn.\n Problem - Description In Comments\n Assessment:\n Pt with h/o corneal abration.eye is still red and clouded\n Action:\n Bacitracin eye oint and tears natural applied per order., tried to put\n steristripes on eye lid , but pt opens eye and not able to keep it\n closed\n Response:\n Eye is still red and clouded\n Plan:\n Cont eye treatments per order.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655543, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 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:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655931, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n - pt opens eyes spontaneously, R pupil is 3mm equal and\n reactive, L pupil is unable to assess\n - pt moves L arm and leg spontaneously, will reach for his\n trach, inconsistently following commands\n - flexes R leg to nail bed, and no response from RUE\n Action:\n - neuro checks changed to q4h\n - eye ointment and artifical tears applied as ordered\n Response:\n - neuro status unchanged throughout shift\n Plan:\n - continue q4h neuro checks\n - continue with eye care\n Rash\n Assessment:\n - rash covering pts chest, torso, arms, legs, and buttocks\n - rash consists of tiny red pinpoint spots, not raised\n Action:\n - notified team\n team assessed pts rash on rounds\n - Zosyn stopped ? drug rash ?\n Response:\n - no response noted at this time\n Plan:\n - continue frequent turning, repositioning and skin care\n Hypertension, benign\n Assessment:\n - SBP elevated to 180s\n Action:\n - hydralazine IV 10mg given\n Response:\n - SBP decreased to 130s\n Plan:\n - continue to monitor BP\n - goal SBP < 60\n Respiratory failure, acute (not ARDS/)\n Assessment:\n - ? slight leak in trach\n - Pt has copious amts of oral secretions\n Action:\n - trach inserted to take place of reg trach\n - ventilator settings changed to CPAP 10 and 10\n - frequent suctioning and mouth care\n Response:\n - pt has moderate amts of thick yellow secretions suctioned\n out\n - pt has copious thin, clear oral secretions\n Plan:\n - continue with frequent suctioning and mouth care\n - continue with frequent turning and repositioning\n - monitor pt with changes in vent settings\n Tachycardia, Other\n Assessment:\n - pt tachycardic to 120s\n Action:\n - lopressor 2.5mg IV given\n Response:\n - HR decreased to reg rate\n Plan:\n - continue to monitor and treat tachycardia\n" }, { "category": "Physician ", "chartdate": "2157-01-26 00:00:00.000", "description": "Intensivist Note", "row_id": 655967, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Infusions:\n Other ICU medications:\n Hydralazine - 04:00 PM\n Metoprolol - 04:05 PM\n Heparin Sodium (Prophylaxis) - 04:06 PM\n Famotidine (Pepcid) - 08:30 PM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.2\nC (100.8\n T current: 37.7\nC (99.9\n HR: 98 (87 - 109) bpm\n BP: 156/84(101) {97/52(65) - 169/88(109)} mmHg\n RR: 18 (13 - 45) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,458 mL\n 627 mL\n PO:\n Tube feeding:\n 1,574 mL\n 405 mL\n IV Fluid:\n 423 mL\n 62 mL\n Blood products:\n Total out:\n 1,050 mL\n 655 mL\n Urine:\n 1,050 mL\n 655 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,408 mL\n -28 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 571 (549 - 682) mL\n PS : 10 cmH2O\n RR (Spontaneous): 14\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI Deferred: PEEP > 10\n PIP: 21 cmH2O\n SPO2: 99%\n ABG: ///23/\n Ve: 10.8 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 383 K/uL\n 7.8 g/dL\n 107 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.3 %\n 12.5 K/uL\n [image002.jpg]\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n WBC\n 14.5\n 13.3\n 11.8\n 12.5\n Hct\n 22.6\n 22.1\n 22.1\n 21.3\n Plt\n 83\n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n 1.4\n TCO2\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.0 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach\n Gastrointestinal / Abdomen: NPO, TF\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Hct 21\n Endocrine: RISS\n Infectious Disease: sputum from with Klebsiella pneumonia (no\n yeast cultured), cipro started for VAP\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC\n Wounds: left corneal ulcer (optho following)\n Imaging:\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:11 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nutrition", "chartdate": "2157-01-26 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 655973, "text": "Adm Wt: 67kg\n Current Wt: 71kg\n Pertinent medications: RISS, Mvit, Thaimine, Folic Acid, FAmotidine,\n Reglan, Abd, Colace, Heparin, others noted\n Labs:\n Value\n Date\n Glucose\n 107 mg/dL\n 02:12 AM\n Glucose Finger Stick\n 152\n 10:00 AM\n BUN\n 36 mg/dL\n 02:12 AM\n Creatinine\n 1.4 mg/dL\n 02:12 AM\n Sodium\n 138 mEq/L\n 02:12 AM\n Potassium\n 4.5 mEq/L\n 02:12 AM\n Chloride\n 105 mEq/L\n 02:12 AM\n TCO2\n 23 mEq/L\n 02:12 AM\n PO2 (arterial)\n 106 mm Hg\n 04:54 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:54 AM\n pH (arterial)\n 7.41 units\n 04:54 AM\n pH (urine)\n 5.5 units\n 02:29 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 04:19 AM\n Calcium non-ionized\n 9.0 mg/dL\n 02:12 AM\n Phosphorus\n 3.9 mg/dL\n 02:12 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:10 AM\n Magnesium\n 2.1 mg/dL\n 02:12 AM\n Phenytoin (Dilantin)\n 11.3 ug/mL\n 03:01 AM\n WBC\n 12.5 K/uL\n 02:12 AM\n Hgb\n 7.8 g/dL\n 02:12 AM\n Hematocrit\n 21.3 %\n 02:12 AM\n Current diet order / nutrition support: TF: Replete with Fiber @\n 65cc/hr (1560kcal, 97g protein)\n GI: abd soft, +BS\n Assessment of Nutritional Status\n 53 y.o. M with pontine SAH with IVH in left lateral ventricle.\n Incidental 2mm aneurysm of right basilar artery. Pt s/p trach and PEG\n placement (), remains on vent support and receiving TF at goal for\n nutrition support. Pt is tolerating current TF, which is meeting 100%\n of estimated needs.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec continue with current TF rx, no changes recommended at\n this time.\n 2) Cont. with 60cc H20 flushes q4hrs.\n 3) Will follow\n please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2157-01-26 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656048, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough), Tachycardia, and Tachypnea\n Assessment:\n - Pt is trached, vent settings have been decreased all day,\n PEEP down to 5 from 10, with pressure support at 10.\n - Pt became tachycardic when tried on trach mask this\n afternoon\n - Pt also became tachypneic to 50s-60s when turned onto R side\n Action:\n - given labatelol 10mg for HR control\n - given Fentanyl 25mcg for ? of pain and discomfort\n - given versed 0.5mg for ? anxiety\n - Pt repositioned to supine\n - Suctioned pt multiple times throughout tachypneic episode\n Response:\n - HR decreased to 98-100 after actions performed in the order\n stated above\n Plan:\n - continue to assess and treat tachycardia and tachypnea\n - continue to turn and reposition\n" }, { "category": "Nursing", "chartdate": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655615, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt is alert, following commands inconsistently, purposeful movements,\n PERL. Lt eye still red, rt hand not moving, rt leg slight ly\n withdrawing to pain\n Action:\n Neuro checks q2h, SBP goal<160, reoriented with place and time and\n activities, versed 1mg x2 as pt is widely awake and SBP 170\n Response:\n Unchanged neuro stastus,SBP <160 with regular Po meds and versed , no\n prn\ns anti HT meds given overnight,\n Plan:\n Cont monitoring, neurochecks q2h, SBP <160, wean vent as tolerates,\n support to pt and family, social work and case manager involvement for\n further care after discharge from hosp.\n" }, { "category": "Nursing", "chartdate": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655706, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Patient 500cc positive this am. Urine output adequate.\n Action:\n Given 10 mg lasix IV x1 and 20 mg lasix IV\n Response:\n patient almost even in afternoon, urine output decreased from 100cc/hr\n to 30 cch/hr. then 500 cc positive again by 1600.\n Plan:\n continue to monitor, make patient 500 cc negative today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient suctioned for moderate amounts of thick yellow secretions.\n Breath sounds clear but diminished at bases.\n Action:\n Given lasix x 2 to take off some fluid, suctioned and repositioned\n frequently, chest PT. Continues on antibiotics.\n Response:\n pending.\n Plan:\n continue to monitor.\n" }, { "category": "Physician ", "chartdate": "2157-01-27 00:00:00.000", "description": "Intensivist Note", "row_id": 656125, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12%\n Oral Rinse, ChlorproMAZINE, Ciprofloxacin HCl, Docusate Sodium\n (Liquid), Escitalopram Oxalate, Famotidine, Fentanyl Citrate, FoLIC\n Acid, Heparin, HydrALAzine, Insulin, Labetalol, Magnesium Sulfate,\n Metoclopramide, Midazolam, Multivitamins, Olanzapine,\n OxycoDONE-Acetaminophen Elixir, Thiamine\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Caspofungin - 05:55 PM\n Piperacillin/Tazobactam (Zosyn) - 12:06 AM\n Piperacillin - 08:00 AM\n Ciprofloxacin - 08:30 PM\n Other ICU medications:\n Labetalol - 05:10 PM\n Fentanyl - 11:30 PM\n Heparin Sodium (Prophylaxis) - 11:55 PM\n Midazolam (Versed) - 05:04 AM\n Flowsheet Data as of 05:16 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: 36.6\nC (97.8\n HR: 104 (71 - 115) bpm\n BP: 149/77(94) {91/50(60) - 162/85(104)} mmHg\n RR: 20 (13 - 35) insp/min\n SPO2: 98%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 70.3 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,274 mL\n 389 mL\n PO:\n Tube feeding:\n 1,584 mL\n 339 mL\n IV Fluid:\n 111 mL\n Blood products:\n Total out:\n 2,153 mL\n 440 mL\n Urine:\n 2,153 mL\n 440 mL\n NG:\n Stool:\n Drains:\n Balance:\n 121 mL\n -51 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 375 (286 - 684) mL\n PS : 10 cmH2O\n RR (Spontaneous): 28\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 16 cmH2O\n SPO2: 98%\n ABG: ////\n Ve: 11.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Diminished: )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 2+)\n Right Extremities: (Edema: 2+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n Moves all extremities\n Labs / Radiology\n 383 K/uL\n 7.8 g/dL\n 107 mg/dL\n 1.4 mg/dL\n 23 mEq/L\n 4.5 mEq/L\n 36 mg/dL\n 105 mEq/L\n 138 mEq/L\n 21.3 %\n 12.5 K/uL\n [image002.jpg]\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n 04:54 AM\n 05:18 AM\n 02:12 AM\n WBC\n 14.5\n 13.3\n 11.8\n 12.5\n Hct\n 22.6\n 22.1\n 22.1\n 21.3\n Plt\n 83\n Creatinine\n 1.3\n 1.4\n 1.1\n 1.4\n 1.4\n TCO2\n 25\n 24\n 26\n Glucose\n 108\n 103\n 190\n 137\n 133\n 120\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:75.7 %, Lymph:8.2 %, Mono:9.3 %,\n Eos:6.7 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.0 mg/dL,\n Mg:2.1 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n TACHYCARDIA, OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA\n (LOW SODIUM, HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER,\n AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND\n COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED,\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED\n MENTAL STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT\n ARDS/), INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n SSRI, prn versed for agitation\n Cardiovascular: goal SBP < 160, labetolol to 300 tid, hydral 25 tid\n Pulmonary: stable on CPAP/PS, trach collar trials, bilat pleural\n effusions improved with diuresis, Klebsiella PNA, changed to bovona\n trach, albuterol prn\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, lasix 10mg/20mg, goal 500cc negative\n Hematology: Serial Hct, Hct drifting down\n Endocrine: RISS\n Infectious Disease:\n Lines / Tubes / Drains: trach, foley, PEG, rt PICC, TPA for PICC line,\n repeat sputum culture\n Wounds: left corneal ulcer (optho following)\n Imaging: none\n Fluids: KVO\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 09:45 PM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 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: Transfer to rehab / long term facility\n Total time spent: 34 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-21 00:00:00.000", "description": "Intensivist Note", "row_id": 655168, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH\n PMHx:\n ?hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. Chlorhexidine Gluconate 0.12%\n Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid). Famotidine.\n Fentanyl Citrate. FoLIC Acid. Furosemide. Heparin. HydrALAzine.\n Insulin. Labetalol. Magnesium Sulfate. Midazolam. Multivitamins.\n Olanzapine. OxycoDONE-Acetaminophen. Potassium Chloride. Thiamine\n 24 Hour Events:\n Lasix diuresis of 1L negative\n Became tachypneic on trach , placed back on CPAP/PS\n Chest CT yesterday showed bilateral effusion, IP does not want to tap\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Labetalol - 02:30 AM\n Furosemide (Lasix) - 04:45 AM\n Midazolam (Versed) - 05:01 AM\n Fentanyl - 05:01 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.8\nC (98.3\n HR: 88 (79 - 104) bpm\n BP: 150/69(99) {128/53(85) - 184/88(126)} mmHg\n RR: 21 (11 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,670 mL\n 535 mL\n PO:\n Tube feeding:\n 1,150 mL\n 412 mL\n IV Fluid:\n 340 mL\n 63 mL\n Blood products:\n Total out:\n 2,740 mL\n 610 mL\n Urine:\n 2,740 mL\n 610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,070 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (376 - 676) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 104\n PIP: 17 cmH2O\n SPO2: 98%\n ABG: 7.44/40/134/24/3\n Ve: 6.4 L/min\n PaO2 / FiO2: 335\n Physical Examination\n Labs / Radiology\n 290 K/uL\n 9.0 g/dL\n 87 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 107 mEq/L\n 142 mEq/L\n 25.2 %\n 11.0 K/uL\n [image002.jpg]\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n WBC\n 7.4\n 8.8\n 10.6\n 11.0\n Hct\n 25.7\n 27.1\n 26.3\n 25.2\n Plt\n 90\n Creatinine\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 22\n 26\n 27\n 26\n 25\n 28\n Glucose\n 110\n 100\n 107\n 87\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS, cont\n zyprexa, versed for agitation, Start SSRI\n CV: goal SBP < 160, labetolol 400 tid, prn Hydral and IV labetolol\n Resp: Trach trials, bilat pleural effusions IP does not want to\n tap\n GI: TFs\n GU: adequate UOP, ARF resolved, PRN lasix, goal 1L negative\n FEN: TFs\n Heme: stable Hct\n Endo: RISS\n ID: multiple cultures negative to date, f/u cultures\n TLD: trach, foley, a-line, VPS, PEG, rt PICC\n Wound: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Prophylaxis: famotidine, SQH\n Imaging: none\n Dispo: start screening for vented rehab. no insurance or health care\n proxy. social work following\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:49 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 AM\n Prophylaxis:\n DVT: SQH\n Stress ulcer: H2B\n VAP bundle:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition: icu\n Total time spent: 32\n" }, { "category": "Physician ", "chartdate": "2157-01-24 00:00:00.000", "description": "Intensivist Note", "row_id": 655609, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Chief complaint:\n CVA\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Artificial Tear Ointment 5. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Caspofungin 9. Caspofungin 10.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. ChlorproMAZINE 12. Docusate Sodium (Liquid) 13. Escitalopram\n Oxalate 14. Famotidine 15. Fentanyl Citrate\n 16. Fentanyl Citrate 17. FoLIC Acid 18. Heparin 19. HydrALAzine 20.\n HydrALAzine 21. 22. Insulin\n 23. Influenza Virus Vaccine 24. Labetalol 25. Labetalol 26. Magnesium\n Sulfate 27. Midazolam 28. Multivitamins\n 29. Olanzapine 30. OxycoDONE-Acetaminophen Elixir 31.\n Piperacillin-Tazobactam\n 24 Hour Events:\n ARTERIAL LINE - STOP 05:39 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Caspofungin - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Midazolam (Versed) - 12:12 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: 37.1\nC (98.8\n T current: 36.4\nC (97.6\n HR: 91 (71 - 96) bpm\n BP: 135/71(86) {115/65(77) - 179/105(119)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,237 mL\n 578 mL\n PO:\n Tube feeding:\n 1,277 mL\n 389 mL\n IV Fluid:\n 840 mL\n 159 mL\n Blood products:\n Total out:\n 1,960 mL\n 340 mL\n Urine:\n 1,960 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 277 mL\n 238 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 681 (410 - 681) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 83.3 cmH2O/mL\n SPO2: 98%\n ABG: ///23/\n Ve: 10.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli, Unresponsive), Moves all extremities\n Labs / Radiology\n 337 K/uL\n 7.8 g/dL\n 133 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 102 mEq/L\n 135 mEq/L\n 22.1 %\n 13.3 K/uL\n [image002.jpg]\n 02:14 PM\n 02:46 AM\n 02:56 AM\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n WBC\n 10.8\n 14.5\n 13.3\n Hct\n 23.3\n 22.6\n 22.1\n Plt\n \n Creatinine\n 1.2\n 1.3\n 1.4\n 1.1\n TCO2\n 28\n 27\n 25\n 24\n Glucose\n 141\n 108\n 103\n 190\n 137\n 133\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.6 mg/dL,\n Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI,\n Cardiovascular: goal SBP < 160, hypotensive requred fluid bolus and\n albumin. Decreased labetolol to 300'''/hydral 25'''. DC aline\n Pulmonary: Trach collar trials, bilat pleural effusions IP does not\n want to tap. Dropped sats (likely to atelectasis) after tachypnic\n episode and placed back on CMV. f/u CXR, consulted IP for high trach\n cuff pressures\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, PRN lasix,\n Hematology: f/u Hct, checking B12, folate, retic count\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date including BAL\n with oropharyngeal flora believed to be from microaspiration. zosyn\n started for VAP. temp spike and pan cx'd, caspofungin started for\n in sputum, CT abdomen PND\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids:\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:58 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 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: 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": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655696, "text": "Electrolyte & fluid disorder, other\n Assessment:\n Patient 500cc positive this am. Urine output adequate.\n Action:\n Given 10 mg lasix IV x1 and 20 mg lasix IV\n Response:\n patient almost even in afternoon, urine output decreased from 100cc/hr\n to 30 cch/hr. then 500 cc positive again by 1600.\n Plan:\n continue to monitor, make patient 500 cc negative today.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient suctioned for moderate amounts of thick yellow secretions.\n Breath sounds clear but diminished at bases.\n Action:\n Given lasix x 2 to take off some fluid, suctioned and repositioned\n frequently, chest PT. Continues on antibiotics.\n Response:\n pending.\n Plan:\n continue to monitor.\n" }, { "category": "Nursing", "chartdate": "2157-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655081, "text": "53yr old male s/p SAH with IVH in left lateral ventricle. Now s/p trach\n and peg and VP shunt.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Lungs coarse, secretions blood tinged in moderate amount. Respiratory\n effort unlabored.\n Action:\n Chest CT, intermittent suctioning, hob>30, diuresed with 20mg lasix\n IVP. Placed on Cpap/ps\n Response:\n Bilateral pleural effusion by CT to small to tap per IP. Pt tolerates\n suctioning and vent changes well.\n Plan:\n Continue diuresis with daily goal net neg 1l, Continue vent wean with\n goal of transition to trach mask as tolerated.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Right pupil briskly reactive to light, 2mm. Unable to assess left pupil\n corneal abrasion. Nods head to yes/no questions with response\n delayed. Unable to follow commands, moves left arm purposefully.\n Action:\n Neuro assessment q4yrs, reoriented pt to course of events, day/day and\n time and surroundings.\n Response:\n Neuro assessment unchanged.\n Plan:\n Notify team of any decline in assessment, continue to reorient prn.\n Balance, Impaired\n Assessment:\n Little to no balance when dangled at bedside by PT\n see notes.\n Action:\n Slide board to chair at bedside and upright x 60 minutes.\n Response:\n Initial relative asymptomatic hypotension. Pt able to sit upright with\n pillows padding sides. Continues to move left arm independently.\n Plan:\n Continue PT, follow reccs. Increase activity as tolerated. Encourage pt\n to assist with ADL\ns when appropriate. Rehab as long term goal.\n Problem\n Corneal abrasion O.S.\n Assessment:\n Left eye sclera Injected, cornea opaque\n Action:\n Aqua tear and bacitracin ointments as ordered.\n Response:\n No change noted in assessment\n Plan:\n Continue treatments as ordered, notify team of any change,\n Ophthalmology service following.\n" }, { "category": "Physician ", "chartdate": "2157-01-22 00:00:00.000", "description": "Intensivist Note", "row_id": 655338, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 02:00 PM\n Piperacillin/Tazobactam (Zosyn) - 01:00 AM\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 04:45 AM\n Midazolam (Versed) - 05:01 AM\n Fentanyl - 05:01 AM\n Other medications:\n Flowsheet Data as of 04:42 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.4\nC (101.1\n T current: 37.3\nC (99.1\n HR: 87 (76 - 108) bpm\n BP: 105/50(70) {72/37(50) - 178/80(116)} mmHg\n RR: 24 (11 - 34) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,321 mL\n 558 mL\n PO:\n Tube feeding:\n 1,621 mL\n 163 mL\n IV Fluid:\n 541 mL\n 396 mL\n Blood products:\n Total out:\n 2,705 mL\n 200 mL\n Urine:\n 2,705 mL\n 200 mL\n NG:\n Stool:\n Drains:\n Balance:\n -384 mL\n 358 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 498 (396 - 774) mL\n PS : 10 cmH2O\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 104\n PIP: 19 cmH2O\n SPO2: 96%\n ABG: 7.40/42/104/25/0\n Ve: 7.5 L/min\n PaO2 / FiO2: 260\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Wheezes : bilaterally)\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 309 K/uL\n 8.5 g/dL\n 141 mg/dL\n 1.2 mg/dL\n 25 mEq/L\n 3.6 mEq/L\n 29 mg/dL\n 104 mEq/L\n 139 mEq/L\n 23.3 %\n 10.8 K/uL\n [image002.jpg]\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n 02:02 PM\n 02:14 PM\n 02:46 AM\n 02:56 AM\n WBC\n 10.6\n 11.0\n 12.2\n 10.8\n Hct\n 26.3\n 25.2\n 25.9\n 23.3\n Plt\n 326\n 290\n 318\n 309\n Creatinine\n 1.1\n 1.1\n 1.0\n 1.2\n TCO2\n 27\n 26\n 25\n 28\n 28\n 27\n Glucose\n 107\n 87\n 121\n 141\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI\n Cardiovascular: goal SBP < 160, labetolol 400 tid, prn Hydral and IV\n labetolol, hypotensive requred fluid bolus o/n\n Pulmonary: Trach collar trials, bilat pleural effusions\n Gastrointestinal / Abdomen: TFs\n Nutrition: Tube feeding\n Renal: adequate UOP, ARF resolved, PRN lasix, goal 1L negative\n Hematology: f/u Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures.\n repeat CBC, WBC increasing, vanc/zosyn started for presumed VAP\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: KVO\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-23 00:00:00.000", "description": "Intensivist Note", "row_id": 655506, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B Sulfate\n Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine Gluconate 0.12%\n Oral Rinse, ChlorproMAZINE, Docusate Sodium (Liquid), Escitalopram\n Oxalate, Famotidine, Fentanyl Citrate, FoLIC Acid, Heparin,\n HydrALAzine, Insulin, Labetalol, Magnesium Sulfate, Multivitamins,\n Olanzapine, OxycoDONE-Acetaminophen Elixir, Piperacillin-Tazobactam Na,\n Potassium Chloride,Thiamine, Vancomycin\n 24 Hour Events:\n FEVER - 101.1\nF - 04:00 PM\n : pan cultured, required multiple fluid bolus, decreased antiHTN\n meds\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Piperacillin/Tazobactam (Zosyn) - 12:00 AM\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 AM\n Heparin Sodium (Prophylaxis) - 12:08 AM\n Flowsheet Data as of 03:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.7\nC (103.4\n T current: 38\nC (100.4\n HR: 72 (72 - 111) bpm\n BP: 94/48(64) {78/41(53) - 187/80(117)} mmHg\n RR: 19 (13 - 30) insp/min\n SPO2: 99%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 3,467 mL\n 338 mL\n PO:\n Tube feeding:\n 1,597 mL\n 206 mL\n IV Fluid:\n 1,690 mL\n 132 mL\n Blood products:\n Total out:\n 2,075 mL\n 270 mL\n Urine:\n 2,075 mL\n 270 mL\n NG:\n Stool:\n Drains:\n Balance:\n 1,392 mL\n 68 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 501 (501 - 664) mL\n PS : 10 cmH2O\n RR (Set): 18\n RR (Spontaneous): 0\n PEEP: 10 cmH2O\n FiO2: 40%\n RSBI: 160\n PIP: 23 cmH2O\n Plateau: 21 cmH2O\n Compliance: 45.5 cmH2O/mL\n SPO2: 99%\n ABG: 7.44/36/72/25/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 180\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: No(t) Rhonchorous : , Diminished:\n )\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Responds to: Verbal stimuli)\n Labs / Radiology\n 309 K/uL\n 8.5 g/dL\n 108 mg/dL\n 1.3 mg/dL\n 25 mEq/L\n 4.7 mEq/L\n 29 mg/dL\n 105 mEq/L\n 139 mEq/L\n 23.3 %\n 10.8 K/uL\n [image002.jpg]\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n 02:02 PM\n 02:14 PM\n 02:46 AM\n 02:56 AM\n 01:22 PM\n 01:50 PM\n WBC\n 11.0\n 12.2\n 10.8\n Hct\n 25.2\n 25.9\n 23.3\n Plt\n 290\n 318\n 309\n Creatinine\n 1.1\n 1.0\n 1.2\n 1.3\n TCO2\n 26\n 25\n 28\n 28\n 27\n 25\n Glucose\n 87\n 121\n 141\n 108\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.4 mg/dL,\n Mg:1.9 mg/dL, PO4:3.5 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI\n Cardiovascular: goal SBP < 160, hypotensive requred fluid bolus and\n albumin. Decreased labetolol to 300'''/hydral 25'''. With increased\n PEEP and dropped BP. Gave 500 ml NS bolus\n Pulmonary: Trach collar trials, bilat pleural effusions IP does not\n want to tap. Dropped sats (likely to atelectasis) after tachypnic\n episode and placed back on CMV. f/u CXR. will wean in AM. IP to fix\n trach\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, PRN lasix, euvolemic today\n Hematology: f/u Hct, checking B12, folte, retic count\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date including BAL\n with oropharyngeal flora believed to be from microaspiration.\n vanc/zosyn started for presumed VAP. vanc level 12, considering\n increasing dosage for levels closer to 15 for better lung penetration.\n temp spike and pan cx'd\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: multiple fluid bolus\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:16 AM 65 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 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: Transfer to rehab / long term facility\n Total time spent: 32 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654444, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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 / Tenacious\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:\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: Intolerant of\n weaning attempts, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Pt was weaned from CMV to PSV then to trach collar, tol for approx.\n 6hrs. ABG\ns wnl on all modes of ventilation. RR ranges 18-50\n Placed back on CMV, slight ^ in HR,BP. Plan to continue with weaning\n attempts.\n" }, { "category": "Nursing", "chartdate": "2157-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654448, "text": "HPI:\n 67 year old right handed woman with a history of CAD s/p MI x2, HTN,\n DM, PVD s/p bilateral BKA, and s/p living un-related renal transplant\n 10 years prior who initially presented to on with a \n month history of left arm shaking, weakness and dysarthria, who was\n found to have a right MCA infarction. Her mental status declined and a\n repeat head CT in the evening showed an acute large right MCA infarct.\n On her mental status worsened and a repeat head CT showed\n increasing infarct involving right ACA and MCA so she went to the OR\n for a decompressive right hemicraniectomy\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt w/ eye twitching, not tracking\n Right pupil 3mm and briskly reactive. Left eye 2mm and\n nonreactive\n Left eye w/ corneal abrasion\n Moving left arm. Intermittently follows commands w/ left\n arm. No RUE movement/hand is edematous\n BLE move on bed L>R\n Inc to head w/ dsgs c/d/i. Abd inc OTA. No signs of\n infection\n Low grade temp 100.6. Team feels neuro involvement and\n possibly from prior Dilantin\n Goal is to keep SBP <160\n NA 146\n Action:\n Neuro checks Q4hrs\n Eye gtts and abx cream to left eye per order\n Tylenol PRN for temp\n Scheduled Labetolol 200mg TID/Hydralazine 10mg IV x2 for SBP\n 170\n Response:\n Neuro checks unchanged\n Pt afebrile. 98.1\n SBP down to 140\n Plan:\n Continue Q4hrs Neuro checks\n Monitor VS/Labs\n Screening for vent rehab\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper lobes and decreased at bases\n Trached on CMV/AS upon receiving\n RR 20\ns. Shallow breathing w/ accessory muscle use\n Action:\n Placed pt on CPAP w/ Psupp tolerated well w/ adequate ABG\n Removed off vent for trial of trach collar mask\n Tolerated trach collar mask for approximately 5hrs then\n became very tachypneic (RR 60\ns), tachycardic (HR 100), and\n hypertensive (SBP 170\n Received Fentanyl x2 and Hydralazine x2\n Placed back on CPAP w/ Psupp per SICU team request\n Response:\n Pt did not tolerate CPAP and had to be placed on CMV d/t\n continued tachypnea/tachycardia/hypertension\n Plan:\n Continue to monitor Resp status\n Continue to attempt to wean from vent as tolerated\n CXR in morning\n rehab screen\n" }, { "category": "Nursing", "chartdate": "2157-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654888, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt w/ eye twitching, not tracking\n Right pupil 3mm and briskly reactive. Left eye 2mm and\n nonreactive\n Left eye w/ corneal abrasion\n Moving left arm. Intermittently follows commands w/ left\n arm. No RUE movement/hand is edematous\n BLE move on bed L>R\n Inc to head w/ dsgs c/d/i. Abd inc OTA. No signs of\n infection\n Low grade temp 100.6. Team feels neuro involvement and\n possibly from prior Dilantin\n Goal is to keep SBP <160\n NA 146\n Action:\n Neuro checks Q4hrs\n Eye gtts and abx cream to left eye per order\n Tylenol PRN for temp\n Scheduled Labetolol 200mg TID/Hydralazine 10mg IV x2 for SBP\n 170\n Response:\n Neuro checks unchanged\n Pt afebrile. 98.1\n SBP down to 140\n Plan:\n Continue Q4hrs Neuro checks\n Monitor VS/Labs\n Screening for vent rehab\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper lobes and decreased at bases\n Trached on CMV/AS upon receiving\n RR 20\ns. Shallow breathing w/ accessory muscle use\n Action:\n Placed pt on CPAP w/ Psupp tolerated well w/ adequate ABG\n Removed off vent for trial of trach collar mask\n Tolerated trach collar mask for approximately 5hrs then\n became very tachypneic (RR 60\ns), tachycardic (HR 100), and\n hypertensive (SBP 170\n Received Fentanyl x2 and Hydralazine x2\n Placed back on CPAP w/ Psupp per SICU team request\n Response:\n Pt did not tolerate CPAP and had to be placed on CMV d/t\n continued tachypnea/tachycardia/hypertension\n Plan:\n Continue to monitor Resp status\n Continue to attempt to wean from vent as tolerated\n CXR in morning\n rehab screen\n Nursing progress 7a-7P. Incorrect H&P in previous note written-\n RN\n" }, { "category": "Nursing", "chartdate": "2157-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654889, "text": "HPI:\n 67 year old right handed woman with a history of CAD s/p MI x2, HTN,\n DM, PVD s/p bilateral BKA, and s/p living un-related renal transplant\n 10 years prior who initially presented to on with a \n month history of left arm shaking, weakness and dysarthria, who was\n found to have a right MCA infarction. Her mental status declined and a\n repeat head CT in the evening showed an acute large right MCA infarct.\n On her mental status worsened and a repeat head CT showed\n increasing infarct involving right ACA and MCA so she went to the OR\n for a decompressive right hemicraniectomy\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt w/ eye twitching, not tracking\n Right pupil 3mm and briskly reactive. Left eye 2mm and\n nonreactive\n Left eye w/ corneal abrasion\n Moving left arm. Intermittently follows commands w/ left\n arm. No RUE movement/hand is edematous\n BLE move on bed L>R\n Inc to head w/ dsgs c/d/i. Abd inc OTA. No signs of\n infection\n Low grade temp 100.6. Team feels neuro involvement and\n possibly from prior Dilantin\n Goal is to keep SBP <160\n NA 146\n Action:\n Neuro checks Q4hrs\n Eye gtts and abx cream to left eye per order\n Tylenol PRN for temp\n Scheduled Labetolol 200mg TID/Hydralazine 10mg IV x2 for SBP\n 170\n Response:\n Neuro checks unchanged\n Pt afebrile. 98.1\n SBP down to 140\n Plan:\n Continue Q4hrs Neuro checks\n Monitor VS/Labs\n Screening for vent rehab\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS clear to upper lobes and decreased at bases\n Trached on CMV/AS upon receiving\n RR 20\ns. Shallow breathing w/ accessory muscle use\n Action:\n Placed pt on CPAP w/ Psupp tolerated well w/ adequate ABG\n Removed off vent for trial of trach collar mask\n Tolerated trach collar mask for approximately 5hrs then\n became very tachypneic (RR 60\ns), tachycardic (HR 100), and\n hypertensive (SBP 170\n Received Fentanyl x2 and Hydralazine x2\n Placed back on CPAP w/ Psupp per SICU team request\n Response:\n Pt did not tolerate CPAP and had to be placed on CMV d/t\n continued tachypnea/tachycardia/hypertension\n Plan:\n Continue to monitor Resp status\n Continue to attempt to wean from vent as tolerated\n CXR in morning\n rehab screen\n ------ Protected Section------\n See note signed on . Incorrect H&P . RN\n ------ Protected Section Error Entered By: on:\n 19:26 ------\n" }, { "category": "Nursing", "chartdate": "2157-01-27 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656219, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Initially on PS 10/5 At rest RR 20s, with any stressor RR up to 50s\n with VT 200, Ins wheezing, HR and BP also up with dyspnea CXR\n atelectatic at bases, RLL PNA, WBC 21.9 today Fully cultures this am\n Sput this am + cocci . Copious oral and tracheal secreations, BS\n rhonchorous upper airways\n Action:\n Vanco started for pna; Albuteral nebs started prn; Dangled at edge of\n bed. OOB to chair X 2\n hr; LENEs done, Oral and tracheal Sx Q \n hours. Lasix 10 mg IV X 1\n Response:\n T max 99.6. Wheezing only rare after INH still associated with\n activity. \ns negative. Upper airways clear after suctioning.\n Increased u/o 60-80 prior to lasix, increased only to 140 for about\n three hours post lasix\n Plan:\n OOB at least twice daily. Dangle at edge of bed at least >>> to\n strengthen all muscles esp resp muscles\n Check with ID for vanco approval for further doses, Cont INH; Will\n probably need higher dose of lasix. Discuss addition of vagolytic drug\n to decrease oral secretions and aspiration of same (ie scopaolomine)\n" }, { "category": "Respiratory ", "chartdate": "2157-01-29 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656427, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 33\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type:\n Manufacturer: Portex\n Size:\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 30 cmH2O\n Cuff volume: 8 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: Rhonchi\n Comments:\n Secretions\n Sputum color / consistency: /\n Sputum source/amount: /\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours:\n Reason for continuing current ventilatory support:\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Unsuccessful in weaning to trach collar; requiring increased PSV due to\n tachypnea. Attempt again in AM. No secretions.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-24 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655695, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 28\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Diminished\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Diminished\n Comments:\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654437, "text": "HPI:\n 67 year old right handed woman with a history of CAD s/p MI x2, HTN,\n DM, PVD s/p bilateral BKA, and s/p living un-related renal transplant\n 10 years prior who initially presented to on with a \n month history of left arm shaking, weakness and dysarthria, who was\n found to have a right MCA infarction. Her mental status declined and a\n repeat head CT in the evening showed an acute large right MCA infarct.\n On her mental status worsened and a repeat head CT showed\n increasing infarct involving right ACA and MCA so she went to the OR\n for a decompressive right hemicraniectomy\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt w/ eye twitching, not tracking\n Right pupil 3mm and briskly reactive. Left eye 2mm and\n nonreactive\n Left eye w/ corneal abrasion\n Moving left arm. Intermittently follows commands w/ left\n arm. No RUE movement/hand is edematous\n BLE move on bed L>R\n Low grade temps 100\n Goal is to keep SBP <160\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654498, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tracheostomy tube:\n Type: Standard, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / 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 Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI attempted, not successful due to rapid increase in RR\n (>45).\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts, Underlying illness not resolved\n" }, { "category": "Nursing", "chartdate": "2157-01-28 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656303, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt had bronchscopy which showed Trach in right main stem\n bronch\n Action:\n Trach changed to # 9 portex\n Cxr done\n Pt received 20mg of iv lasix\n Sputum cultures obtained from bronchscopy\n Response:\n Pt at times with a positional cuff leak, dr. aware\n Suctioned pt for scant to moderate amt of thick yellow\n secretions\n Plan:\n Continue to monitor\n Attempt to wean pressure support\n Await results from sputum cultures\n Goal is to have pt 500cc negative\n Interventational pulmonary to see patient ? stent on Monday\n Intracerebral hemorrhage (ICH)\n Assessment:\n Right eye 3mm and briskly reactive to light\n Left pupils unable to assess secondary to cloudiness and\n corneal abrasion\n pt spontanouesly moves left arm and leg leg on bed\n pt will intermittently follow commands\n Action:\n no action taken\n Response:\n Neuro signs unchanged\n Plan:\n Continue to monitor\n Keep sbp less than 160\n" }, { "category": "Respiratory ", "chartdate": "2157-01-28 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 656319, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 32\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 9.0mm\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: Diminished\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No 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: Underlying illness\n not resolved\n Respiratory Care Shift Procedures\n Bedside Procedures:\n Bronchoscopy (1000)\n" }, { "category": "Rehab Services", "chartdate": "2157-01-28 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 656321, "text": "Subjective:\n Pt. nonverbal but seemed to attempt verbalization at one point\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education, reassessment of\n cognition/arousal, endurance training.\n Updated medical status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n X\n Supine/\n Sidelying to Sit:\n\n\n\n\n X\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 Aerobic Activity Response:\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 146/75\n 27\n 99\n Activity\n Sit\n 69\n 110/58\n 25\n 98\n Recovery\n Supine\n 88\n 147/87\n 24\n 99\n Total distance walked:\n Minutes:\n Bed Mobility: Rolling and Supine to Sit Total A x 2. With max cues pt\n able to bend L knee minimally to prepare for rolling.\n Balance: Pt able to maintain midline c mod A x 1 @ EOB, occasionally\n able to maintain c min A however question pt effort vs result of muscle\n tension and positioning. Pt demonstrated minimal protective response\n c active L tricep contraction c sidebend to bed on L. Pt also\n demonstrated L biceps contraction to A prevention of posterior LOB.\n Education / Communication: Pt. ed re: role of PT\n Rn re: pt. status. attempts to pull at vent\n Other: Cognition: Pt. cont to follow <5 % commands and inconsistently.\n Pt. unable to track and did not initiate eye contact throughout\n treatment. Pt. does blink to threat and withdraws to pain LUE and LLE\n only.\n Respiratory Status: FiO2 40%, PEEP 10, PS 8, CPAP; suctioned for\n scant brown secretions (sterile in-line catheter), sats well throughout\n treatment.\n Tone: 1+ L triceps, IR's, shoulder elevators, hip add's\n Assessment: Pt. is a 53 yo M s/p L IPH c IVH. Continues to pw impaired\n arousal and cognition. Questionable improvement in EOB static balance\n during today's treatment. Given pt's age, PLOF and nature of his\n injury, pt cont to be a good candidate for rehab once medically stable.\n Anticipated Discharge: Rehab\n Plan: Cont POC : Increase arousal, EOB sitting balance, frequent\n re-eval of cognitive status\n Rec for nsg: OOB to chair c slideboard.\n Time: 17:05-17:35\n , PT/s pgr # \n , PT pgr #\n" }, { "category": "Nursing", "chartdate": "2157-01-29 00:00:00.000", "description": "Nursing Progress Note", "row_id": 656423, "text": "Respiratory failure, acute (not ARDS/)\n Assessment:\n On 40% cpap5/8ps this am, bs+ all lobes, clear, diminished to bases,\n minimal secretions\n Action:\n Placed on 5 PS this am briefly , not tolerating & placed back on ps 8,\n PS increased to 10 @ 1600 for increased RR, sux q 2 -4 hrs, q 4 hr\n oral/VAP care\n Response:\n Not tolerating lowering PS today, not able to wean to trach collar\n today\n Plan:\n Continue with ventilatory support, wean PS as tolerated, wean to trach\n collar as tolerated\n" }, { "category": "Nursing", "chartdate": "2157-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655246, "text": "Hypertension, benign\n Assessment:\n Sbp greater than 168, hr 114\n Action:\n Received 10mg of iv labetatol\n Response:\n Sbp less than 160\n Plan:\n Continue to monitor\n Keep sbp less than 160\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Temp 101.1\n Action:\n Dr. aware, no blood cultures ordered. Pt received\n tylenol\n Response:\n Await effect from tylenol\n Plan:\n Continue to monitor\n Pt started on zosyn and vanco for ? pneumonia.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-18 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 654620, "text": "Subjective:\n pt non-verbal\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training\n Updated medical status: pt tolerated trach mask x 5 hrs \n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n\n\n\n\n\n Supine/\n Sidelying to Sit:\n\n\n\n\n\n Transfer:\n\n\n\n\n\n Sit to Stand:\n\n\n\n\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 84\n 166/77\n 95% on CMV\n Activity\n Sit\n 93\n 152/69\n 95% on CMV\n Recovery\n /\n Total distance walked:\n Minutes:\n Gait: Patient required total assist for supine-to-sit, unable to\n participate in mobility\n Balance: Patient tolerated sitting at edge of bed x 10 minutes,\n requires mod A to maintain static sitting at edge of bed, LOB backward\n and to left with no postural reflexes\n Education / Communication: Patient alert, following <5% of commands.\n Communicated with nsg re: status\n Other: Visually tracking across midline consistently, nystagmus\n Pt moving LUE purposefully- puts yankauer to his mouth\n Pt moving B , RUE hypotonic\n Assessment: 53 yo M with ICH continues to tolerate PT and sitting at\n edge of bed. Patient making improvements with volitional movement and\n arousal, however following minimal commands at this time. Rehab\n potential remains guarded due to severity of hemmorhage, however given\n his improved level of alertness and his age would conitnue to recommend\n rehab upon d/c.\n Anticipated Discharge: Rehab\n Plan: Continue with POC\n" }, { "category": "Nursing", "chartdate": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655590, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt is alert, following commands inconsistently, purposeful movements,\n PERL. Lt eye still red, rt hand not moving, rt leg slight ly\n withdrawing to pain\n Action:\n Neuro checks q2h, SBP goal<160, reoriented with place and time and\n activities, versed 1mg x2 as pt is widely awake and SBP 170\n Response:\n Unchanged neuro stastus,SBP <160 with regular Po meds and versed , no\n prn\ns anti HT meds given overnight,\n Plan:\n Cont monitoring, neurochecks q2h, SBP <160, wean vent as tolerates,\n support to pt and family, social work and case manager involvement for\n further care after discharge from hosp.\n" }, { "category": "Nursing", "chartdate": "2157-01-21 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655122, "text": "Hypertension, benign\n Assessment:\n SBP frequently above 160\n After scheduled medication and additional IVP labetalol BP down briefly\n but not maintaining <160\n Action:\n Dr notified\n Hydralizine po increased\n Hydralizine iv prn restarted\n Response:\n SBP 150\ns after dose increased po hydralizine\n Plan:\n Cont to monitor and adjust medications as tolerated.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Tolerating CPAP PS 12 Peep 5\n Increased secretions\n ~1 liter negative at midnight\n Action:\n Pm dose Lasix held per Dr and given early this am when fluid\n balance even\n Pressure support decreased to 10\n Response:\n Tolerated vent change\n Plan:\n Cont to wean as tolerated\n Ineffective Coping\n Assessment:\n Pt noted to be crying for long periods of time\n Action:\n Given versed and tenanyl for mild sedation\n Emotional support provided\n Response:\n Pt relaxed and able to sleep\n Plan:\n Cont to provide support.\n" }, { "category": "Nursing", "chartdate": "2157-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654129, "text": "Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653236, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Squeezing left hand and wiggling left toes to command consistently. RUE\n and RLE withdrawing to nail bed pressure. Right pupil 3mm and briskly\n reactive, left pupil 2mm and nonreactive\n Action:\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653622, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient\ns neuro exam essentially unchanged. Eyes open spontaneously,\n moving left upper extremity frequently. No movement RUE, bilat LE\n withdraw to pain and move slightly on bed. Rarely following commands\n overnight. Pupils approx 3mm equal & brisk. Vent drain 20 cm @ tragus\n with approx 5-10 cc csf every 2 hours. ICPs ranging .\n Action:\n Vent drain clamped as ordered by NSURG approx 11pm. Cont\nd to follow\n neuro exam and ICPs.\n Response:\n ICP 6-10\n Plan:\n Open drain if ICPs rise to 20. VP shunt today if patient unable to\n tolerate clamping trial.\n Hypertension, benign\n Assessment:\n Occasionally hypertensive 180-200\ns. Heart rate mostly 90\ns, NSR.\n Appears comfortable, does not appear in pain but restless @ times.\n Action:\n Patient on PO Labetolol. Also given prn doses Lopressor &\n hydralazine. Tylenol for ? comfort.\n Response:\n Patient\ns sbp now 140-150\n Plan:\n Continue to maintain sbp < 180.\n" }, { "category": "Nursing", "chartdate": "2157-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655400, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt does open his eyes when you call his name\n At times will look toward you when you call his name\n Right pupil 3mm and briskly reactive to light\n Left pupil with corneal abrasion unable to assess\n Pt will intermittently follow commands\n Action:\n Neuro assessment every 2 hours as ordered\n Response:\n Unchanged neuro exam\n Plan:\n Continue to monitor\n Notify team if any neuro changed\n Problem\n corneal abrasion\n Assessment:\n Left eye remains reddened and cloudy\n Action:\n Bacitracin and artifical tears applied as ordered\n Attempt to put steri-strips to keep left eye closed\n Response:\n Pt keeping eyes open spontanously\n Plan:\n Continue with current plan.\n" }, { "category": "Nursing", "chartdate": "2157-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654133, "text": "Hypertension, benign\n Assessment:\n Pt with episodes of SBP < 180. New SBP >160 per neuro medicine.\n Action:\n Fentanyl 50mcg for assumed incisional pain and 10mg prn IVP Labetalol.\n Response:\n Pt when afebrile, SBP 130\ns. HR 80\ns-90\n Plan:\n Continue current regime. Alert SICU Resident if pt sustains SBP <160\n s/p interventions.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt TMAX 102.3 at 1600. Pt alert and moving in bed. No neuro changes\n noted.\n Action:\n SICU Resident aware. Cooling blanket applied. Pan Cultured.\n Aggressive pulmonary suctioning.\n Response:\n Current PO temp 101.5.\n Plan:\n Continue to monitor, cooling blanket. Await pending bld cultures.\n" }, { "category": "Physician ", "chartdate": "2157-01-16 00:00:00.000", "description": "Intensivist Note", "row_id": 654206, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH with IVH in left lateral ventricle\n PMHx:\n HTN, SAH\n Current medications:\n Acetaminophen 5. Artificial Tear Ointment 6. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. ChlorproMAZINE\n 11. Docusate Sodium (Liquid) 12. Famotidine 13. Fentanyl Citrate 14.\n FoLIC Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Magnesium\n Sulfate 22. Multivitamins\n 23. OxycoDONE-Acetaminophen Elixir 24. Phenytoin 25. Potassium Chloride\n 26. Sodium Chloride 0.9% Flush\n 27. Sodium Chloride 0.9% Flush 28. Thiamine 29. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 102.3\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Vancomycin - 09:30 PM\n Infusions:\n Labetalol - 1.5 mg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 12:30 AM\n Labetalol - 02:50 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.1\nC (102.3\n T current: 37.4\nC (99.3\n HR: 92 (91 - 111) bpm\n BP: 149/72(100) {119/58(81) - 193/94(132)} mmHg\n RR: 26 (13 - 35) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,006 mL\n 279 mL\n PO:\n Tube feeding:\n 120 mL\n 158 mL\n IV Fluid:\n 1,826 mL\n 121 mL\n Blood products:\n Total out:\n 1,290 mL\n 300 mL\n Urine:\n 1,290 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 716 mL\n -21 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 160 (160 - 160) mL\n PS : 15 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 94%\n ABG: 7.42/33/98./17/-1\n Ve: 11.5 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli), Moves all\n extremities\n Labs / Radiology\n 300 K/uL\n 9.5 g/dL\n 112 mg/dL\n 1.0 mg/dL\n 17 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 115 mEq/L\n 143 mEq/L\n 27.1 %\n 8.6 K/uL\n [image002.jpg]\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n WBC\n 12.0\n 9.4\n 8.5\n 8.5\n 8.6\n Hct\n 26.5\n 29.1\n 27.2\n 27.7\n 27.1\n Plt\n 98\n 300\n Creatinine\n 1.4\n 1.2\n 1.3\n 1.1\n 1.0\n TCO2\n 22\n 23\n 25\n 22\n 22\n Glucose\n 121\n 114\n 81\n 91\n 112\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.3 mg/dL,\n Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, dilantin, ICP sustained in 20s\n so EVD opened to 20cm H2O drainage, VPS with unchanged repeat CT\n head\n Cardiovascular: goal SBP < 160, labetolol gtt due to difficult to\n control BP with PO, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs restarted.\n Nutrition: Tube feeding\n Renal: Foley, follow UOP\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, Kefzol stopped for rash, dosed\n intraop and post op Vanc for ventric drain, pancultured for temp of\n 102. received ID approval for vanc, follow vanco level\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\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: ICU consent signed Comments:\n Code status: Full code\n Disposition: sicu\n Total time spent: 31 min\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653411, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n 24 hour TMAX 101.7. Continues to be afebrile, TMAX this shift\n Action:\n Pan Cultured this am\n Response:\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-01-13 00:00:00.000", "description": "Intensivist Note", "row_id": 653691, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 PM\n URINE CULTURE - At 04:00 PM\n SPUTUM CULTURE - At 09:00 PM\n FEVER - 101.9\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Labetalol - 04:00 PM\n Metoprolol - 12:00 AM\n Hydralazine - 12:30 AM\n Other medications:\n Flowsheet Data as of 09:37 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: 37.9\nC (100.2\n HR: 111 (75 - 111) bpm\n BP: 183/85(121) {125/60(83) - 199/87(128)} mmHg\n RR: 28 (12 - 31) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 73.9 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 15 (1 - 16) mmHg\n Total In:\n 1,133 mL\n 235 mL\n PO:\n Tube feeding:\n 713 mL\n IV Fluid:\n 150 mL\n 145 mL\n Blood products:\n Total out:\n 1,386 mL\n 700 mL\n Urine:\n 1,310 mL\n 700 mL\n NG:\n Stool:\n Drains:\n 76 mL\n Balance:\n -253 mL\n -465 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: ///22/\n Ve: 9.4 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\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 473 K/uL\n 10.4 g/dL\n 114 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 108 mEq/L\n 139 mEq/L\n 29.1 %\n 9.4 K/uL\n [image002.jpg]\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n WBC\n 15.4\n 12.0\n 9.4\n Hct\n 30.6\n 26.5\n 29.1\n Plt\n \n Creatinine\n 1.6\n 1.7\n 1.6\n 1.4\n 1.2\n TCO2\n 21\n 22\n 22\n 22\n 23\n Glucose\n 134\n 100\n 96\n 121\n 114\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, continue dilantin, OR for VPS\n today\n Cardiovascular: goal SBP < 180, lopressor 100 TID, labetolol po, prn\n Hydralazine\n Pulmonary: s/p Trach, cont to wean to trach collar, CXR in am (stable\n LLL opacification)\n Gastrointestinal / Abdomen: TF via PEG\n Nutrition: Tube feeding\n Renal: Adequate UO\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: febrile, check cultures Vanc/Zosyn (empiric for\n fever)/Fluc (yeast in sputum) stopped, Kefzol started for ventric\n drain,\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: normal saline @ 75cc/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-13 00:00:00.000", "description": "Intensivist Note", "row_id": 653699, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Chief complaint:\n PMHx:\n HTN\n Current medications:\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 PM\n URINE CULTURE - At 04:00 PM\n SPUTUM CULTURE - At 09:00 PM\n FEVER - 101.9\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Labetalol - 04:00 PM\n Metoprolol - 12:00 AM\n Hydralazine - 12:30 AM\n Other medications:\n Flowsheet Data as of 09:37 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: 37.9\nC (100.2\n HR: 111 (75 - 111) bpm\n BP: 183/85(121) {125/60(83) - 199/87(128)} mmHg\n RR: 28 (12 - 31) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 73.9 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 15 (1 - 16) mmHg\n Total In:\n 1,133 mL\n 235 mL\n PO:\n Tube feeding:\n 713 mL\n IV Fluid:\n 150 mL\n 145 mL\n Blood products:\n Total out:\n 1,386 mL\n 700 mL\n Urine:\n 1,310 mL\n 700 mL\n NG:\n Stool:\n Drains:\n 76 mL\n Balance:\n -253 mL\n -465 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: ///22/\n Ve: 9.4 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\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 473 K/uL\n 10.4 g/dL\n 114 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 108 mEq/L\n 139 mEq/L\n 29.1 %\n 9.4 K/uL\n [image002.jpg]\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n WBC\n 15.4\n 12.0\n 9.4\n Hct\n 30.6\n 26.5\n 29.1\n Plt\n \n Creatinine\n 1.6\n 1.7\n 1.6\n 1.4\n 1.2\n TCO2\n 21\n 22\n 22\n 22\n 23\n Glucose\n 134\n 100\n 96\n 121\n 114\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, continue dilantin, ct head\n today\n improved, clamp evd, vp shunt postponed\n Cardiovascular: goal SBP < 180, lopressor 100 TID, labetolol po, prn\n Hydralazine\n Pulmonary: s/p Trach, cont to wean to trach collar, CXR in am (stable\n LLL opacification)\n Gastrointestinal / Abdomen: TF via PEG\n Nutrition: Tube feeding\n Renal: Adequate UO\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: febrile, check cultures Vanc/Zosyn (empiric for\n fever)/Fluc (yeast in sputum) stopped, Kefzol started for ventric\n drain,\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: normal saline @ 75cc/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 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: 35 minutes\n" }, { "category": "Respiratory ", "chartdate": "2157-01-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655468, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Tube Type\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 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: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n No changes made overnight, remains fully supported on AC mode. No RSBI\n this am, secondary to PEEP @ 10. See flowsheet for further pt data.\n Will follow.\n 06:06\n" }, { "category": "Nursing", "chartdate": "2157-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655573, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt will open his eyes when you call his name, pt will\n intermittently follow commands pt does move left arm and left leg on\n bed, pt does withdraw right leg to painful stimuli, slight withdraw\n right arm to painful stimuli, right pupil 3mm and briskly reactive to\n light, left pupil unable to assess secondary to corneal abrasion\n Suctioning pt for thick yellow secretions\n Hct 22.6\n Vanco 30\n Action:\n Vanco d/c\n Pt started on caspofugin\n Pt to have ct scan to have 1800\n Response:\n Neuro status unchanged\n Plan:\n Continue to monitor\n Check neuro signs as ordered\n Hypertension, benign\n Assessment:\n Sbp 170-180\n Action:\n Pt received labetatol a total of 20mg\n Pt received 50mcg fentanyl\n Response:\n Pt remains hypertensive in 170\ns, dr. aware pt\n received labetatol @\n Plan:\n Continue to monitor\n Goal is to keep sbp less than 160\n" }, { "category": "Nursing", "chartdate": "2157-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654284, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt continues to have periods elevated temps. TMAX this shift 101.3.\n Action:\n SICU and Neurology Team aware. Dilantin discontinued, ? cause of\n elevated temps.\n Response:\n Last dose of Dilantin po at 1200.\n Plan:\n Continue to monitor. Last Bld Cultures sent . Pending results.\n Hypotension (not Shock)\n Assessment:\n Pt\ns Labetalol gtt discontinued this am prior to increased po labetalol\n dose of 400 mg. Pt hypotensive SBP < 92, MAP 64 for a sustained period\n of time s/p po administration.\n Action:\n SICU Resident aware. Reduced Labetalol po to 200 mg.\n Response:\n Pt currently maintaining a SBP 130\ns-140\ns. SBP Goal per Neuro Med <\n 160.\n Plan:\n Continue to monitor. Adjust hypertensive medications as needed to\n maintain a stable hemodynamic state.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-13 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653784, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 17\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 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: Blood Tinged / Thick\n Sputum source/amount: Suctioned / Moderate\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No claim of dyspnea.\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with current settings at this time.\n Reason for continuing current ventilatory support: Pending procedure /\n OR, Underlying illness not resolved\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n CT\n 1100\n Transport was without any incident.\n" }, { "category": "Nursing", "chartdate": "2157-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653789, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt\ns temperature up to 102.0 orally. Cultures from pending.\n Consulted w/ SICU resident.\n Action:\n Tylenol elixir. Blood, urine, sputum cultures obtained.\n Response:\n Temp down to 101.7 orally.\n Plan:\n Cefazolin as ordered for ICP drain, f/u w/ culture results.\n Hypertension, benign\n Assessment:\n SBP up to 180s-190s.\n Action:\n 10mg IV hydralazine as ordered PRN\n Response:\n SBP down to 130s-150s, but required another dose of hydralazine approx.\n 6hrs later.\n Plan:\n Antihypertensive medication as ordered to maintain SBP <160. Discuss\n increasing standing ordered antihypertensives.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continued on assist controlled ventilation. BS vary from clear to\n ronchorous. Breathing unlabored. Sao2 95-98%\n Action:\n Suctioned fro small amts of thick tan secretions.\n Response:\n Tolerating current vent settings.\n Plan:\n Continue on current ventilation settings.\n Altered mental status (not Delirium)\n Assessment:\n Ventricular drain clamped all day w/ ICP <20 except when Pt coughing or\n being suctioned. Opens eyes spontaneously. Pupils 2-3mm bilaterally,\n briskly reactive. Left pupil sometimes difficult to assess d/t\n abrasion. (+) cough, gag, corneal reflex. Does not follow commands.\n NO movement RUE, RLE movement on bed with nailbed pressure, Moves LUE\n frequently picking at things, LLE moves on bed. No seizure activity\n observed. Repeat head CT. Tubefeeds on hold d/t plan for OR today. .\n Action:\n Ventricular drain clamped. Tubefeeds restarted, and subcutaneous\n heparin given because Pt did not go to OR today.\n Response:\n Neuro exam unchanged. ICP < 20 with drain clamped.\n Plan:\n Hold tubefeeds and heparin for possible shunt placement tomorrow.\n Continue to monitor neuro status, repeat head CT \n Problem - Description In Comments Corneal abrasions\n Assessment:\n Corneal abrasions present in both eyes. Left eye worse.\n Action:\n Opthamology in to examine: contact placed in left eye. Eye ointment/\n antibiotic regimen refined. Eyes taped closed w/ .\n Response:\n Difficult to maintain eye closure w/ tape.\n Plan:\n Opthamology will examine Pt tomorrow, lacrilube q2hrs in left eye, and\n q6hrs in right eye. Antibiotic ointment q6hrs in left eye. Will try to\n keep eyes closed w/ gauze and then because eyes are moist\n from ointments and \n well.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-15 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654110, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 19\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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 / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance:\n Visual assessment of breathing pattern:\n Assessment of breathing comfort:\n Non-invasive ventilation assessment:\n Invasive ventilation assessment:\n Trigger work assessment:\n Dysynchrony assessment:\n Comments:\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated\n Reason for continuing current ventilatory support: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation still wearing an 8.0\n Percutaneous Portex, breath sounds bilaterally clear, suctioned\n intermittently for small amounts of loose clear to white secretions,\n responded with tachypnea and hypertension to weaning attempt, is\n febrile , cooling blanket being used beside Tylenol given, will\n continues to be followed.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-11 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653406, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 15\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / 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 Plan\n Next 24-48 hours: Patient was not put on PSV secondary to episodes of\n increased Blood Pressure throughout the shift. Plan to continue with\n current settings at this time.\n Reason for continuing current ventilatory support: Hemodynimic\n instability, Underlying illness not resolved\n" }, { "category": "Respiratory ", "chartdate": "2157-01-12 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 653447, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 16\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type:\n Size:\n Tracheostomy tube:\n Type: Cuffed, Inner Cannula, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 40 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:\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: Comments: Pt cont trached and on mech vent as per Metavision.\n Lung sounds rhonchi improve somewhat with suct for mod th off white\n sput. ABGs improved ; no vent changes required overnoc. Cont mech vent\n support.\n" }, { "category": "Physician ", "chartdate": "2157-01-14 00:00:00.000", "description": "Intensivist Note", "row_id": 653843, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n Chief complaint:\n SAH, IVH left lateral ventricle\n PMHx:\n ?Hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. CefazoLIN. Chlorhexidine\n Gluconate 0.12% Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid).\n Famotidine. Fentanyl Citrate. FoLIC Acid. Heparin. HydrALAzine.\n Insulin. Labetalol. Magnesium Sulfate. Multivitamins.\n OxycoDONE-Acetaminophen Elixir. Phenytoin. Potassium Chloride. Thiamine\n 24 Hour Events:\n PAN CULTURE - At 05:00 PM\n Blood, urine, sputum\n FEVER - 102.0\nF - 04:00 PM\n Pancultured for fever to 102\n ICP persistently 21-23 so EVD uncapped and drained at 20cm H2O\n NPO/IVF for potential VPS or EVD removal\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 04:44 AM\n Infusions:\n Other ICU medications:\n Labetalol - 10:00 PM\n Hydralazine - 02:00 AM\n Other medications:\n Flowsheet Data as of 06:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.9\nC (102\n T current: 38.2\nC (100.7\n HR: 96 (96 - 115) bpm\n BP: 136/62(88) {136/62(88) - 195/88(128)} mmHg\n RR: 22 (13 - 31) insp/min\n SPO2: 96%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 8 (6 - 21) mmHg\n Total In:\n 1,045 mL\n 373 mL\n PO:\n Tube feeding:\n 265 mL\n 3 mL\n IV Fluid:\n 390 mL\n 310 mL\n Blood products:\n Total out:\n 2,125 mL\n 562 mL\n Urine:\n 2,100 mL\n 540 mL\n NG:\n Stool:\n Drains:\n 25 mL\n 22 mL\n Balance:\n -1,081 mL\n -189 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 19 cmH2O\n Plateau: 16 cmH2O\n SPO2: 96%\n ABG: 7.46/34/106/24/0\n Ve: 10.4 L/min\n PaO2 / FiO2: 265\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL, Left pupil reactive\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: coarse breath sounds bilaterally\n Abdominal: Soft, Non-distended, Non-tender, Bowel sounds present\n Left Extremities: (Edema: Absent, No(t) 1+), (Temperature: Warm),\n (Pulse - Posterior tibial: Diminished)\n Right Extremities: (Edema: No(t) Absent, 1+), (Temperature: Warm),\n (Pulse - Dorsalis pedis: Diminished), (Pulse - Posterior tibial:\n Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: (Awake / Alert / Oriented: x 2), Follows simple commands,\n No(t) Moves all extremities, (RUE: No movement), (RLE: No movement),\n (LLE: Weakness)\n Labs / Radiology\n 481 K/uL\n 10.2 g/dL\n 81 mg/dL\n 1.3 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 24 mg/dL\n 109 mEq/L\n 141 mEq/L\n 27.2 %\n 8.5 K/uL\n [image002.jpg]\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n WBC\n 15.4\n 12.0\n 9.4\n 8.5\n Hct\n 30.6\n 26.5\n 29.1\n 27.2\n Plt\n 81\n Creatinine\n 1.7\n 1.6\n 1.4\n 1.2\n 1.3\n TCO2\n 22\n 22\n 22\n 23\n 25\n Glucose\n 100\n 96\n 121\n 114\n 81\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.3 mg/dL,\n Mg:2.2 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, dilantin,\n repeat head CT, ICP sustained in 20s so EVD opened to 20cm H2O\n drainage, likely needs VPS\n CV: goal SBP < 180, labetolol po, prn Hydralazine\n Resp: s/p Trach, wean to PSV\n GI: TFs held via PEG\n GU: adequate UOP, renal failure resolving\n FEN: TFs held, NS @ 75cc/hr\n Heme: stable Hct\n Endo: RISS\n ID: Kefzol for ventric drain, pancultured for temp of 102\n TLD: trach, foley, a-line, EVD, PEG\n Wound: left corneal ulcer, optho following - on bacitracin oint\n Prophylaxis: famotidine, SQH\n Imaging: none\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 AM\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": "2157-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655557, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt will open his eyes when you call his name, pt will\n intermittently follow commands pt does move left arm and left leg on\n bed, pt does withdraw right leg to painful stimuli, slight withdraw\n right arm to painful stimuli, right pupil 3mm and briskly reactive to\n light, left pupil unable to assess secondary to corneal abrasion\n Suctioning pt for thick yellow secretions\n Hct 22.6\n Vanco 30\n Action:\n Vanco d/c\n Pt started on caspofugin\n Pt to have ct scan to have 1800\n Response:\n Neuro status unchanged\n Plan:\n Continue to monitor\n Check neuro signs as ordered\n Hypertension, benign\n Assessment:\n Sbp 170-180\n Action:\n Pt received labetatol a total of 20mg\n Pt received 50mcg fentanyl\n Response:\n Plan:\n" }, { "category": "Respiratory ", "chartdate": "2157-01-23 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 655471, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 27\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tracheostomy tube:\n Type: Standard, Cuffed, Inner Cannula\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 35 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: Rhonchi\n Secretions\n Sputum color / consistency: Yellow / Thick\n Sputum source/amount: Suctioned / Small\n Comments/Plan\n No changes made overnight, remains on AC mode.\n" }, { "category": "Nursing", "chartdate": "2157-01-23 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655572, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt on q2h neuro checks, following commands inconsistently, rt pupil 2mm\n & sluggish reaction, lt pupil unable to assess d/o corneal abration.rt\n side not moving.\n Action:\n Neuro checks q2h, SBP goal <160, t max 103.6, urine c/s sent, Tylenol\n prn given\n Response:\n Unchanged neuro status, fever down to 100.4 after Tylenol and bath.\n Plan:\n Cont monitoring, neuron checks, SBP goal <160, fluid boluses for\n hypotension\n Hypotension (not Shock)\n Assessment:\n Noted pt\ns SBP 86-89 after po anti HT meds\n Action:\n SICU MD informed, fluid bolus of NS 250ml per order.\n Response:\n SBP to 120-130\ns after fluid bolus\n Plan:\n Cont monitoring, fluid boluses prn.\n Problem - Description In Comments\n Assessment:\n Pt with h/o corneal abration.eye is still red and clouded\n Action:\n Bacitracin eye oint and tears natural applied per order., tried to put\n steristripes on eye lid , but pt opens eye and not able to keep it\n closed\n Response:\n Eye is still red and clouded\n Plan:\n Cont eye treatments per order.\n" }, { "category": "Physician ", "chartdate": "2157-01-16 00:00:00.000", "description": "Intensivist Note", "row_id": 654175, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH with IVH in left lateral ventricle\n PMHx:\n HTN, SAH\n Current medications:\n Acetaminophen 5. Artificial Tear Ointment 6. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. ChlorproMAZINE\n 11. Docusate Sodium (Liquid) 12. Famotidine 13. Fentanyl Citrate 14.\n FoLIC Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Magnesium\n Sulfate 22. Multivitamins\n 23. OxycoDONE-Acetaminophen Elixir 24. Phenytoin 25. Potassium Chloride\n 26. Sodium Chloride 0.9% Flush\n 27. Sodium Chloride 0.9% Flush 28. Thiamine 29. Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 04:00 PM\n FEVER - 102.3\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Vancomycin - 09:30 PM\n Infusions:\n Labetalol - 1.5 mg/min\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 12:30 AM\n Labetalol - 02:50 AM\n Other medications:\n Flowsheet Data as of 05:23 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 39.1\nC (102.3\n T current: 37.4\nC (99.3\n HR: 92 (91 - 111) bpm\n BP: 149/72(100) {119/58(81) - 193/94(132)} mmHg\n RR: 26 (13 - 35) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,006 mL\n 279 mL\n PO:\n Tube feeding:\n 120 mL\n 158 mL\n IV Fluid:\n 1,826 mL\n 121 mL\n Blood products:\n Total out:\n 1,290 mL\n 300 mL\n Urine:\n 1,290 mL\n 300 mL\n NG:\n Stool:\n Drains:\n Balance:\n 716 mL\n -21 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 160 (160 - 160) mL\n PS : 15 cmH2O\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 22 cmH2O\n Plateau: 16 cmH2O\n Compliance: 54.5 cmH2O/mL\n SPO2: 94%\n ABG: 7.42/33/98./17/-1\n Ve: 11.5 L/min\n PaO2 / FiO2: 245\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli), Moves all\n extremities\n Labs / Radiology\n 300 K/uL\n 9.5 g/dL\n 112 mg/dL\n 1.0 mg/dL\n 17 mEq/L\n 4.0 mEq/L\n 19 mg/dL\n 115 mEq/L\n 143 mEq/L\n 27.1 %\n 8.6 K/uL\n [image002.jpg]\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n WBC\n 12.0\n 9.4\n 8.5\n 8.5\n 8.6\n Hct\n 26.5\n 29.1\n 27.2\n 27.7\n 27.1\n Plt\n 98\n 300\n Creatinine\n 1.4\n 1.2\n 1.3\n 1.1\n 1.0\n TCO2\n 22\n 23\n 25\n 22\n 22\n Glucose\n 121\n 114\n 81\n 91\n 112\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.3 mg/dL,\n Mg:2.0 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, dilantin, ICP sustained in 20s\n so EVD opened to 20cm H2O drainage, VPS with unchanged repeat CT\n head\n Cardiovascular: goal SBP < 160, labetolol gtt due to difficult to\n control BP with PO, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs restarted.\n Nutrition: Tube feeding\n Renal: Foley, follow UOP\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Check cultures, Kefzol stopped for rash, dosed\n intraop and post op Vanc for ventric drain, pancultured for temp of\n 102. recieved ID approval for vanc, follow vanco level\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid, Subdural)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 08:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\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: ICU consent signed Comments:\n Code status: Full code\n Disposition:\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-01-24 00:00:00.000", "description": "Intensivist Note", "row_id": 655649, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Chief complaint:\n CVA\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Artificial Tear Ointment 5. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Caspofungin 9. Caspofungin 10.\n Chlorhexidine Gluconate 0.12% Oral Rinse\n 11. ChlorproMAZINE 12. Docusate Sodium (Liquid) 13. Escitalopram\n Oxalate 14. Famotidine 15. Fentanyl Citrate\n 16. Fentanyl Citrate 17. FoLIC Acid 18. Heparin 19. HydrALAzine 20.\n HydrALAzine 21. 22. Insulin\n 23. Influenza Virus Vaccine 24. Labetalol 25. Labetalol 26. Magnesium\n Sulfate 27. Midazolam 28. Multivitamins\n 29. Olanzapine 30. OxycoDONE-Acetaminophen Elixir 31.\n Piperacillin-Tazobactam\n 24 Hour Events:\n ARTERIAL LINE - STOP 05:39 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Vancomycin - 08:30 PM\n Caspofungin - 04:00 PM\n Piperacillin/Tazobactam (Zosyn) - 02:00 AM\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:52 AM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Midazolam (Versed) - 12:12 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: 37.1\nC (98.8\n T current: 36.4\nC (97.6\n HR: 91 (71 - 96) bpm\n BP: 135/71(86) {115/65(77) - 179/105(119)} mmHg\n RR: 16 (15 - 24) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 2,237 mL\n 578 mL\n PO:\n Tube feeding:\n 1,277 mL\n 389 mL\n IV Fluid:\n 840 mL\n 159 mL\n Blood products:\n Total out:\n 1,960 mL\n 340 mL\n Urine:\n 1,960 mL\n 340 mL\n NG:\n Stool:\n Drains:\n Balance:\n 277 mL\n 238 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 500 (500 - 500) mL\n Vt (Spontaneous): 681 (410 - 681) mL\n PS : 12 cmH2O\n RR (Set): 12\n RR (Spontaneous): 16\n PEEP: 10 cmH2O\n FiO2: 40%\n PIP: 23 cmH2O\n Plateau: 16 cmH2O\n Compliance: 83.3 cmH2O/mL\n SPO2: 98%\n ABG: ///23/\n Ve: 10.5 L/min\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Absent), (Temperature: Warm)\n Right Extremities: (Edema: Absent), (Temperature: Warm)\n Neurologic: (Responds to: Verbal stimuli, Tactile stimuli, Noxious\n stimuli, Unresponsive), Moves all extremities\n Labs / Radiology\n 337 K/uL\n 7.8 g/dL\n 133 mg/dL\n 1.1 mg/dL\n 23 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 102 mEq/L\n 135 mEq/L\n 22.1 %\n 13.3 K/uL\n [image002.jpg]\n 02:14 PM\n 02:46 AM\n 02:56 AM\n 01:22 PM\n 01:50 PM\n 02:55 AM\n 03:10 AM\n 10:00 AM\n 04:00 PM\n 02:52 AM\n WBC\n 10.8\n 14.5\n 13.3\n Hct\n 23.3\n 22.6\n 22.1\n Plt\n \n Creatinine\n 1.2\n 1.3\n 1.4\n 1.1\n TCO2\n 28\n 27\n 25\n 24\n Glucose\n 141\n 108\n 103\n 190\n 137\n 133\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:8.6 mg/dL,\n Mg:2.1 mg/dL, PO4:3.1 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, cont zyprexa and\n increase dose, versed for agitation, started SSRI,\n Cardiovascular: goal SBP < 160, Decreased labetolol to 300'''/hydral\n 25'''.\n Pulmonary: Trach collar trials, bilat pleural effusions IP does not\n want to tap. Dropped sats (likely to atelectasis) after tachypnic\n episode and placed back on CMV. f/u CXR, consulted IP for high trach\n cuff pressures\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs\n Renal: adequate UOP, ARF resolved, PRN lasix,\n Hematology: f/u Hct, checking B12, folate, retic count\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date including BAL\n with oropharyngeal flora believed to be from microaspiration. zosyn\n started for VAP. temp spike and pan cx'd, caspofungin started for\n in sputum, CT abdomen PND\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids:\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid), (Respiratory\n distress: Failure)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 12:58 AM 65.\n mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 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: 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": "2157-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653442, "text": "Hypertension, benign\n Assessment:\n SBP 90-150\n Action:\n Labetalol gtt off after dose lopressor\n Response:\n SBP initially down to 90\ns then back up to 120\n Plan:\n Cont to monitor BP, maintain SBP <180\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro status unchaged from previous assessments\n ICP stable \n Minimal output from ventriculostomy\n Action:\n Q1 ICP\n Q2 Neuro assessment\n Monitor CSF output\n Plan:\n To OR for VP shunt on Thursday\n" }, { "category": "Physician ", "chartdate": "2157-01-15 00:00:00.000", "description": "Intensivist Note", "row_id": 654053, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B\n Sulfate Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine\n Gluconate 0.12% Oral Rinse, ChlorproMAZINE, Docusate Sodium (Liquid),\n Famotidine, Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine ,\n Insulin, Influenza Virus Vaccine, Labetalol,Magnesium Sulfate,\n Multivitamins, OxycoDONE-Acetaminophen Elixir, Phenytoin, Potassium\n Chloride,Thiamine, Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 05:00 PM\n Blood, urine, sputum\n FEVER - 102.0\nF - 04:00 PM\n : worsened with restarting ancef. Switched to vancomycin.\n awaiting AM level and then will need ID approval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Other ICU medications:\n Labetalol - 07:30 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 02:45 AM\n Flowsheet Data as of 03:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.6\nC (99.6\n HR: 98 (78 - 104) bpm\n BP: 154/70(101) {104/58(83) - 183/85(120)} mmHg\n RR: 18 (14 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (5 - 15) mmHg\n Total In:\n 1,999 mL\n 283 mL\n PO:\n Tube feeding:\n 3 mL\n IV Fluid:\n 1,936 mL\n 283 mL\n Blood products:\n Total out:\n 2,561 mL\n 160 mL\n Urine:\n 1,550 mL\n 160 mL\n NG:\n Stool:\n Drains:\n 51 mL\n Balance:\n -562 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 97%\n ABG: 7.43/32/96./19/-1\n Ve: 11.4 L/min\n PaO2 / FiO2: 242\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: )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: :\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No movement), (LUE: Weakness), (RLE:\n No movement), (LLE: Weakness)\n Labs / Radiology\n 398 K/uL\n 9.9 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 112 mEq/L\n 141 mEq/L\n 27.7 %\n 8.5 K/uL\n [image002.jpg]\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n WBC\n 15.4\n 12.0\n 9.4\n 8.5\n 8.5\n Hct\n 30.6\n 26.5\n 29.1\n 27.2\n 27.7\n Plt\n 81\n 398\n Creatinine\n 1.6\n 1.4\n 1.2\n 1.3\n 1.1\n TCO2\n 22\n 22\n 23\n 25\n 22\n Glucose\n 96\n 121\n 114\n 81\n 91\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.6 mg/dL,\n Mg:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), , ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, dilantin, repeat head CT, ICP\n sustained in 20s so EVD opened to 20cm H2O drainage, VPS with\n unchanged repeat CT head\n Cardiovascular: goal SBP < 180, labetolol po, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs held via PEG. resume in AM. overnight\n multiple large watery BM sent for C.Diff\n Nutrition: TFs held, NS @ 75cc/hr. KVO and resume TF in AM\n Renal: Foley, Adequate UO, adequate UOP, renal failure resolving\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Kefzol stopped for , start Vanc for\n ventric drain, pancultured for temp of 102. Vanc level in AM and will\n need ID approval for vanc check c.diff\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CT head: Unchanged size of lateral ventricles with patency of\n the fourth ventricle. Unchanged appearance of the left frontal\n hemorrhage, intraventricular hemorrhage and scattered foci of\n subarachnoid hemorrhage. No new focus of hemorrhage is detected\n Fluids: NS\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-01-15 00:00:00.000", "description": "Intensivist Note", "row_id": 653998, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n PMHx:\n HTN\n Current medications:\n Acetaminophen, Artificial Tear Ointment, Bacitracin/Polymyxin B\n Sulfate Opht. Oint, Bisacodyl, Calcium Gluconate, Chlorhexidine\n Gluconate 0.12% Oral Rinse, ChlorproMAZINE, Docusate Sodium (Liquid),\n Famotidine, Fentanyl Citrate, FoLIC Acid, Heparin, HydrALAzine ,\n Insulin, Influenza Virus Vaccine, Labetalol,Magnesium Sulfate,\n Multivitamins, OxycoDONE-Acetaminophen Elixir, Phenytoin, Potassium\n Chloride,Thiamine, Vancomycin\n 24 Hour Events:\n PAN CULTURE - At 05:00 PM\n Blood, urine, sputum\n FEVER - 102.0\nF - 04:00 PM\n : worsened with restarting ancef. Switched to vancomycin.\n awaiting AM level and then will need ID approval\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Other ICU medications:\n Labetalol - 07:30 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Fentanyl - 02:45 AM\n Flowsheet Data as of 03:53 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.7\nC (101.7\n T current: 37.6\nC (99.6\n HR: 98 (78 - 104) bpm\n BP: 154/70(101) {104/58(83) - 183/85(120)} mmHg\n RR: 18 (14 - 22) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (5 - 15) mmHg\n Total In:\n 1,999 mL\n 283 mL\n PO:\n Tube feeding:\n 3 mL\n IV Fluid:\n 1,936 mL\n 283 mL\n Blood products:\n Total out:\n 2,561 mL\n 160 mL\n Urine:\n 1,550 mL\n 160 mL\n NG:\n Stool:\n Drains:\n 51 mL\n Balance:\n -562 mL\n 123 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 97%\n ABG: 7.43/32/96./19/-1\n Ve: 11.4 L/min\n PaO2 / FiO2: 242\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: )\n Abdominal: Soft, Non-distended, Non-tender\n Left Extremities: (Edema: 1+)\n Right Extremities: (Edema: 1+)\n Skin: :\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli),\n No(t) Moves all extremities, (RUE: No movement), (LUE: Weakness), (RLE:\n No movement), (LLE: Weakness)\n Labs / Radiology\n 398 K/uL\n 9.9 g/dL\n 91 mg/dL\n 1.1 mg/dL\n 19 mEq/L\n 4.2 mEq/L\n 21 mg/dL\n 112 mEq/L\n 141 mEq/L\n 27.7 %\n 8.5 K/uL\n [image002.jpg]\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n WBC\n 15.4\n 12.0\n 9.4\n 8.5\n 8.5\n Hct\n 30.6\n 26.5\n 29.1\n 27.2\n 27.7\n Plt\n 81\n 398\n Creatinine\n 1.6\n 1.4\n 1.2\n 1.3\n 1.1\n TCO2\n 22\n 22\n 23\n 25\n 22\n Glucose\n 96\n 121\n 114\n 81\n 91\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.6 mg/dL,\n Mg:1.8 mg/dL, PO4:3.7 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), , ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, dilantin, repeat head CT, ICP\n sustained in 20s so EVD opened to 20cm H2O drainage, VPS with\n unchanged repeat CT head\n Cardiovascular: goal SBP < 180, labetolol po, prn Hydralazine\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs held via PEG. resume in AM. overnight\n multiple large watery BM sent for C.Diff\n Nutrition: TFs held, NS @ 75cc/hr. KVO and resume TF in AM\n Renal: Foley, Adequate UO, adequate UOP, renal failure resolving\n Hematology: Serial Hct\n Endocrine: RISS\n Infectious Disease: Kefzol stopped for , start Vanc for\n ventric drain, pancultured for temp of 102. Vanc level in AM and will\n need ID approval for vanc\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CT head: Unchanged size of lateral ventricles with patency of\n the fourth ventricle. Unchanged appearance of the left frontal\n hemorrhage, intraventricular hemorrhage and scattered foci of\n subarachnoid hemorrhage. No new focus of hemorrhage is detected\n Fluids: NS\n Consults: Neuro surgery, Neurology, Nephrology\n Billing Diagnosis:\n ICU Care\n Nutrition:\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Communication: Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent:\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654314, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH with IVH in left lateral ventricle\n PMHx:\n HTN, SAH\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro checks ordered for q 4 hrs\n Action:\n Performed q 4 hrs\n Response:\n Pts neuro exam unchanged, moves left arm, tracks, follows some\n commands, PERLA\n Plan:\n Cont q 4 hr neuro checks\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Resp therapist stated he thought pt should be exempt from RSBI d/t pt\n w/ hi resp rate to 50\n Action:\n Cont pulm toilet/cares, pt suctioned approx q 3 hrs\n Response:\n Pt\ns O2 sat 94-95% after suctioning\n Plan:\n Cont turning pt, suctioning q 2-3 hrs\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt conts to have low grade fevers\n Action:\n Received Tylenol at 20:00 and 04:00\n Response:\n Pt w/out T spike or significantly elevated T\n Plan:\n Cont T q 4 hrs and prn\n Anemia, other\n Assessment:\n Hct 25 this a.m., was 27 yest a.m.\n Action:\n No orders for transfusion at this time\n Response:\n ***\n Plan:\n Cont to follow hct qd and prn\n" }, { "category": "Nursing", "chartdate": "2157-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654422, "text": "Intracerebral hemorrhage (ICH)\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": "2157-01-17 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654423, "text": "HPI:\n 67 year old right handed woman with a history of CAD s/p MI x2, HTN,\n DM, PVD s/p bilateral BKA, and s/p living un-related renal transplant\n 10 years prior who initially presented to on with a \n month history of left arm shaking, weakness and dysarthria, who was\n found to have a right MCA infarction. Her mental status declined and a\n repeat head CT in the evening showed an acute large right MCA infarct.\n On her mental status worsened and a repeat head CT showed\n increasing infarct involving right ACA and MCA so she went to the OR\n for a decompressive right hemicraniectomy\n Intracerebral hemorrhage (ICH)\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": "2157-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653608, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient\ns neuro exam essentially unchanged. Eyes open spontaneously,\n moving left upper extremity frequently. No movement RUE, bilat LE\n withdraw to pain and move slightly on bed. Rarely following commands\n overnight. Pupils approx 3mm equal & brisk. Vent drain 20 cm @ tragus\n with approx 5-10 cc csf every 2 hours. ICPs ranging .\n Action:\n Vent drain clamped as ordered by NSURG approx 11pm. Cont\nd to follow\n neuro exam and ICPs.\n Response:\n ICP 6-10\n Plan:\n Open drain if ICPs rise to 20. VP shunt today if patient unable to\n tolerate clamping trial.\n Hypertension, benign\n Assessment:\n Occasionally hypertensive 180-200\ns. Heart rate mostly 90\ns, NSR.\n Appears comfortable, does not appear in pain but restless @ times.\n Action:\n Patient on PO Labetolol. Also given prn doses Lopressor &\n hydralazine. Tylenol for ? comfort.\n Response:\n Patient\ns sbp now 140-150\n Plan:\n Continue to maintain sbp < 180.\n" }, { "category": "Nursing", "chartdate": "2157-01-16 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654169, "text": "Hypertension, benign\n Assessment:\n SBP 150-170\n Per nmed new bp goal <160\n After mult doses labetalol bp decreasing transiently <160 but not\n sustaining\n Medicated for discomfort\n Medicated for fever\n Action:\n Po dose increased\n no effect\n Labetalol gtt restarted\n Response:\n BP well controlled on labetalol gtt\n Plan:\n F/u re: new po regimen to wean off gtt\n" }, { "category": "Nursing", "chartdate": "2157-01-24 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655720, "text": "Hypertension, benign\n Assessment:\n Nbp 140-160\ns systolic\n Action:\n Labetalol and hydralizine given per \n Response:\n No need for prn medications, systolic nbp remains <160\n Plan:\n Cont to monitor nbp and keep systolic <160\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro status remains the same from days, pt alert, perrla, moves left\n arm and left leg withdraws to pain, no movement to right arm noted ,\n some reflexive movement noted in right leg\n Action:\n Q 2 hour neuron checks,\n Response:\n No change in neuro status\n Plan:\n Cont with q 2 hour neuron checks\n" }, { "category": "Nursing", "chartdate": "2157-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654526, "text": "HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt awake and intermittently follows commands on the left side. No\n movement of the right arm. Withdraws right. Side to painful stimuli\n Able to lift and hold left arm and moves left leg on bed. Right pupil\n reacts briskly to light. Left pupil unable to assess due to corneal\n ulcer. Head dressing intact and abd incision intact with no reddness or\n drainage.\n Action:\n Continue with neuro checks\n Response:\n No change in neuro status\n Plan:\n Continue with neuro checks. No change in current plan\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Pt resting on cmv . pt appears comfortable on current rate breath\n sounds are clear. Pt suctioned for thin yellow sputum. Trache site is\n clean and dry.\n Action:\n ? wean back ot cpap or trache collar today.\n Response:\n Pt comfortable on cmv at this time\n Plan:\n Try to wean back to cpap and trache collar if tolerating today.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-18 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654636, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 22\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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 / 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: Intolerant of\n weaning attempts, Cannot protect airway\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Interventional radiology\n Bedside Procedures:\n Comments:\n" }, { "category": "Nursing", "chartdate": "2157-01-18 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654652, "text": ".H/O airway, Inability to Protect (Risk for Aspiration, Altered Gag,\n Airway Clearance, Cough)\n Assessment:\n Continues to have moderate to copious thick, white, secretions in oral\n and trach. Per\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653606, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Patient\ns neuro exam essentially unchanged. Eyes open spontaneously,\n moving left upper extremity frequently. No movement RUE, bilat LE\n withdraw to pain and move slightly on bed. Rarely following commands\n overnight. Pupils approx 3mm equal & brisk. Vent drain 20 cm @ tragus\n with approx 5-10 cc csf every 2 hours. ICPs ranging .\n Action:\n Vent drain clamped as ordered by NSURG. Cont\nd to follow neuro exam\n and ICPs.\n Response:\n ICP 6-10\n Plan:\n Unclamp drain if ICPs rise to 20. VP shunt today if patient unable to\n tolerate clamping trial.\n Hypertension, benign\n Assessment:\n Occasionally hypertensive 180-200\ns. Heart rate mostly 90\ns, NSR.\n Appears comfortable, does not appear in pain but restless @ times.\n Action:\n Patient on PO Labetolol. Also given prn doses Lopressor & hydralazine.\n Response:\n Plan:\n" }, { "category": "Social Work", "chartdate": "2157-01-14 00:00:00.000", "description": "Social Work Progress Note", "row_id": 653930, "text": "Pt\ns cousin and friend came in today to see pt, to\n get a medical update and to pick up documents for legal guardianship.\n cousin , they just left the rehab center where pt\ns mother is\n staying post d/c from the hospital. The social worker at the rehab\n arranged for an elder legal group to meet with the mother, cousin and\n friend to plan for mother ; health care proxy and financial\n matters. The legal group has offered to take pt\ns case as well. \n and they will be able to get advise and guidance with re; to\n long term planning for mother and pt.\n Reviewed the guardianship forms and discussed the process that will\n occur at the probate court. Paperwork provided. Arranged for\n the neurology resident to update cousin and friend with pt medical\n status . Cousin and friend asked questions so that they could relay\n information to pt\ns mother and to help them to represent pt\ns case in\n petitioning for guardianship. Cousin will request guardianship of\n person and estate and will ask the judge to appoint the friend as\n co-guardian.\n cousin pt\ns current insurance will term at the end of the month and\n she will be looking into the possibility of arranging Cobra payment for\n pt\ns care.\n Will continue to follow and to support cousin and friend who are trying\n to work together on behalf of pt and his yr old mother as there is\n no other family.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-16 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654254, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 20\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Procedure location:\n Reason:\n Tube Type\n ETT:\n Position: cm at teeth\n Route:\n Type: Not applicable\n Size: Not applicable\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 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 / 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: Intolerant of\n weaning attempts\n Respiratory Care Shift Procedures\n Transports:\n Destination (R/T)\n Time\n Complications\n Comments\n Bedside Procedures:\n Comments:\n Patient remains on mechanical ventilation, still wearing an 8\n Percutaneous Portex trach tube, breath sounds went from clear/crackles\n to clear, suctioned intermittently for small amounts of loose white\n secretions, no distress occurred, SPO2 remained mid to upper 90s, will\n continues to be followed.\n" }, { "category": "Rehab Services", "chartdate": "2157-01-11 00:00:00.000", "description": "Physical Therapy Progress Note", "row_id": 653359, "text": "Subjective:\n pt nonverbal, nodding yes/no to few questions\n Objective:\n Follow up PT visit to address goals of: . Patient seen today\n for balance training, patient education\n Updated medical status: Awaiting VP shunt on Thursday \n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Rolling:\n max A x 2\n\n\n\n\n\n T\n Supine/\n Sidelying to Sit:\n max A x 2\n\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 Aerobic Activity Response: Trached and on vent, CMV, 40% fiO2, TV 600,\n f 12, P 5\n Position\n HR\n BP\n RR\n O[2] sat\n RPE\n Rest\n Supine\n 80\n 146/72\n 13\n 98%\n Activity\n Sit\n 170/80\n 16-18\n Recovery\n Supine\n 86\n 168/75\n 16\n 97%\n Total distance walked: n/a\n Minutes:\n Gait: Clarification:\n Rolling: required max A x 2, pt did not initiate movement or assist\n with movement\n Sup to sit: required max A x 2, pt did not initiate movement or assist\n with movement\n Balance: Seated: sat x 5 min, required max A to maintain, no\n attempts to use UE to support self or prevent LOB, required max A for\n head control as well\n Education / Communication: Educated patient as to role of PT.\n Communicated with RN and MD to clarify orders. OK for sitting \n MD. Co-treated with OT.\n Other: Of note, SBP was consistently in the 160-170 range at .\n After 5 min, BP abruptly dropped to 130/80 according to arterial BP.\n Upon return to supine, BP stabilized.\n BS: coarse BS B lung fields, diminished at B bases\n Assessment: Patient tolerated fairly well today. Continues to have\n limited participation and poor balance reactions at . However, pt\n did initiate more breathes spontaneously at . Patient continues to\n need rehab on d/c with guarded rehab potential.\n Anticipated Discharge: Rehab\n Plan: Sup to sit\n Seated balance at \n Stretching B UE/LE\n Ther-ex\n Face Time: 14:45\n 15:15\n" }, { "category": "Nursing", "chartdate": "2157-01-19 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654715, "text": "Hypertension, benign\n Assessment:\n SBP sustaining >160\n Action:\n Given prn IV labetalol\n Given Fentanyl for suspected discomfort\n Given hydralizine\n Response:\n After mult doses labetalol back down <160\n Plan:\n Cont to monitor and medicate as needed.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remains on AC overnight\n Action:\n Attempted CPAP 15 PS this am\n Response:\n Tol x 30 min then RR up to 50\ns. Placed back on AC.\n Plan:\n Cont to wean as tolerated.\n Corneal Arasion\n Assessment:\n Left eye remains reddened and cloudy over cornea\n Action:\n Artificial tears and bacitracin ointment as ordered\n Attempted to steri strip eyes closed\n Response:\n pt opening eyes spontaneously and not staying cosed.\n Plan:\n Cont with current plan.\n" }, { "category": "Nursing", "chartdate": "2157-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653597, "text": "Hypertension, benign\n Assessment:\n Pt changed to PO labetalol 200 mg TID. Continued with PRN IV 10mg\n Labetalol for SBP >180.\n Action:\n Pt maintained SBP <180 for most of shift. Sustained SBP in 180\ns with\n HR in 100\ns with spiked febrile period. SBP did not respond to IVP\n Labetalol or IVP Hydralazine. MD aware and waiting to see if with\n reduced fever if SBP will lower.\n Response:\n Placed on cooling blanket. Minimizing stimulation.\n Plan:\n Continue po labetalol. IVP prn Labetalol. Monitor and continue to\n inform SICU resident with sustained SBP <180.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Planned VP Shunt for .\n Action:\n EVD continues to drain clear csf. Leveled at 20 above tragus.\n Response:\n ICP WNL. Output for EVD WNL.\n Plan:\n Pt to be NPO at 2400. Hold Heparin SQ at 2400. Send blood bank\n specimen for type and cross.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n TMAX 101.9. SICU Team and Attending aware.\n Action:\n 650mg Tylenol. Urine and Blood Cultures Sent. Neurosurg Team declined\n to send CSF for culture. Sputum culture when patient produces enough of\n a sample. Cooling Blanket applied.\n Response:\n Latest TMAX 101.7\n Plan:\n Continue to apply cooling blanket. Await culture results. ? OR with\n elevated PO temp.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-17 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654340, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 21\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tube Type\n Tracheostomy tube:\n Type: Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV: No\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 mL /\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Secretions\n Sputum color / consistency: White / Thick\n Sputum source/amount: Suctioned / Small\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing;\n Comments: Remain on vent support/ No vent changes.\n Assessment of breathing comfort: No response (sleeping / sedated)\n Invasive ventilation assessment:\n Trigger work assessment: Triggering synchronously\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated,\n Maintain PEEP at current level and reduce FiO2 as tolerated; Comments:\n Unable to complete RSBI R > 35bpm.\n Reason for continuing current ventilatory support: Sedated / Paralyzed,\n Underlying illness not resolved\n" }, { "category": "Physician ", "chartdate": "2157-01-17 00:00:00.000", "description": "Intensivist Note", "row_id": 654359, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH, IVH\n PMHx:\n ?Hypertension\n Current medications:\n Acetaminophen 5. Artificial Tear Ointment 6. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. ChlorproMAZINE\n 11. Docusate Sodium (Liquid) 12. Famotidine 13. Fentanyl Citrate 14.\n FoLIC Acid 15. Furosemide 16. Heparin\n 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine 21.\n Labetalol 22. Labetalol 23. Magnesium Sulfate\n 24. Multivitamins 25. OxycoDONE-Acetaminophen Elixir 26. Potassium\n Chloride 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Thiamine\n 24 Hour Events:\n FEVER - 101.3\nF - 12:00 PM\n Hypertension improved on labetolol po\n Lasix started by neuro\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.2\nC (100.8\n HR: 96 (79 - 103) bpm\n BP: 136/71(95) {93/50(65) - 164/79(111)} mmHg\n RR: 19 (15 - 32) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,352 mL\n 392 mL\n PO:\n Tube feeding:\n 721 mL\n 219 mL\n IV Fluid:\n 411 mL\n 73 mL\n Blood products:\n Total out:\n 972 mL\n 690 mL\n Urine:\n 972 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 380 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SPO2: 94%\n ABG: 7.49/30/113/22/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 283\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Crackles :\n scattered)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), No(t) Moves all extremities, (RUE: No movement),\n (LUE: Weakness), (RLE: No movement), (LLE: Weakness), Sedated,\n Intermittently follows commands\n Labs / Radiology\n 297 K/uL\n 9.1 g/dL\n 110 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 116 mEq/L\n 146 mEq/L\n 25.0 %\n 7.5 K/uL\n [image002.jpg]\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n WBC\n 9.4\n 8.5\n 8.5\n 8.6\n 7.5\n Hct\n 29.1\n 27.2\n 27.7\n 27.1\n 25.0\n Plt\n 00\n 297\n Creatinine\n 1.2\n 1.3\n 1.1\n 1.0\n 1.3\n TCO2\n 23\n 25\n 22\n 22\n 23\n Glucose\n 114\n 81\n 91\n 112\n 110\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.8 mg/dL,\n Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS,\n dilantin stopped\n CV: goal SBP < 180, started on labetolol po for hypertension, prn\n Hydralazine\n Resp: s/p Trach, wean to PSV\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix 20mg daily started\n FEN: TFs, hypernatremic, may start free water boluses via PEG, d/c\n lasix\n Heme: stable Hct\n Endo: RISS\n ID: multiple cultures negative to date, f/u cultures\n TLD: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wound: left corneal ulcer, optho following - on bacitracin oint\n Prophylaxis: famotidine, SQH\n Imaging: none\n Dispo: start screening for vented rehab\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:17 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\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": "Physician ", "chartdate": "2157-01-17 00:00:00.000", "description": "Intensivist Note", "row_id": 654375, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n SAH, IVH\n PMHx:\n ?Hypertension\n Current medications:\n Acetaminophen 5. Artificial Tear Ointment 6. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. ChlorproMAZINE\n 11. Docusate Sodium (Liquid) 12. Famotidine 13. Fentanyl Citrate 14.\n FoLIC Acid 15. Furosemide 16. Heparin\n 17. HydrALAzine 18. 19. Insulin 20. Influenza Virus Vaccine 21.\n Labetalol 22. Labetalol 23. Magnesium Sulfate\n 24. Multivitamins 25. OxycoDONE-Acetaminophen Elixir 26. Potassium\n Chloride 27. Sodium Chloride 0.9% Flush\n 28. Sodium Chloride 0.9% Flush 29. Thiamine\n 24 Hour Events:\n FEVER - 101.3\nF - 12:00 PM\n Hypertension improved on labetolol po\n Lasix started by neuro\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 12:15 PM\n Vancomycin - 09:30 PM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:10 AM\n Other medications:\n Flowsheet Data as of 07:21 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.5\nC (101.3\n T current: 38.2\nC (100.8\n HR: 96 (79 - 103) bpm\n BP: 136/71(95) {93/50(65) - 164/79(111)} mmHg\n RR: 19 (15 - 32) insp/min\n SPO2: 94%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,352 mL\n 392 mL\n PO:\n Tube feeding:\n 721 mL\n 219 mL\n IV Fluid:\n 411 mL\n 73 mL\n Blood products:\n Total out:\n 972 mL\n 690 mL\n Urine:\n 972 mL\n 540 mL\n NG:\n Stool:\n Drains:\n Balance:\n 380 mL\n -298 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI Deferred: RR >35\n PIP: 23 cmH2O\n Plateau: 18 cmH2O\n SPO2: 94%\n ABG: 7.49/30/113/22/0\n Ve: 11.3 L/min\n PaO2 / FiO2: 283\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: CTA bilateral : , Crackles :\n scattered)\n Abdominal: Soft, Non-distended, Bowel sounds present\n Left Extremities: (Edema: Trace), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: 1+), (Temperature: Warm), (Pulse - Dorsalis\n pedis: Diminished), (Pulse - Posterior tibial: Diminished)\n Skin: (Incision: Clean / Dry / Intact)\n Neurologic: Follows simple commands, (Responds to: Verbal stimuli,\n Tactile stimuli), No(t) Moves all extremities, (RUE: No movement),\n (LUE: Weakness), (RLE: No movement), (LLE: Weakness), Sedated,\n Intermittently follows commands\n Labs / Radiology\n 297 K/uL\n 9.1 g/dL\n 110 mg/dL\n 1.3 mg/dL\n 22 mEq/L\n 3.7 mEq/L\n 22 mg/dL\n 116 mEq/L\n 146 mEq/L\n 25.0 %\n 7.5 K/uL\n [image002.jpg]\n 03:35 AM\n 02:28 AM\n 02:32 AM\n 04:59 AM\n 02:13 AM\n 02:27 AM\n 03:01 AM\n 03:33 AM\n 04:12 AM\n 05:43 AM\n WBC\n 9.4\n 8.5\n 8.5\n 8.6\n 7.5\n Hct\n 29.1\n 27.2\n 27.7\n 27.1\n 25.0\n Plt\n 00\n 297\n Creatinine\n 1.2\n 1.3\n 1.1\n 1.0\n 1.3\n TCO2\n 23\n 25\n 22\n 22\n 23\n Glucose\n 114\n 81\n 91\n 112\n 110\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:7.8 mg/dL,\n Mg:2.1 mg/dL, PO4:2.8 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neuro: stable cerebral hemorrhages, s/p VPS, dilantin stopped\n CV: goal SBP < 180, started on labetolol po for hypertension, prn\n Hydralazine\n Resp: s/p Trach, wean to CPAP/PSV\n GI: TFs\n GU: adequate UOP, ARF resolved, lasix 20mg daily started per neurology\n will now stop increased creatinine and hypernatremia\n FEN: TFs, hypernatremic, may start free water boluses via PEG, d/c\n lasix\n Heme: stable Hct\n Endo: RISS\n ID: multiple cultures negative to date, f/u cultures\n TLD: trach, foley, a-line, EVD, PEG, rt PICC, VPS\n Wound: left corneal ulcer, optho following - on bacitracin oint\n Prophylaxis: famotidine, SQH\n Imaging: none\n Dispo: start screening for vented rehab\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 05:17 AM 30 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\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": "Rehab Services", "chartdate": "2157-01-17 00:00:00.000", "description": "Physical Therapy Evaluation Note", "row_id": 654379, "text": "Attending Physician: \n Medical Diagnosis / ICD 9: / 431\n History of Present Illness / Subjective Complaint: 53 yo M admitted to\n OSH with c/o headache and right sided weakness, head CT showed L\n ponto-medullary IPH with transferred to on and vent\n drain placed. Suspected cavernoma or AVM is likely etiology. Course\n complicated by failed extubation now with trach and peg on , VP\n shunt and PICC line placed . Pt currently intubated on CMV and\n febrile\n Past Medical / Surgical History: see initial evaluation\n Medications: Lasix, Heparin, Hydralazine, Percocet, Labetalol,\n Vancomycin\n Radiology: head CT : unchanged ventricular enlargement, unchanged\n L frontal hemorrhage\n Labs:\n 25.0\n 9.1\n 297\n 7.5\n [image002.jpg]\n Other labs:\n ABGs : 113/30/7.49/23\n Activity Orders: bedrest on POE but spoke to team who reports ok to sit\n edge of bed\n Social / Occupational History: see initial eval\n Living Environment: see initial eval\n Prior Functional Status / Activity Level: see initial eval\n Objective Test\n Arousal / Attention / Cognition / Communication: eyes open throughout\n treatment; inconsistently responds to verbal stimulation to look toward\n therapist. following only 5% simple commands with multiple verbal and\n physical cues; constant beats nystagmus\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 97\n 158/73\n 18\n 98%\n Rest\n /\n Sit\n 95\n 144/70\n 25\n 100%\n Activity\n /\n Stand\n /\n Recovery\n 95\n 144/66\n 18\n 100%\n Total distance walked:\n Minutes:\n Pulmonary Status: Pt on CMV 40% FiO2, TV ~600mL; BS: course rhonchi\n throughout, diminished at bases; breathing pattern slightly labored\n after sitting; spontaneous coughing during sitting-- in-line suctioned\n for large amount thick yellow secretions\n Integumentary / Vascular: R cranial gauze dressing C/D/I, staple in\n place; L eye corneal abrasion RN with stitches lateral eyelids--L\n eye red; R UE PICC and radial arterial line; RUE edema, foley, rectal\n tube, PEG tube, trach\n Sensory Integrity: Withdraws to pain all but RUE\n Pain / Limiting Symptoms: BP elevation with RLE passive ROM and tone\n testing\n Posture: sulcus R -- 1 finger in sitting\n Range of Motion\n Muscle Performance\n WFL throughtout extremities PROM\n LUE moving at least partially against gravity all joints; LLE resists\n ROM and some movement noted against gravity; RLE trace movement\n anterior tib; RUE no active movement seen\n Motor Function: LUE isolated and purposeful movement; LLE limited\n spontaneous movement but able to hold flexed knee against gravity and\n slowly lower into extension; some LLE flexor pattern exhibited with\n stress; RUE no movement-- triceps and shoulder extensor tone 1+/5,\n biceps and shoulder flexors hypotonic; RLE trace anterior tib, tone\n normal\n Functional Status:\n Activity\n Clarification\n I\n S\n CG\n Min\n Mod\n Max\n Gait, Locomotion: dependent roll to right; dependent supine to sit with\n assist of two\n Rolling:\n Dependent\n\n\n\n\n\n\n Supine /\n Sidelying to Sit:\n Dependent\n\n\n\n\n\n\n Transfer:\n N/A\n\n\n\n\n\n\n Sit to Stand:\n N/A\n\n\n\n\n\n\n Ambulation:\n N/A\n\n\n\n\n\n\n Stairs:\n N/A\n\n\n\n\n\n\n Balance: sat edge of bed for 3 minutes with mod-maxA of one-- pt using\n LUE to support self intermittently; pt losing balace to left and\n posteriorly\n Education / Communication: communication with RN, neuro team, and\n surgical team regarding patient status\n Intervention: edge of bed balance\n Diagnosis:\n 1.\n Aerobic Capacity / Endurance, Impaired\n 2.\n Arousal, Attention, and Cognition, Impaired\n 3.\n Balance, Impaired\n 4.\n Muscle Performace, Impaired\n 5.\n Impaired ventilation\n 6.\n Impaired gas exchange\n 7.\n Impaired airway clearance\n Clinical impression / Prognosis: 53m with prolonged hospital stay for\n intracranial hemorrhage and ventilatory failure requiring prolonged\n intubation p/w above impairments c/w CNS dysfunction as well as\n ventilatory pump failure. Pt has not made improvements since\n evaluation; however feel this is secondary to extensive illness\n preventing physical therapy intervention. Pt will require d/c to rehab\n once medically stable. Rehab potential may be limited by degree and\n location of hemorrhage as well as extensive complications; however\n patient is young and has a high baseline status.\n Goals\n Time frame: 1 week\n 1.\n patient follow 75% simple 1 step commands\n 2.\n pt roll with maxAx1\n 3.\n supine to sit with maxAx2\n 4.\n sit edge of bed with minAx1\n 5.\n pt wean to CPAP\n 6.\n Anticipated Discharge: Rehab\n Treatment Plan:\n Frequency / Duration: 2-4x/week x1 week\n bed mobility training, sup to sit training; edge of bed balance;\n progress to transfers once able; neuromuscular re-education;\n bronchopulmonary hygiene as needed; patient/caregiver education,\n discharge planning\n Nursing rec's: recommend out of bed to chair as able medically\n Patient agrees with the above goals and is willing to participate in\n the rehabilitation program.\npatient unable secondary to mental status\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653244, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Squeezing left hand and wiggling left toes to command consistently.\n RUE and RLE withdrawing to nail bed pressure.\n Right pupil 3mm and briskly reactive, left pupil 2mm and non-reactive\n (left outer eyelid sutured shut).\n Ophthalmologist in to assess for corneal abrasions.\n Ventriculostomy drain at 20cm above tragus.\n Action:\n Neuro assessments q 2 hours.\n Eye drops each eye q 1 hour\n taped shut overnight. Left eye antibiotic\n ointment q 6 hours.\n Monitor ventriculostomy drain and maintain 20 cm above tragus at all\n times.\n Response:\n Neuro assessment unchanged overnight.\n Ventriculostomy drain with minimal amount clear/blood-tinged drainage.\n Plan:\n Pt to go to OR for VP shunt.\n Continue to monitor neuro status closely.\n Eye care per ophthalmology recommendations.\n Continue to monitor ICP and ventriculostomy drain.\n Hypertension, benign\n Assessment:\n Pt with SBP > 180 sustained.\n Action:\n Gave 10mg hydralazine x3 overnight.\n Response:\n SBP 160\ns post-hydralazine.\n Plan:\n Continue to monitor SBP closely and administer hydralazine prn.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Pt temp 101.2-101.7 overnight.\n Action:\n Dr. made aware.\n Blood cultures from still pending.\n Tylenol administered.\n Response:\n Awaiting effect of Tylenol.\n Plan:\n Continue to monitor temperature curve closely.\n Draw blood cultures if indicated.\n Tylenol for comfort.\n" }, { "category": "Respiratory ", "chartdate": "2157-01-19 00:00:00.000", "description": "Respiratory Care Shift Note", "row_id": 654707, "text": "Demographics\n Day of intubation:\n Day of mechanical ventilation: 23\n Ideal body weight: 67.1 None\n Ideal tidal volume: 268.4 / 402.6 / 536.8 mL/kg\n Airway\n Airway Placement Data\n Known difficult intubation: Unknown\n Tracheostomy tube:\n Type: Standard, Perc Trach\n Manufacturer: Portex\n Size: 8.0mm\n PMV:\n Cuff Management:\n Vol/Press:\n Cuff pressure: 45 cmH2O\n Cuff volume: 8 mL /\n Airway problems:\n Comments:\n Lung sounds\n RLL Lung Sounds: Clear\n RUL Lung Sounds: Clear\n LUL Lung Sounds: Clear\n LLL Lung Sounds: Clear\n Comments:\n Secretions\n Sputum color / consistency: White / Thin\n Sputum source/amount: Suctioned / Small\n Comments:\n Ventilation Assessment\n Level of breathing assistance: Continuous invasive ventilation\n Visual assessment of breathing pattern: Normal quiet breathing\n Assessment of breathing comfort: No response (sleeping / sedated)\n Plan\n Next 24-48 hours: Continue with daily RSBI tests & SBT's as tolerated;\n Comments: RSBI deferred due to RR >45\n Reason for continuing current ventilatory support: Underlying illness\n not resolved\n" }, { "category": "Nursing", "chartdate": "2157-01-20 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654970, "text": "Hypertension, benign\n Assessment:\n Continues to have labile blood pressure frequently >160\n Action:\n Given PRN IV labetalol, prn hydralizine for HTN\n Given fentanyl for likely discomfort\n Given versed for likely anxiety\n Response:\n Good effect from hydralizine, moderate effect from labetalol. Good\n effect from fentanyl and versed.\n Plan:\n Cont to titrate po regimen to control BP and reduce need for IV PRN\n antihypertensives. Assess for pain and treat as needed, cont with\n zyprexa and treat with additional versed if indicated.\n Arousal, Attention, and Cognition, Impaired\n Assessment:\n More focused this morning, engaging and attentive, attempting to\n communicate needs by mouthing words and using gestures.\n Action:\n Encourage pt to use gestures to clearly identify needs.\n Reorient pt and explain current plan of care.\n Response:\n Ability to communicate inconsistent and attentiveness inconsistent.\n Appeared to become anxious re: current state of health, pointing and\n touching right arm repeatedly but unable to move.\n Plan:\n Cont to engage pt and reorient, provide emotional support.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Remained on CMV overnight\n Action:\n Placed on CPAP PS 12 PS 5 Peep\n Response:\n Tolerating well\n RR irregular\n ABG unchanged\n Plan:\n Cont to wean as tolerated.\n" }, { "category": "Physician ", "chartdate": "2157-01-20 00:00:00.000", "description": "Intensivist Note", "row_id": 654973, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Intracranial bleed respiratory failure\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Artificial Tear Ointment 5. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. ChlorproMAZINE 10. Docusate Sodium (Liquid)\n 11. Famotidine 12. Fentanyl Citrate 13. FoLIC Acid 14. Furosemide 15.\n Heparin 16. HydrALAzine 17.\n 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol 22.\n Magnesium Sulfate 23. Midazolam\n 24. Multivitamins 25. Olanzapine 26. OxycoDONE-Acetaminophen Elixir 27.\n Potassium Chloride 28. Propofol\n 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9% Flush 31.\n Thiamine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Furosemide (Lasix) - 05:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Labetalol - 01:45 AM\n Hydralazine - 03:00 AM\n Fentanyl - 04:30 AM\n Midazolam (Versed) - 04:45 AM\n Other medications:\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.7\nC (98.1\n HR: 94 (75 - 100) bpm\n BP: 149/72(102) {123/63(84) - 186/88(123)} mmHg\n RR: 27 (13 - 38) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,501 mL\n 481 mL\n PO:\n Tube feeding:\n 561 mL\n 313 mL\n IV Fluid:\n 340 mL\n 169 mL\n Blood products:\n Total out:\n 2,650 mL\n 710 mL\n Urine:\n 2,650 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,149 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 709 (709 - 709) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 97%\n ABG: 7.45/35/137/24/1\n Ve: 9.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities\n Labs / Radiology\n 326 K/uL\n 9.4 g/dL\n 107 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 109 mEq/L\n 143 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n WBC\n 7.4\n 8.8\n 10.6\n Hct\n 25.7\n 27.1\n 26.3\n Plt\n \n Creatinine\n 1.1\n 1.0\n 1.1\n TCO2\n 21\n 21\n 22\n 26\n 27\n 26\n 25\n Glucose\n 110\n 100\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, dilantin stopped,\n olanzipine added\n Cardiovascular: goal SBP < 160, started on labetolol po for\n hypertension, prn Hydralazine and IV labetolol\n Pulmonary: s/p Trach, wean to PSV\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs, hypernatremic, increase free water flushes, NS at 75\n Renal: adequate UOP, ARF resolved, PRN lasix\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:31 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-01-20 00:00:00.000", "description": "Intensivist Note", "row_id": 655000, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n Intracranial bleed respiratory failure\n PMHx:\n HTN\n Current medications:\n Acetaminophen 4. Artificial Tear Ointment 5. Bacitracin/Polymyxin B\n Sulfate Opht. Oint\n 6. Bisacodyl 7. Calcium Gluconate 8. Chlorhexidine Gluconate 0.12% Oral\n Rinse 9. ChlorproMAZINE 10. Docusate Sodium (Liquid)\n 11. Famotidine 12. Fentanyl Citrate 13. FoLIC Acid 14. Furosemide 15.\n Heparin 16. HydrALAzine 17.\n 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol 22.\n Magnesium Sulfate 23. Midazolam\n 24. Multivitamins 25. Olanzapine 26. OxycoDONE-Acetaminophen Elixir 27.\n Potassium Chloride 28. Propofol\n 29. Sodium Chloride 0.9% Flush 30. Sodium Chloride 0.9% Flush 31.\n Thiamine\n Allergies:\n No Known Drug Allergies\n Other ICU medications:\n Furosemide (Lasix) - 05:00 PM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Labetalol - 01:45 AM\n Hydralazine - 03:00 AM\n Fentanyl - 04:30 AM\n Flowsheet Data as of 06:55 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 38.1\nC (100.6\n T current: 36.7\nC (98.1\n HR: 94 (75 - 100) bpm\n BP: 149/72(102) {123/63(84) - 186/88(123)} mmHg\n RR: 27 (13 - 38) insp/min\n SPO2: 97%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,501 mL\n 481 mL\n PO:\n Tube feeding:\n 561 mL\n 313 mL\n IV Fluid:\n 340 mL\n 169 mL\n Blood products:\n Total out:\n 2,650 mL\n 710 mL\n Urine:\n 2,650 mL\n 710 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,149 mL\n -229 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Set): 600 (600 - 600) mL\n Vt (Spontaneous): 709 (709 - 709) mL\n PS : 12 cmH2O\n RR (Set): 10\n RR (Spontaneous): 14\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n Compliance: 60 cmH2O/mL\n SPO2: 97%\n ABG: 7.45/35/137/24/1\n Ve: 9.2 L/min\n PaO2 / FiO2: 343\n Physical Examination\n General Appearance: No acute distress\n HEENT: PERRL\n Cardiovascular: (Rhythm: Regular)\n Respiratory / Chest: (Breath Sounds: Rhonchorous : )\n Abdominal: Soft\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: (Responds to: Tactile stimuli), Moves all extremities\n Labs / Radiology\n 326 K/uL\n 9.4 g/dL\n 107 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.0 mEq/L\n 24 mg/dL\n 109 mEq/L\n 143 mEq/L\n 26.3 %\n 10.6 K/uL\n [image002.jpg]\n 10:58 AM\n 01:03 PM\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n WBC\n 7.4\n 8.8\n 10.6\n Hct\n 25.7\n 27.1\n 26.3\n Plt\n \n Creatinine\n 1.1\n 1.0\n 1.1\n TCO2\n 21\n 21\n 22\n 26\n 27\n 26\n 25\n Glucose\n 110\n 100\n 107\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.3 mg/dL,\n Mg:1.8 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan:\n Neurologic: stable cerebral hemorrhages, s/p VPS, dilantin stopped,\n olanzipine added and improving\n Cardiovascular: goal SBP < 160, started on labetolol 400\n PO for\n hypertension, schedule Hydralazine PO and prn IV labetolol\n Pulmonary: s/p Trach on CPAP trial, CT chest to look for pleural\n effusion vs pneuomonia\n Gastrointestinal / Abdomen: TFs\n Nutrition: TFs, hypernatremic, increase free water flushes, NS at 75\n Renal: adequate UOP, ARF resolved, PRN lasix, target for -1L/day\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: multiple cultures negative to date, f/u cultures,\n increasing WBC, check CT chest for possible PNA\n Lines / Tubes / Drains: trach, foley, a-line, VPS, PEG, rt PICC, VPS\n Wounds: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Imaging: CXR today\n Fluids: KVO\n Consults: Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Subdural)\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 04:31 AM 50 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: ICU consent signed Comments:\n Code status: Full code\n Disposition: ICU\n Total time spent: 34 minutes\n Patient is critically ill\n" }, { "category": "Nursing", "chartdate": "2157-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653815, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Hypertension, benign\n Assessment:\n SBP 140s-190s via a-line.\n Action:\n Response:\n Plan:\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653819, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Hypertension, benign\n Assessment:\n SBP 140s-190s via a-line. HR 90s-120s SR/ST, no ectopy.\n Action:\n Hydralazine and labetalol prn for goal SBP <180.\n Response:\n Responds well to antihypertensives.\n Plan:\n Continue to monitor BP and treat for SBP>180.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent. drain intact. ICPs >20 at beginning of shift. MD notified.\n Continues on dilantin.\n Action:\n Drain unclamped and at 20cm above tragus.\n Response:\n Pinkish clear fluid draining in small amts. ICP down to 4-10.\n Plan:\n Continue to monitor ICPs. Plan for possible shunt in OR today. Has\n been NPO since MN. Still needs surgery consent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on ACV 600x12 Peep +5 FiO2 40%. Breathing over vent. LS with\n scattered rhonchi.\n Action:\n Moderate amts of thick yellow-tan secretions via trach.\n Response:\n O2 Sat 95-98%.\n Plan:\n Continue pulmonary toilet. Sputum cx pending.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7.\n Action:\n Bed bath given and room temp kept low.\n Response:\n No Tylenol given, came down to 100.7 on own.\n Plan:\n Continue to monitor temps.\n Abx. Ointment and artificial tear ointment applied as ordered to\n corneal abrasions. Eyes kept closed with gauze and steri-strips.\n Social work involved working on guardianship of pt.\n" }, { "category": "Nutrition", "chartdate": "2157-01-11 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 653349, "text": "Current Wt: 76.1kg\n Pertinent medications: RISS, Colace, Mvit, THiamine, Folic Acid,\n Famotidine, others noted\n Labs:\n Value\n Date\n Glucose\n 96 mg/dL\n 03:10 AM\n Glucose Finger Stick\n 151\n 10:00 AM\n BUN\n 26 mg/dL\n 03:10 AM\n Creatinine\n 1.6 mg/dL\n 03:10 AM\n Sodium\n 136 mEq/L\n 03:10 AM\n Potassium\n 3.9 mEq/L\n 03:10 AM\n Chloride\n 105 mEq/L\n 03:10 AM\n TCO2\n 21 mEq/L\n 03:10 AM\n PO2 (arterial)\n 105 mm Hg\n 06:12 AM\n PCO2 (arterial)\n 33 mm Hg\n 06:12 AM\n pH (arterial)\n 7.42 units\n 06:12 AM\n pH (urine)\n 5.0 units\n 11:28 AM\n CO2 (Calc) arterial\n 22 mEq/L\n 06:12 AM\n Albumin\n 3.3 g/dL\n 04:28 AM\n Calcium non-ionized\n 8.1 mg/dL\n 03:10 AM\n Phosphorus\n 3.6 mg/dL\n 03:10 AM\n Ionized Calcium\n 1.10 mmol/L\n 06:12 AM\n Magnesium\n 2.3 mg/dL\n 03:10 AM\n Current diet order / nutrition support: TF: off\n GI: abd soft, +BS\n Assessment of Nutritional Status\n 53 y.o. M adm with SAH with IVH in the left lateral ventricle. Pt now\n s/p trach/PEG . Pt has been receiving TF via PEG, and rx was\n recently changed to a much more concentrated formula, as team suspected\n that pt had SIADH. Na is now improved to 136 today. TF is currently\n off for possible VP shunt placement today.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Rec resume TF after procedure.\n 2) Monitory lytes and hydration, adding H20 flushes as needed to\n maintain Na levels WNL.\n 3) Cont. with RISS for BG management.\n Following\n please page with ?\ns \n" }, { "category": "Nursing", "chartdate": "2157-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653818, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Hypertension, benign\n Assessment:\n SBP 140s-190s via a-line. HR 90s-120s SR/ST, no ectopy.\n Action:\n Hydralazine and labetalol prn for goal SBP <180.\n Response:\n Responds well to antihypertensives.\n Plan:\n Continue to monitor BP and treat for SBP>180.\n Intracerebral hemorrhage (ICH)\n Assessment:\n Vent. drain intact. ICPs >20 at beginning of shift. MD notified.\n Continues on dilantin.\n Action:\n Drain unclamped and at 20cm above tragus.\n Response:\n Pinkish clear fluid draining in small amts. ICP down to 4-10.\n Plan:\n Continue to monitor ICPs. Plan for possible shunt in OR today. Has\n been NPO since MN. Still needs surgery consent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Continues on ACV 600x12 Peep +5 FiO2 40%. Breathing over vent. LS with\n scattered rhonchi.\n Action:\n Moderate amts of thick yellow-tan secretions via trach.\n Response:\n O2 Sat 95-98%.\n Plan:\n Continue pulmonary toilet. Sputum cx pending.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Tmax 101.7.\n Action:\n Bed bath given and room temp kept low.\n Response:\n No Tylenol given, came down to 100.7 on own.\n Plan:\n Continue to monitor temps.\n Abx. Ointment and artificial tear ointment applied as ordered.\n Social work involved working on\n" }, { "category": "Nursing", "chartdate": "2157-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653911, "text": "Hypertension, benign\n Assessment:\n Sbp greater than 180\n Action:\n Pt received 10mg of iv labetatol and scheduled dose of po\n labetatol thru peg tube\n Response:\n Sbp less than 180\n Plan:\n Continue to monitor\n Give antihypertensives as ordered\n Keep sbp less than 180\n Intracerebral hemorrhage (ICH)\n Assessment:\n Right pupils 3mm and briskly reactive to light\n Left pupil 3mm and unable to assess reaction to light\n secondary to cloudiness\n Pt spontanoues moves left side on bed, pt will\n intermittently follow commands\n Pt does withdraw right leg to painful stimuli, does not\n withdraw right arm to painful stimuli\n Icp drain clamped at 1000 for preparation for OR\n Action:\n Pt went to head ct\n Response:\n Icp has been less than 20\n Plan:\n Continue to monitor, if icp is greater than 20 to call\n neurosurgical team.\n Pt to or for vp shunt.\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653414, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n 24 hour TMAX 101.7. Continues to be afebrile, TMAX this shift 100.8.\n Copious thick yellow secretions from oral cavity and trach.\n Action:\n Pan Cultured this am. Continued on Cefazolin.\n Response:\n Currently 98.9.\n Plan:\n Continue to monitor. Cooling interventions if warranted. Awaiting\n pending culture results.\n Hypertension, benign\n Assessment:\n Pt sustained SBP < 180 this am despite multiple boluses of IVP\n metoprolol and hydralazine. Increased BP with stimulation.\n Action:\n Labetalol gtt started and maintained at 0.5mg/min.\n Response:\n Pt\n :\n Intracerebral hemorrhage (ICH)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653415, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n 24 hour TMAX 101.7. Continues to be afebrile, TMAX this shift 100.8.\n Copious thick yellow secretions from oral cavity and trach.\n Action:\n Pan Cultured this am. Continued on Cefazolin.\n Response:\n Currently 98.9.\n Plan:\n Continue to monitor. Cooling interventions if warranted. Awaiting\n pending culture results.\n Hypertension, benign\n Assessment:\n Pt sustained SBP < 180 this am despite multiple boluses of IVP\n metoprolol and hydralazine. Increased BP with stimulation.\n Action:\n Labetalol gtt started and maintained at 0.5mg/min. PO Metoprolol\n increased to 150mg TID.\n Response:\n Pt SBP maintained at 120\ns-150\ns since administration of Labetalol gtt.\n Plan:\n Continue to monitor SBP closely. Per Neuro Med maintain SBP <180.\n Cont labetalol gtt until managed with po\n Intracerebral hemorrhage (ICH)\n Assessment:\n Continues to have clear-blood tinged CSF in EVD.\n Action:\n EVD 20 above tragus.\n Response:\n ICP WNL. Minimal output.\n Plan:\n IVP Shunt planned for Thursday.\n" }, { "category": "Social Work", "chartdate": "2157-01-13 00:00:00.000", "description": "Social Work Progress Note", "row_id": 653723, "text": "Spoke at length with pt\ns cousin re: the\n role/responsibility of guardianship, she is willing to petition the\n courts. Per Ms. pt\ns yr old mother has been d/c from the\n hospital and is currently in rehab at Health Care in\n . Guardianship documents have been completed. Ms \n would like to meet with the medical team for a report on pt\ns status\n and care needs prior to going to the court as she feel she will need\n this information to support her request. Pt\ns friend has been a\n good support for pt\ns mother and Ms. , will attend the\n meeting and go to the court with MsDeVitt.\n There is a meeting today at the Health Care Center with staff,\n Ms and to inform mother of pt\ns anticipated needs and to\n help the mother understand that she will require the services of the\n facility as the pt will no longer have the capacity to care for her.\n Will arrange family meeting for medical update.\n Will explain process for presenting guardianship papers to the probate\n court.\n" }, { "category": "Physician ", "chartdate": "2157-01-13 00:00:00.000", "description": "Intensivist Note", "row_id": 653731, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n PMHx:\n HTN\n 24 Hour Events:\n BLOOD CULTURED - At 04:00 PM\n URINE CULTURE - At 04:00 PM\n SPUTUM CULTURE - At 09:00 PM\n FEVER - 101.9\nF - 04:00 PM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Cefazolin - 03:35 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:00 PM\n Labetalol - 04:00 PM\n Metoprolol - 12:00 AM\n Hydralazine - 12:30 AM\n Flowsheet Data as of 09:37 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: 37.9\nC (100.2\n HR: 111 (75 - 111) bpm\n BP: 183/85(121) {125/60(83) - 199/87(128)} mmHg\n RR: 28 (12 - 31) insp/min\n SPO2: 97%\n Heart rhythm: ST (Sinus Tachycardia)\n Wgt (current): 73.9 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 15 (1 - 16) mmHg\n Total In:\n 1,133 mL\n 235 mL\n PO:\n Tube feeding:\n 713 mL\n IV Fluid:\n 150 mL\n 145 mL\n Blood products:\n Total out:\n 1,386 mL\n 700 mL\n Urine:\n 1,310 mL\n 700 mL\n NG:\n Stool:\n Drains:\n 76 mL\n Balance:\n -253 mL\n -465 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n PS : 10 cmH2O\n RR (Set): 12\n RR (Spontaneous): 1\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 27 cmH2O\n Plateau: 16 cmH2O\n SPO2: 97%\n ABG: ///22/\n Ve: 9.4 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\n Left Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 473 K/uL\n 10.4 g/dL\n 114 mg/dL\n 1.2 mg/dL\n 22 mEq/L\n 4.2 mEq/L\n 26 mg/dL\n 108 mEq/L\n 139 mEq/L\n 29.1 %\n 9.4 K/uL\n [image002.jpg]\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n 02:28 AM\n WBC\n 15.4\n 12.0\n 9.4\n Hct\n 30.6\n 26.5\n 29.1\n Plt\n \n Creatinine\n 1.6\n 1.7\n 1.6\n 1.4\n 1.2\n TCO2\n 21\n 22\n 22\n 22\n 23\n Glucose\n 134\n 100\n 96\n 121\n 114\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.5 mg/dL,\n Mg:2.2 mg/dL, PO4:3.9 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM, HYPOSMOLALITY), AEROBIC\n CAPACITY / ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION,\n IMPAIRED, BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, FEVER,\n UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA), RASH, ALTERED MENTAL\n STATUS (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/),\n INTRACEREBRAL HEMORRHAGE (ICH), HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, continue dilantin, ct head\n today\n improved, clamp evd, vp shunt postponed\n Cardiovascular: goal SBP < 180, lopressor 100 TID, labetolol po, prn\n Hydralazine\n Pulmonary: s/p Trach, cont to wean to trach collar, CXR in am (stable\n LLL opacification)\n Gastrointestinal / Abdomen: TF via PEG\n Nutrition: Tube feeding\n Renal: Adequate UO\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: febrile, check cultures Vanc/Zosyn (empiric for\n fever)/Fluc (yeast in sputum) stopped, Kefzol started for ventric\n drain,\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: normal saline @ 75cc/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition: tube feeds\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 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: 35 minutes\n" }, { "category": "Physician ", "chartdate": "2157-01-21 00:00:00.000", "description": "Intensivist Note", "row_id": 655133, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH\n PMHx:\n ?hypertension\n Current medications:\n Acetaminophen. Artificial Tear Ointment. Bacitracin/Polymyxin B Sulfate\n Opht. Oint. Bisacodyl. Calcium Gluconate. Chlorhexidine Gluconate 0.12%\n Oral Rinse. ChlorproMAZINE. Docusate Sodium (Liquid). Famotidine.\n Fentanyl Citrate. FoLIC Acid. Furosemide. Heparin. HydrALAzine.\n Insulin. Labetalol. Magnesium Sulfate. Midazolam. Multivitamins.\n Olanzapine. OxycoDONE-Acetaminophen. Potassium Chloride. Thiamine\n 24 Hour Events:\n Lasix diuresis of 1L negative\n Became tachypneic on trach , placed back on CPAP/PS\n Chest CT yesterday showed bilateral effusion, IP does not want to tap\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\n Labetalol - 02:30 AM\n Furosemide (Lasix) - 04:45 AM\n Midazolam (Versed) - 05:01 AM\n Fentanyl - 05:01 AM\n Other medications:\n Flowsheet Data as of 06:24 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.8\nC (100.1\n T current: 36.8\nC (98.3\n HR: 88 (79 - 104) bpm\n BP: 150/69(99) {128/53(85) - 184/88(126)} mmHg\n RR: 21 (11 - 23) insp/min\n SPO2: 98%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 73.2 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,670 mL\n 535 mL\n PO:\n Tube feeding:\n 1,150 mL\n 412 mL\n IV Fluid:\n 340 mL\n 63 mL\n Blood products:\n Total out:\n 2,740 mL\n 610 mL\n Urine:\n 2,740 mL\n 610 mL\n NG:\n Stool:\n Drains:\n Balance:\n -1,070 mL\n -75 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 550 (376 - 676) mL\n PS : 10 cmH2O\n RR (Spontaneous): 10\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 104\n PIP: 17 cmH2O\n SPO2: 98%\n ABG: 7.44/40/134/24/3\n Ve: 6.4 L/min\n PaO2 / FiO2: 335\n Physical Examination\n Labs / Radiology\n 290 K/uL\n 9.0 g/dL\n 87 mg/dL\n 1.1 mg/dL\n 24 mEq/L\n 4.4 mEq/L\n 27 mg/dL\n 107 mEq/L\n 142 mEq/L\n 25.2 %\n 11.0 K/uL\n [image002.jpg]\n 03:44 PM\n 02:33 AM\n 02:48 AM\n 02:58 AM\n 11:48 PM\n 03:48 AM\n 04:16 AM\n 05:44 AM\n 04:19 AM\n 04:41 AM\n WBC\n 7.4\n 8.8\n 10.6\n 11.0\n Hct\n 25.7\n 27.1\n 26.3\n 25.2\n Plt\n 90\n Creatinine\n 1.1\n 1.0\n 1.1\n 1.1\n TCO2\n 22\n 26\n 27\n 26\n 25\n 28\n Glucose\n 110\n 100\n 107\n 87\n Other labs: PT / PTT / INR:15.0/28.6/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.4 mg/dL,\n Mg:2.2 mg/dL, PO4:4.4 mg/dL\n Assessment and Plan\n INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: Neuro: stable cerebral hemorrhages, s/p VPS, cont\n zyprexa, versed for agitation\n CV: goal SBP < 160, labetolol 400 tid, prn Hydral and IV labetolol\n Resp: Trach trials, bilat pleural effusions IP does not want to\n tap\n GI: TFs\n GU: adequate UOP, ARF resolved, PRN lasix, goal 1L negative\n FEN: TFs\n Heme: stable Hct\n Endo: RISS\n ID: multiple cultures negative to date, f/u cultures\n TLD: trach, foley, a-line, VPS, PEG, rt PICC\n Wound: left corneal ulcer, optho following - on bacitracin oint and\n improving\n Prophylaxis: famotidine, SQH\n Imaging: none\n Dispo: start screening for vented rehab. no insurance or health care\n proxy. social work following\n ICU Care\n Nutrition:\n Replete with Fiber (Full) - 02:49 AM 65 mL/hour\n Glycemic Control:\n Lines:\n Arterial Line - 05:00 PM\n PICC Line - 11:14 AM\n 18 Gauge - 11:00 AM\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": "2157-01-15 00:00:00.000", "description": "Nursing Progress Note", "row_id": 654028, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n s/p vp shunt placement\n no changes in neuro assessment\n Action:\n Post op head ct\n Q2 neuro assessments\n Tubefeeds held overnight per NSURG d/t post op\n Response:\n CT unchaged\n Neuro status remains stable.\n Plan:\n F/u re starting tubefeeds, f/u with nsurg re frequency of neuro exams\n to promote rest.\n Rash\n Assessment:\n Rash noted to be worse than previous assessment this evening\n Action:\n Dr (sicu) aware\n Monitor closely\n Cefazolin is suspected cause\n cont to hold\n Response:\n Looks slightly improved this am\n Plan:\n Cont to monitor.\n" }, { "category": "Nursing", "chartdate": "2157-01-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653468, "text": "Hypertension, benign\n Assessment:\n SBP 90-150\n Action:\n Labetalol gtt off after dose lopressor\n Response:\n SBP initially down to 90\ns then back up to 120\n Plan:\n Cont to monitor BP, maintain SBP <180\n Intracerebral hemorrhage (ICH)\n Assessment:\n Neuro status unchaged from previous assessments\n ICP stable \n Minimal output from ventriculostomy\n Action:\n Q1 ICP\n Q2 Neuro assessment\n Monitor CSF output\n Plan:\n To OR for VP shunt on Thursday\n" }, { "category": "Physician ", "chartdate": "2157-01-12 00:00:00.000", "description": "Intensivist Note", "row_id": 653477, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n Chief complaint:\n PMHx:\n Current medications:\n 24 Hour Events:\n PAN CULTURE - At 11:00 AM\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Fluconazole - 04:07 PM\n Piperacillin/Tazobactam (Zosyn) - 05:23 AM\n Cefazolin - 04:00 AM\n Infusions:\n Other ICU medications:\n Hydralazine - 08:00 AM\n Fentanyl - 08:20 AM\n Metoprolol - 10:30 AM\n Famotidine (Pepcid) - 08:00 PM\n Heparin Sodium (Prophylaxis) - 12:00 AM\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: 38.2\nC (100.8\n T current: 38\nC (100.4\n HR: 82 (70 - 100) bpm\n BP: 143/66(93) {111/51(71) - 200/88(129)} mmHg\n RR: 19 (15 - 31) insp/min\n SPO2: 95%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 74.2 kg (admission): 67 kg\n Height: 67 Inch\n ICP: 13 (2 - 15) mmHg\n Total In:\n 1,932 mL\n 313 mL\n PO:\n Tube feeding:\n 300 mL\n 203 mL\n IV Fluid:\n 1,422 mL\n 50 mL\n Blood products:\n Total out:\n 1,933 mL\n 414 mL\n Urine:\n 1,880 mL\n 390 mL\n NG:\n Stool:\n Drains:\n 53 mL\n 24 mL\n Balance:\n -1 mL\n -102 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CMV/ASSIST/AutoFlow\n Vt (Set): 600 (600 - 600) mL\n RR (Set): 12\n RR (Spontaneous): 0\n PEEP: 5 cmH2O\n FiO2: 40%\n PIP: 17 cmH2O\n Plateau: 15 cmH2O\n SPO2: 95%\n ABG: 7.42/35/102/21/0\n Ve: 10.7 L/min\n PaO2 / FiO2: 255\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), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Right Extremities: (Edema: Absent), (Temperature: Warm), (Pulse -\n Dorsalis pedis: Present), (Pulse - Posterior tibial: Present)\n Neurologic: Moves all extremities\n Labs / Radiology\n 473 K/uL\n 9.7 g/dL\n 121 mg/dL\n 1.4 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 27 mg/dL\n 108 mEq/L\n 136 mEq/L\n 26.5 %\n 12.0 K/uL\n [image002.jpg]\n 04:49 AM\n 05:28 PM\n 05:36 PM\n 02:52 AM\n 03:03 AM\n 10:25 PM\n 03:10 AM\n 06:12 AM\n 03:22 AM\n 03:35 AM\n WBC\n 15.4\n 12.0\n Hct\n 30.6\n 26.5\n Plt\n 516\n 473\n Creatinine\n 1.6\n 1.7\n 1.6\n 1.4\n TCO2\n 21\n 21\n 22\n 22\n 22\n 23\n Glucose\n 134\n 100\n 96\n 121\n Other labs: PT / PTT / INR:13.9/28.8/1.2, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:81.4 %, Lymph:6.4 %, Mono:9.7 %,\n Eos:2.0 %, Lactic Acid:0.6 mmol/L, Albumin:3.3 g/dL, Ca:8.2 mg/dL,\n Mg:2.2 mg/dL, PO4:4.0 mg/dL\n Assessment and Plan\n ANEMIA, OTHER, HYPOTENSION (NOT SHOCK), HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), AEROBIC CAPACITY / ENDURANCE, IMPAIRED, AROUSAL,\n ATTENTION, AND COGNITION, IMPAIRED, BALANCE, IMPAIRED, MUSCLE\n PERFORMACE, IMPAIRED, FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA,\n PYREXIA), RASH, ALTERED MENTAL STATUS (NOT DELIRIUM), RESPIRATORY\n FAILURE, ACUTE (NOT ARDS/), INTRACEREBRAL HEMORRHAGE (ICH),\n HYPERTENSION, BENIGN\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neurologic: stable cerebral hemorrhages, continue dilantin, OR for VPS\n on Thursday\n Cardiovascular: goal SBP < 180, lopressor 100 TID, labetolol drip, prn\n Hydralazine\n Pulmonary: s/p Trach, cont to wean to trach collar, CXR in am (stable\n LLL opacification)\n Gastrointestinal / Abdomen: TF via PEG\n Nutrition: Tube feeding\n Renal: Adequate UO\n Hematology: stable Hct\n Endocrine: RISS\n Infectious Disease: Vanc/Zosyn (empiric for fever)/Fluc (yeast in\n sputum) stopped, Kefzol started for ventric drain, f/u cultures\n Lines / Tubes / Drains: trach, foley, a-line, EVD, PEG\n Wounds: left corneal ulcer, optho following - on bacitracin oint\n Imaging: CXR today\n Fluids: normal saline @ 75cc/hr\n Consults: Neuro surgery, Neurology\n Billing Diagnosis: (Hemorrhage, NOS: Sub-arachnoid)\n ICU Care\n Nutrition:\n Nutren 2.0 (Full) - 02:00 PM 30 mL/hour\n Glycemic Control: Regular insulin sliding scale\n Lines:\n ICP Catheter - 04:00 PM\n Arterial Line - 05:00 PM\n 20 Gauge - 10:00 AM\n 22 Gauge - 04:00 AM\n Prophylaxis:\n DVT: Boots, SQ UF Heparin\n Stress ulcer: H2 blocker\n VAP bundle:\n Comments:\n Communication: Patient discussed on interdisciplinary rounds , ICU\n Code status: Full code\n Disposition: ICU\n Total time spent: 35 minutes\n" }, { "category": "Nursing", "chartdate": "2157-01-22 00:00:00.000", "description": "Nursing Progress Note", "row_id": 655307, "text": "Hypotension (not Shock)\n Assessment:\n Sbp down to 82 after 5mg of zyprexa and 400mg of labetolol at . sbp\n responds to stimulation. Lasix 10mg given at 1800 with fair response.\n Action:\n Dr. aware. Fluid bolus of 250cc of normal saline given.\n Response:\n Sbp up greater than 100 after fluid bolus. Pt sleeping but arousable\n during the night. No further episodes of hypotension.\n Plan:\n Monitor for hypotension. Monitor fluid balance. Assess for signs of\n infection.\n" }, { "category": "Nursing", "chartdate": "2157-01-14 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653970, "text": " Problem - Description In Comments left corneal ulcer\n Assessment:\n Left eye remains reddened, and cloudy, unable to assess if\n pupil reacts to light\n Action:\n pt continue on eyedrops, ophthalmology into assess pupils\n this afternoon.\n Response:\n opthamlomogy felt left eye was better\n Plan:\n continue with eye drops: per ophthalmology it put\n bacitricain tube and artifical tear ointment 30min prior to\n administering. Put steri-strips to eye when to asleep, put\n steri-strips on diagonal\n Intracerebral hemorrhage (ICH)\n Assessment:\n Pt s/p vent drain placement under general anethesia\n Action:\n Pt starting to wake-up from anesthesia(please see flow sheet\n Response:\n Plan:\n Continue to monitor,\n Pt to have head ct at around \n Monitor neuro signs as ordered.\n d/c kefzol per dr. ,(dr. felt kefzol was giving\n pt a rash)\n" }, { "category": "Nursing", "chartdate": "2157-01-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 653241, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Squeezing left hand and wiggling left toes to command consistently.\n RUE and RLE withdrawing to nail bed pressure.\n Right pupil 3mm and briskly reactive, left pupil 2mm and non-reactive\n (left outer eyelid sutured shut).\n Ventriculostomy drain at 20cm above tragus\n minimal clear/blood-tinged\n drainage.\n Action:\n Neuro assessments q 2 hours.\n Eye drops each eye q 1 hour\n taped shut overnight. Left eye antibiotic\n ointment q 6 hours.\n Monitor ventriculostomy drain and maintain 20 cm above tragus at all\n times.\n Response:\n Neuro assessment unchanged overnight.\n Plan:\n Hypertension, benign\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2157-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 658360, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH with IVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Escitalopram Oxalate 12. Famotidine 13. Fentanyl Citrate 14. FoLIC\n Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol\n 22. Magnesium Sulfate\n 23. Metoclopramide 24. Midazolam 25. Miconazole Powder 2% 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:33 AM\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\nC (98.6\n T current: 35.8\nC (96.4\n HR: 81 (78 - 97) bpm\n BP: 122/76(87) {100/60(69) - 169/90(109)} mmHg\n RR: 18 (13 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,811 mL\n 485 mL\n PO:\n Tube feeding:\n 1,441 mL\n 425 mL\n IV Fluid:\n 131 mL\n Blood products:\n Total out:\n 1,370 mL\n 480 mL\n Urine:\n 1,370 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 441 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 356 (356 - 516) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 66\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///32/\n Ve: 9.8 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\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Moves all extremities\n Labs / Radiology\n 308 K/uL\n 8.6 g/dL\n 146 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.8 mEq/L\n 34 mg/dL\n 103 mEq/L\n 142 mEq/L\n 24.7 %\n 12.4 K/uL\n [image002.jpg]\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n 03:35 AM\n WBC\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n 12.4\n Hct\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n 24.7\n Plt\n 50\n 08\n Creatinine\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n 146\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental aneurysm of right basilar artery. Ventilator\n dependent.\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol, hydralazine prn\n Pulmonary: stable on CPAP/PS 5/5, unable tolerate trach trial for\n significant period of time. Will re-evaluate \n Gastrointestinal / Abdomen: PEG. no acute issues\n Nutrition: Fibersource HN Full strength goal 60 cc/hr\n Renal: UOP adequate, no issues\n Hematology: Hct stable at 25 after 1 unit PRBC \n Endocrine: RISS\n Infectious Disease: cipro completed for VAP 14 day course\n Lines / Tubes / Drains: left corneal ulcer (optho following). Follow up\n with MEEI regarding course of action.\n Wounds: trach, foley, PEG, rt PICC\n Imaging:\n Fluids:\n Consults:\n Billing Diagnosis: (Hemorrhage, NOS)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:42 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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:\n Total time spent:\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 658367, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n Chief complaint:\n pontine SAH with IVH\n PMHx:\n ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Escitalopram Oxalate 12. Famotidine 13. Fentanyl Citrate 14. FoLIC\n Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol\n 22. Magnesium Sulfate\n 23. Metoclopramide 24. Midazolam 25. Miconazole Powder 2% 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 12:33 AM\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\nC (98.6\n T current: 35.8\nC (96.4\n HR: 81 (78 - 97) bpm\n BP: 122/76(87) {100/60(69) - 169/90(109)} mmHg\n RR: 18 (13 - 24) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,811 mL\n 485 mL\n PO:\n Tube feeding:\n 1,441 mL\n 425 mL\n IV Fluid:\n 131 mL\n Blood products:\n Total out:\n 1,370 mL\n 480 mL\n Urine:\n 1,370 mL\n 480 mL\n NG:\n Stool:\n Drains:\n Balance:\n 441 mL\n 5 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 356 (356 - 516) mL\n PS : 5 cmH2O\n RR (Spontaneous): 23\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 66\n PIP: 11 cmH2O\n SPO2: 100%\n ABG: ///32/\n Ve: 9.8 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\n Left Extremities: (Edema: Trace)\n Right Extremities: (Edema: Trace)\n Neurologic: Moves all extremities\n Labs / Radiology\n 308 K/uL\n 8.6 g/dL\n 146 mg/dL\n 0.9 mg/dL\n 32 mEq/L\n 4.8 mEq/L\n 34 mg/dL\n 103 mEq/L\n 142 mEq/L\n 24.7 %\n 12.4 K/uL\n [image002.jpg]\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n 03:35 AM\n WBC\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n 12.4\n Hct\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n 24.7\n Plt\n 50\n 08\n Creatinine\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n 0.9\n Glucose\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n 146\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental aneurysm of right basilar artery. Ventilator\n dependent. rehab\n AwaitingNeurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol, hydralazine prn\n Pulmonary: stable on CPAP/PS 5/5, unable tolerate trach trial for\n significant period of time. Will try again today\n Gastrointestinal / Abdomen: PEG. no acute issues\n Nutrition: Fibersource HN Full strength goal 60 cc/hr\n Renal: UOP adequate, but overall fluid overloaded. Will start lasix\n Hematology: Hct stable at 25 after 1 unit PRBC \n Endocrine: RISS. Will start NPH\n Infectious Disease: cipro completed for VAP 14 day course\n Lines / Tubes / Drains: left corneal ulcer (optho following). Follow up\n with MEEI regarding course of action.\n Wounds: trach, foley, PEG, rt PICC\n Billing Diagnosis: (Hemorrhage, NOS) Resp failure\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:42 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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: SICU\n Total time spent: 31\n Patient is critically ill\n" }, { "category": "Physician ", "chartdate": "2157-02-10 00:00:00.000", "description": "Intensivist Note", "row_id": 658368, "text": "SICU\n HPI:\n 53M with pontine SAH with IVH in left lateral ventricle. Incidental\n 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Chief complaint:\n PMHx:\n PMH: ?HTN\n Current medications:\n 1. 2. 3. Acetaminophen 4. Albuterol Inhaler 5. Artificial Tear Ointment\n 6. Bacitracin/Polymyxin B Sulfate Opht. Oint\n 7. Bisacodyl 8. Calcium Gluconate 9. Chlorhexidine Gluconate 0.12% Oral\n Rinse 10. Docusate Sodium (Liquid)\n 11. Escitalopram Oxalate 12. Famotidine 13. Fentanyl Citrate 14. FoLIC\n Acid 15. Heparin 16. HydrALAzine\n 17. 18. Insulin 19. Influenza Virus Vaccine 20. Labetalol 21. Labetalol\n 22. Magnesium Sulfate\n 23. Metoclopramide 24. Midazolam 25. Miconazole Powder 2% 26.\n Multivitamins 27. Nystatin Oral Suspension\n 28. Olanzapine 29. Potassium Chloride 30. Sodium Chloride 0.9% Flush\n 31. Thiamine\n 24 Hour Events:\n On currently and tolerating well\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 04:14 PM\n Other medications:\n Flowsheet Data as of 08:16 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since a.m.\n Tmax: 37.9\nC (100.2\n T current: 36.7\nC (98.1\n HR: 88 (79 - 102) bpm\n BP: 133/75(90) {106/64(76) - 168/93(108)} mmHg\n RR: 19 (12 - 37) insp/min\n SPO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Wgt (current): 65.1 kg (admission): 67 kg\n Height: 67 Inch\n Total In:\n 1,960 mL\n 633 mL\n PO:\n Tube feeding:\n 1,440 mL\n 491 mL\n IV Fluid:\n 240 mL\n 82 mL\n Blood products:\n Total out:\n 1,740 mL\n 400 mL\n Urine:\n 1,740 mL\n 400 mL\n NG:\n Stool:\n Drains:\n Balance:\n 220 mL\n 233 mL\n Respiratory support\n O2 Delivery Device: Tracheostomy tube\n Ventilator mode: CPAP/PSV\n Vt (Spontaneous): 566 (386 - 566) mL\n PS : 5 cmH2O\n RR (Spontaneous): 15\n PEEP: 5 cmH2O\n FiO2: 40%\n RSBI: 28\n PIP: 17 cmH2O\n SPO2: 100%\n ABG: ////\n Ve: 8.7 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\n Left Extremities: (Edema: Trace), (Temperature: Warm)\n Right Extremities: (Edema: Trace), (Temperature: Warm)\n Neurologic: Follows simple commands, Moves all extremities\n Labs / Radiology\n 334 K/uL\n 8.2 g/dL\n 134 mg/dL\n 0.9 mg/dL\n 27 mEq/L\n 4.3 mEq/L\n 42 mg/dL\n 108 mEq/L\n 142 mEq/L\n 22.9 %\n 11.7 K/uL\n [image002.jpg]\n 02:37 AM\n 06:06 PM\n 02:54 AM\n 02:53 AM\n 03:15 AM\n 11:21 AM\n 03:03 AM\n 02:27 AM\n 04:35 AM\n 03:30 AM\n WBC\n 9.5\n 11.9\n 10.9\n 16.1\n 19.0\n 13.3\n 15.2\n 11.7\n Hct\n 21.5\n 22.6\n 22.7\n 21.2\n 21.2\n 20.1\n 25.2\n 22.9\n Plt\n 58\n 350\n 337\n 340\n 334\n Creatinine\n 1.0\n 1.0\n 1.0\n 0.9\n 0.9\n 1.0\n 1.2\n 1.0\n 1.0\n 0.9\n Glucose\n 117\n 108\n 118\n 119\n 125\n 107\n 109\n 110\n 101\n 134\n Other labs: PT / PTT / INR:14.6/30.4/1.3, CK / CK-MB / Troponin\n T:169/4/<0.01, Differential-Neuts:67.2 %, Lymph:19.1 %, Mono:7.1 %,\n Eos:6.0 %, Lactic Acid:0.6 mmol/L, Albumin:2.9 g/dL, Ca:9.6 mg/dL,\n Mg:2.1 mg/dL, PO4:4.5 mg/dL\n Assessment and Plan\n KNOWLEDGE, IMPAIRED, RESPIRATION / GAS EXCHANGE, IMPAIRED, TACHYCARDIA,\n OTHER, INEFFECTIVE COPING, ANEMIA, OTHER, HYPONATREMIA (LOW SODIUM,\n HYPOSMOLALITY), ELECTROLYTE & FLUID DISORDER, OTHER, AEROBIC CAPACITY /\n ENDURANCE, IMPAIRED, AROUSAL, ATTENTION, AND COGNITION, IMPAIRED,\n BALANCE, IMPAIRED, MUSCLE PERFORMACE, IMPAIRED, ALTERED MENTAL STATUS\n (NOT DELIRIUM), RESPIRATORY FAILURE, ACUTE (NOT ARDS/)\n Assessment and Plan: 53M with pontine SAH with IVH in left lateral\n ventricle. Incidental 2mm aneurysm of right basilar artery.\n Neuro exam on admission: able to follow basic commands, brainstem\n reflexes appear preserved. He squeezes his hands bilaterally, more\n strongly on the left, and is able to voluntarily bend his left knee,\n just lifting it off the bed. He is not moving the right voluntarily. He\n withdraws in all four extremities, left side more briskly than right.\n VP shunt \n .\n Neurologic: zyprexa, celexa\n Cardiovascular: goal SBP < 160, labetolol 100 tid, hydralazine prn\n Pulmonary: Resp: stable on CPAP/PS , continue to wean to today,\n possible trach trial today although in past pt has taken time to\n recover after failing trach trial; some secretions noted but afebrile\n Gastrointestinal / Abdomen: TFs at goal, changed to fibersource to\n increase Kcals. PEG.\n Nutrition: Tube feeding\n Renal: Foley, Adequate UO, UOP adequate, no issues\n Hematology: Stable, QOD labs\n Endocrine: RISS\n Infectious Disease: completed VAP 14 day course of treatment\n Lines / Tubes / Drains: TLD: trach, foley, PEG, rt PICC\n Wounds: Wound: left corneal ulcer (optho following. Follow up with\n MEEI regarding course of action.\n Imaging: CXR\n Fluids: KVO\n Consults: General surgery\n Billing Diagnosis: (Respiratory distress: Failure)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 01:43 PM 60 mL/hour\n Glycemic Control:\n Lines:\n PICC Line - 11:14 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 rehab / long term facility\n Total time spent: 31 minutes\n Patient is critically ill\n" }, { "category": "Nutrition", "chartdate": "2157-02-10 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 658378, "text": "Adm Wt: 67kg\n Current Wt: 64.4kg\n Pertinent medications: NPH insulin, RISS, colace, Mvit, thiamine, folic\n acid, famotidine, abx, reglan, lasix, others noted\n Labs:\n Value\n Date\n Glucose\n 146 mg/dL\n 03:35 AM\n Glucose Finger Stick\n 159\n 10:00 AM\n BUN\n 34 mg/dL\n 03:35 AM\n Creatinine\n 0.9 mg/dL\n 03:35 AM\n Sodium\n 142 mEq/L\n 03:35 AM\n Potassium\n 4.8 mEq/L\n 03:35 AM\n Chloride\n 103 mEq/L\n 03:35 AM\n TCO2\n 32 mEq/L\n 03:35 AM\n PO2 (arterial)\n 106 mm Hg\n 04:54 AM\n PCO2 (arterial)\n 40 mm Hg\n 04:54 AM\n pH (arterial)\n 7.41 units\n 04:54 AM\n pH (urine)\n 5.0 units\n 09:41 AM\n CO2 (Calc) arterial\n 26 mEq/L\n 04:54 AM\n Albumin\n 2.9 g/dL\n 04:19 AM\n Calcium non-ionized\n 9.6 mg/dL\n 03:30 AM\n Phosphorus\n 4.5 mg/dL\n 03:30 AM\n Ionized Calcium\n 1.13 mmol/L\n 03:10 AM\n Magnesium\n 2.1 mg/dL\n 03:30 AM\n Phenytoin (Dilantin)\n 11.3 ug/mL\n 03:01 AM\n WBC\n 12.4 K/uL\n 03:35 AM\n Hgb\n 8.6 g/dL\n 03:35 AM\n Hematocrit\n 24.7 %\n 03:35 AM\n Current diet order / nutrition support: TF: Fibersource @ 60cc/hr\n (1728kcals, 76g protein)\n GI: soft, +BS\n Assessment of Nutritional Status\n 53 y.o. M on TF at goal via PEG. TF is providing 26kcals/kg and 1.1g\n protein/kg, meeting 100% of estimated needs. TF was changed to\n increase kcals to attempt to achieve weight maintenance. Pt\ns weight\n has decreased 1.4kg over the past 3 days, thus will need to continue to\n monitor closely to prevent significant weight loss.\n Medical Nutrition Therapy Plan - Recommend the Following\n 1) Cont. with TF at goal.\n 2) Monitor daily weights. Pt may need to have TF rate increased\n at intervals until pt\ns weight is stable.\n Following, please page with ?\ns #\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658323, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n aneurysm of right basilar artery. Ventilator dependent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient trached and vented on PS 40% 5/5. Bil LS clear w/transient\n rhonchi which clear after being suctioned for med amnt of white thick\n secretions.\n Action:\n Mechanical ventilation -> will attempt trach mask in am, mouth care\n q4hr and as needed, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent if tolerates.\n Neuro: alert, unable to communicate because of trach/SAH+IVH.\n Inconsistently follows commands. Moves Left upper extr purposefully, no\n movement noted @ RT upper extr. Some movement of the lower extr. Bil\n pupils are equal and reactive. Eye care done ASDIR.\n Cardio: B/P at 100-120\ns/60\ns (elevated to 160\ns during care or\n repositioning) HR at 80\ns no ectopy noted. No peripheral edema noted.\n Peripheral pulses present.\n GI: abd soft distended, non tender. Positive for BS. Small BM during\n the shift. PEG w/TF at goal. No residuals.\n GU: clear yellow urine via foley. Adequate amnt.\n IV access: RT PICC double lumen.\n Social: patient is a FULL CODE. Awaiting placement.\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658406, "text": "Intracerebral hemorrhage (ICH)\n Assessment:\n Pt. alert, responsive, following commands. Very minimal movements with\n right side, but able to weakly squeeze and move leg slightly. Left\n side active. Mouthing words and nodding appropriately.\n Action:\n Neuro exam Q4hr.\n Response:\n No changes noted.\n Plan:\n Continue to monitor\n discharge planning in progress with primary\n team. Pt. has bed in vented rehab and plan is to transfer today; teams\n aware.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n LS diminished bibasilar. Pt. overall weak, deconditioned.\n Action:\n Placed on trach mask this a.m. at approximately 1115. Suctioned once\n for moderate yellow secretions.\n Response:\n Pt. remains on TM in NAD.\n Plan:\n Pulmonary hygiene, TM as tolerated, rehab planning as above.\n Left eye abrasion vs. infection.\n Assessment:\n Left eye with whitish film, sutured at corner to\nfoam\n. Pt. states he\n has visual disturbance (via nodding.)\n Action:\n Lubricant placed Q2hrs. unless due for Q6hr warm bacitracin ointment.\n Eye steri\nd close while napping this afternoon.\n Response:\n No change.\n Plan:\n Continue present regimen per Optho. Rehab planning as above.\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658325, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n aneurysm of right basilar artery. Ventilator dependent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient trached and vented on PS 40% 5/5. Bil LS clear w/transient\n rhonchi which clear after being suctioned for med amnt of white thick\n secretions.\n Action:\n Mechanical ventilation -> will attempt trach mask in am, mouth care\n q4hr and as needed, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent if tolerates.\n Neuro: alert, unable to communicate because of trach/SAH+IVH.\n Inconsistently follows commands. Moves Left upper extr purposefully, no\n movement noted @ RT upper extr. Some movement of the lower extr. Bil\n pupils are equal and reactive. Eyes tape shut 12am-6am as ordered. Eye\n care done ASDIR.\n Cardio: B/P at 100-120\ns/60\ns (elevated to 160\ns during care or\n repositioning) HR at 80\ns no ectopy noted. No peripheral edema noted.\n Peripheral pulses present.\n GI: abd soft distended, non tender. Positive for BS. Small BM during\n the shift. PEG w/TF at goal. No residuals.\n GU: clear yellow urine via foley. Adequate amnt.\n IV access: RT PICC double lumen.\n Social: patient is a FULL CODE. Awaiting placement.\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658321, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n aneurysm of right basilar artery. Ventilator dependent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient trached and vented on PS 40% 5/5. Bil LS clear w/transient\n rhonchi which clear after being suctioned for med amnt of white thick\n secretions.\n Action:\n Mechanical ventilation -> will try trach mask in am, mouth care q4hr\n and as needed, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent if tolerates.\n" }, { "category": "Nursing", "chartdate": "2157-02-10 00:00:00.000", "description": "Nursing Progress Note", "row_id": 658322, "text": "53M with pontine SAH with IVH in left lateral ventricle. Incidental\n aneurysm of right basilar artery. Ventilator dependent.\n Respiratory failure, acute (not ARDS/)\n Assessment:\n Patient trached and vented on PS 40% 5/5. Bil LS clear w/transient\n rhonchi which clear after being suctioned for med amnt of white thick\n secretions.\n Action:\n Mechanical ventilation -> will try trach mask in am, mouth care q4hr\n and as needed, suction PRN.\n Response:\n pending\n Plan:\n Continue to monitor resp status, wean off vent if tolerates.\n Neuro: alert, unable to communicate because of trach/IVH.\n" } ]

[ { "category": "Nursing/other", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 1553774, "text": "Resp Care,\nPt. admitted to MICU from ED with #8 portex extra long trache. Placed on A/C. Suctioned for thick yellow sputum. RSBI 103 this am. See carevue for vent changes ABG. Maintain current vent settings.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 1553775, "text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 extra length Portex trach on full mechanical support. Currently on A/C ventilation w/ PIP/Pplat = 20/16. BLBS coarse, suctioned for moderate amounts of thick yellowish/tan sputum. SpO2 remained 90s. See resp flowhsheet for specific vent settings/data.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 1553776, "text": "NURSING MICU NOTE 7P-7A\n\nNEURO: PT ALERT, UNABLE TO FOLLOW COMMANDS, NO PURPOUSFUL MVT. PT WILL TURN HEAD SIDE TO SIDE. AT TIMES APPEARS TO TURN HEAD TO VOICE, NOT CONSISENT. HEAD CT DONE. NO SEDTION MEDS GIVEN.\n\nRESP: NO CHANGE MADE ON VENT. PT SUCTIONED FOR THICK YELLOW SECREATIONS. MODERATE AMT THICK YELLOW SECREATIONS FROM AROUND TRACH SITE. TRACH CARE DONE FREQUENTLY.\n\nCV: HR 42-55 NSR. SBP 90-110'S. PT GIVEN 500CC NS FB. 1 UITS PRBC'S GIVEN. LAST K+ 1145 4.7. ECHO DONE. PT AFEBRILE. VANCO TROUGH DONE, 2.8 PT THIS PM.\n\nGI/GU: ABD SOFT +BS, MUSHROOM CATH INPLACE. TF CHANGED TO NEPRO 45CC/HR. TOLERATED WELL. LAST BUN/CRT 164/3.9. RENAL US DONE. UA SENT. U/O 10-40CC/HR.\n\nACCESS: RIGHT SUBCLAVIAN WNL. RIGHT BRACHIAL MIDLINE D/C'D DUE TO CLOT.\n\nSKIN: PT WITH +3 PITTING EDEMA IN ALL EXTREMITIES. SMALL SKIN TEAR NOTED ON RIGHT GLUT. BLISTERS NOTED TO BIL HEAL, WAFFEL BOOTS IN PLACE. PT WILL NEED A KINAIR BED TOMORROW.\n\nPLAN: AWAITING RESULTS OF TEST. CONT TO MONTIOR MS, U/O, SBP. PT'S FAMILY IN TO VISIT, UPDATED BY TEAM AND NURSING. PT IS A DNR.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553777, "text": "Respiratory Care Note:\n Patient remains on AC overnight. Suctioned for mod amounts of thick tannish-yellow sputum. Changed to a heated vent circuit to increase humidification. RSBI failed, no weaning done this am. See Carevue flowsheet for specifics.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553778, "text": "NARRATIVE NOTE:\n\nCV: B/P HAS RANGED FROM 112/40-108/31. SB/NSR WITH RATE RANGING FROM 59-71, NO ECTOPY NOTED. CVP 11-14. PPP BUT WEAK BIL. 3+ GENERALIZED EDEMA.\n\nNEURO: PT NON COMMUNICATIVE. OPENS EYES SPONT. DID LOOK AT STAFF BUT DID NOT FOLLOW ANY COMMANDS. PT IS VERY VERY HOH PER WIFE AND PROBABLY DOES NOT HEAR COMMANDS BUT BE STARTLED BY THE LIGHT OR SUDDEN MOVEMENTS. DOES TURN HEAD. NO PURPOSEFUL MOVEMENTS.\n\nRESP: TRACH. ON AC505/550/18/5. SX Q2-3HR FOR LG AMTS OF THICK YELLOWISH TO TANNISH SECRETIONS. RR 18-23. RHONCHI THROUGHOUT. TRACH CARE PROVIDED.\n\nGU/GI: NEPRO AT 45CC HR. ABD SOFT WITH BS. GTUBE FLUSHED WITH HTO AT 0200. SOME STOOL IN MUSHROOM CATH BUT NOT DRAINING WELL. WILL PROBABLY REMOVE WITH AM BATH. FOLEY CATH PATENT DRAINING YELLOW URINE. ZAROXALIN 10MG VIA G-TUBE FOLLOWED BY LASIX 120MG IV WITH MINIMAL RESULTS. UROLOGY WAS IN LAST EVENING AND IS FOLLOWING PT.\n\nSKIN: ABRASION ON R BUTTOCK WAS MEASURED 2.5CMX1CM WASHED WITH SALINE AND COVERED WITH DUDERM.\n\nPLAN. MONITOR U/O. POSSIBLE PT REQUIRE HD. UPDATE FAMILY WITH ANY CHANGES IN PT CONDITION. MONITOR VS AND LABS AND REPLEAT LYTES AS NEEDED. SSIC AS NEEDED. PT IS DNR\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553779, "text": "ADDENDIUM:\n\nPT IS NOW ON A 1500CC FLUID RESTRICTION\n" }, { "category": "Nursing/other", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 1553773, "text": "NURSING PROGRESS NOTE/ADMIT NOTE 1900-0700 HOURS:\n** DNR\n\n** ALLERGY: PCN, SULFA, SULFANOMIDES, HALDOL, RISPERADOL AND ATIVAN.\n\nACCESS: RIGHT SC TLC, RIGHT BRACHIAL MIDLINE (CLOTTED)\n\nPMH: CAD, S/P IMI, S/P 3V CABG (92), S/P CATH IN ' WITH LMCA STENT AND POVA OF LAD, CARDIOMYOPATHY, ISCHEMIC, TTE IN WITH EF 40%, 2+ MR, HTN, HYPERCHOLESTEROLEMIA, EXTENSIVE PVD, COPD WITH BULLOUS EMPHYSEMA, CHRONIC RESP FAILURE, RECENT MRSA WITH STENOROPHOMONAS, PSEUDOMONAS IN SPUTUM.\n\nIN BRIEF: IS A 77YO MAN WHO PRESENT FROM WITH ACUTE RENAL FAILURE. HE WAS ADMITTED THERE ON AFTER ACUTE HOSPITILIZATION FOR ENCEPHALOPATHY OF UNKNOWN ORIGIN, CONCERN FOR NMS (THOUGH RULED OUT NEUROLOGY) AND FAILURE TO WEAN OF MECH VENT. HE HAD ORIGINALLY PRESENTED AT THAT TIME WITH AGITATION, DISORIENTATION AND ADMITTED TO PSYCH. HE RECEIVED HALDOL AND DEVELOPED MOVEMENTS THROUGHOUT HIS BODY. SUBSEQUENT COURSE IS UNKNOWN AT THIS TIME. HIS COURSE OVER THE LAST WEEK HE HAS DEVELOPED RENAL FAILURE. ACCORDING TO LAB RESULTS FROM REHAB HIS CR WAS 2.7 ON .3 ON .9 ON AND TODAY WAS 3.3. BUN HAS BEEN CONSISTENTLY OVER 100. AT REHAB TODAY HE WAS STARTED ON DOPAMINE GTT AT 2 (APPARENTLY TO ATTEMPT RENAL PERFUSION BUT ALSO WITH SBP IN 80'S). DC'D UPON ADMIT TO . IN ED NOTED TO HAVE K OF 6.8-GIVEN CA GLUC, INSULIN, BICARB AND KAYEXALATE.\n\nNEURO: PT IS ALERT WITH EYES OPEN BUT DOES NOTE SEEM TO RESPOND. AT TIMES IT APPEARS AS THOUGH HE MIGHT LOOK TO VOICE AND AT ONE POINT IT APPEARED LIKE HE HAVE MOUTHED A WORD. UNCLEAR. DOES NOT FOLLOW COMMANDS. DOES NOT ILLICIT BLINK RESPONSE. DOES GRIMACE AND WITHDRAW TO PAIN. PEARL AT 3MM/BRISK.\n\nCV: SB WITH HR IN 40'S. LAST K 5.5-. NO ECTOPY. SBP IN 100'S.\n\nRESP: VENT DEPENDENT. PORTEX #8. SETTINGS OF 50%/TV 500/ R 14P 6.\nLUNGS RHONCHI THROUGHOUT. TRACH CARE DONE-YELLOWISH/GREEN DRAINAGE FROM AROUND TRACH SITE-AREA REDDENDED. SATS > 97%.\n\nGI/GU: ABD SOFTLY DISTENDED-3 MODERATE STOOLS SINCE ADMIT-BROWN, HEM NEG-RECTAL TUBE PLACED. POS BS. FOLEY IN PLACE -WAS CHANGED IN ED-ANURIC. SCANT AMT URINE SEEN IN TUBE INDICATING THE RIGHT PLACE-HOWEVER, NO OUTPUT. TO HAVE RENAL U/S TODAY. NEED URINE SPEC SENT IF ENOUGH CAN BE OBTAINED.\n\nID: AFEBRILE. WBC-AM LABS PENDING. TO START CIPRO THIS AM. URINE IN ED REPORTED TO BE VERY DIRTY.\n\nENDO: FS QID WITH S.S. AS ORDERED.\n\nPSYCHOSOCIAL: PT NOW RESIDES AT REHAB-HAS SPOUSE. NO CONTACT OVER NIGHT\n\nDISPO: DNR STATUS. VENT DEPENDENT. TREAT HYPERKALEMIA, MED REGIMEN AND ICU SUPPORTIVE CARE.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553780, "text": "NURSING MICU NOTE 7A-7P\n\nNEURO: NO CHANGE IN MS. TO BE AWAKE, NOT FOLLOWING COMMANDS, NOT RESPONDING TO PAIN. AT TIMES PT WILL MOVE HEAD TO PAINFUL STIMULI, INTERMITTENTLY. NO SPONTANOUES MVT IN ALL EXTREMITIES. PT DUE FOR MRI OF HEAD THIS PM.\n\nRESP: NO CHAGNES MADE ON VENT. PT SUCTIONED FOR THICK YELLOW SECREATIONS. PT HAS MODERATE AMT THICK YELLOW SECREATIONS THAT COME UP AROUND TRACH. FREQUENT TRACH CARE DONE.\n\nCV: HR 42-70 NSR, SBP 90-110'S. PT AFEBRILE.\n\nGI/GU: ABD SOFT, DISTENDED, +BS, SMALL AMT LOOSE STOOL IN MUSHROOM CATH. TF AT 45CC/HR NEPRO. FOLEY INTACT DRAINING YELLOW URINE W/SEDIMENT ~20-40CC/HR. PT GIVEN 25MG ALBUMIN IV THEN GIVEN 120MG IV LASIX AND 10MG METOLAONE IN HOPES PT WILL HAVE AN INCREASE IN U/O. NO RESULTS AS OF YET. IONZED CA+ .76, NOT REPLEATED DUE TO PHOS OF 12.\n\nSKIN: DUODERM TO RIGHT GLUT. WAFFEL BOOTS INPLACE. PT TO BE PLACED ON KNIAIR MATTRESS WHEN RETURNING FROM MRI.\n\nDISPO: TO MONIROT MS, U/O, SBP. PLAN FOR MRI, PLACE IN KINAIR BED, PM LYTES. WIFE CALLED FOR UPDATES. PT IS A DNR.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553781, "text": "Resp Care\nPt remains on AC, no vent changes. Stable shift. Pt went for head MRI. Pt to continue with current tx.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-17 00:00:00.000", "description": "Report", "row_id": 1553782, "text": " nursing note 7a-7p\n\n1630 pt to MRI. Pt medicated with total 8mg IVP Versed and 50mg IVP propofol to tolerate scan. VSS through out procedure. Pt placed on kinair bed. pm lytes sent.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-18 00:00:00.000", "description": "Report", "row_id": 1553783, "text": "Resp Care Note:\n\nPt trached and on mech vent as per Carevue. Lung sounds rhonchi improve with suct mod=>lge th pale yellow sput. PT in NARD on present vent settings; no vent changes required overnoc. mech vent support.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-18 00:00:00.000", "description": "Report", "row_id": 1553784, "text": "Neuro: Pt. opens eyes spontaneously occasionally tracks, moves head, does not follow commands, no extremities movement noted. +PERRLA, impaired gag/cough.Head MRI showed no acute infarct, chronic periventricular microvascular ischemic changes, mild bitemporal atrophy, chronic inflammatory paranasal sinus disease & bilat. mastoid sinus disease.\n\nResp: No vent changes overnight. LS rhonchi, suctioned for thick yellow secretions. No ABG this AM. RR 20s, Sats high 90s.\n\nCV: HR 50s-60s, NSR, no ectopy noted. NBP 110s/30s-40s. Transfused with 1 u of PRBC overnight, tolerated well. UO 20-100cc/hr. Generalized pitting edema persists. Palplable pedal pulses.\n\nGI/GU: Tolerating Nepro FS at 45cc/hr. Abd. obese, soft, nontender, +BS, inc. of small soft brown stools. FOley patent yellow urine with sediment noted.\n\nSKin: Rt. gluteal duoderm intact. SKin care performed prn.\n\nEndo: BS continue in 200s, covered per sliding scale.\n\nAM lytes pending.\n\nSocial: Family called, updated on status by this RN.\n\nPlan: Continue monitor renal function, Ca and Phos, UO, reevaluate agressive diuresis vs. CVVH.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-19 00:00:00.000", "description": "Report", "row_id": 1553785, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod-lrg amts thick yellow scretions.RSBI done on 0 peep/5 ips 30. Will to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-21 00:00:00.000", "description": "Report", "row_id": 1553794, "text": "Respirtory Care Note:\n Patient remains on assist control at this time with plan to change over to PSV later in am as tolerated. He does have a moderate amount of thick tannish sputum. BS=bilat, decreased bases, no wheezing. RSBI=13. Trach ties and dressing changed. + yellowish secretions above cuff.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-21 00:00:00.000", "description": "Report", "row_id": 1553795, "text": "Addendum 1900-0700\nSpoke to team regarding pt having not voided yet. Pt states does not feel the urge and does not wish to have a foley at this time. Team stated that if pt has not voided by rounds, foley will be discussed.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-21 00:00:00.000", "description": "Report", "row_id": 1553796, "text": "NURSING MICU NOTE 7A-7P\n\nNEURO: NO CHANGE IN MS. PT AWAKE, HEAD SIDE TO SIDE. DOES NOT FOLLOW COMMANDS, DOES NOT TRACK. NO RESPONSE TO PAIN STIMULI. NO MVT IN ANY EXTREMITIES.\n\nRESP: NO CHANGES MADE TO VENT. LS COARSE. PT SUCTIONED FOR THICK YELLOW SECREATIONS. MODERATE AMT THIKC YELLOW SECREATIONS FROM AROUND TRACH SITE. TRACH CARE DONE MULTIPLE TIMES.\n\nCV: HR 60-70'S NSR. SBP 130-160'S. AFEBRILE. PT HAS +3 GENERALIZED EDEMA.\n\nGI/GU: ABD SOFT, +BS. SMALL AMT LOOSE GOLDEN STOOL. FOLEY INTACT DRAINING YELLOW URINE W/ SEDIMENT 20-30CC/HR. PT HD AT THIS TIME. TOLERATING WELL. TF AT GOAL 45CC/HR NEPRO VIA PEG.\n\nENDO: BS TO BE GREATER THAN 250. RISS TIGHTEND.\n\nSKIN: DUODERM TO RIGHT GLUT. WAFFEL BOOTS TO BIL HEALS, NO CHANGE IN BIL HEAL BLISTERS. PT IS ON MATTRESS.\n\nDISPO: PLAN IS TO REMOVE TLC ONCE HD IS DONE. PT WILL GO FOR MRI OF SPINE IN AM. CHECKLIST DONE. PT'S FAMILY IN THIS AFTERNOON. PT IS A DNR.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-21 00:00:00.000", "description": "Report", "row_id": 1553797, "text": "Resp. care note - Pt. remaines trached and vented, no vent changes made at this time.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-22 00:00:00.000", "description": "Report", "row_id": 1553798, "text": "NPN 1900-0700\nNeuro: No changes in MS overnight. Pt. flacid and does not follow comands. MRI of Spine in AM to r/o spinal abces.\n\nResp; Pt. trached and on vent 550x18 5 of PEEP and 40% FiO2. O2 sat 96-99%. LS dim and occ coarse cleared with suctioning. No resp. distressed this shift. No plan to wean vent at this time.\n\nCV: VSS. HR 70-80's NSR with no ectopy noted. BP 150-160's systolic. BP slowley trending up. Will address it with team in AM. Pt. noted to be bleeding lg. amount from dressing to dialysis cath. Dressing removed and Pt. was bleeding from site of subclavian CL that was removed late in the evening. Hct. drawn and stable at 28.7 at 2100. Will repeat labs in AM. Bleeding stoped after pressure applied and clean dsg applied. No further bleeding for the remainder of this shift.\n\nGU: Pt. tolerating Nepro TF at 45cc/hr. No stool this shift. Abd. large soft, BS+.\n\nGI; Foley cath drainign dark urine. 20-30cc/hr. HD again on Monday. Pt. . with generalized edema.\n\nSocial: Pt. is DNR. No visit from family this shift.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-22 00:00:00.000", "description": "Report", "row_id": 1553799, "text": "Resp. care note - Pt. remaines trached and vented, transffered to MRI and back to ICU without incident.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-26 00:00:00.000", "description": "Report", "row_id": 1553817, "text": "NURSING MICU NOTE 7A-7P\n\nNEURO: NO CHANGES IN MS. PT REMAINS AWAKE, NOT FOLLOWING COMMANDS, NO MVT IN ANY EXTREMITIES. NOT TRACKIN. NO SEIZURE ACTIVITY NOTED. EEG DONE THIS AFTERNOON.\n\nRESP: NO CHANGES MADE ON VENT. PT SUCTIONED FOR THICK YELLOW SECREATIONS SMALL AMT. TRACH CARE DONE. LS COARSE.\n\nCV: HR 60-80'S NSR. SBP 100-130'S. AFEBRILE.\n\nGI/GU: ABD SOFT, DISTENDED. +BS. MED SOFT BM. TF AT GOAL 45CC/HR NEPRO. FOELY INTACT DRAINING BROWN URINE W/ SEDIMENT.\n\nSKIN: DUODERM REAPPLIED TO COCCYX. SKIN TEAR IMPROVING. PT REMAINS ON MATTRESS.\n\nDISPO: FAMILY MEETING TODAY WIFE WIFE . PENDING THE RESULTS IN EEG, IF NO IMPROVEMT FROM PREVIOUS, IT WAS EXPLAINED THERE IS POOR HOPE OF RECOVERY FROM CURRENT STATE. FAMILY STATES THAT PT WOULD NOT WANT TO LIVE IN THIS STATE. PLAN FOR FAMILY MEETING IN AM AND WILL MAKE PT . PT IS CURRENTLY A DNR.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 1553818, "text": "S/MICU Nursing Progress Note\n Neuro: pt will spont open eyes, does not follow commands, unable to track,no fright response to threat. extermites are flaccid, +cough, +gag,\n Respiratory: remains on the vent with settings of A/C 500cc x 18 PEEP 5cm, FIO2 40% suctioned for thick tan sputum at times requiring NS instill. BS coarse through out all lung fields. O2 sat remain 98-100%. green drainage around the trach site. skin intact.\n Cardiac: HR 60-70's NSR rare to no VEA, BP stable 110-130/70's with +4 pitting edema of extremites.\n GI: on tf of nepro at 45cc/hr abd soft distended. +BS, oozing stool brown med size.\n skin: duoderm on buttocks skin tears noted on the left leg.\n Social: son in tonight discussed family meeting will call in the am about time of meeting. wife in contact with the medical team, wanting test results.\n Plan: family meeting plan for am,\n" }, { "category": "Nursing/other", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 1553819, "text": "RESP CARE: pt remains with x-length Portex trach tube/ on vent per carevue. No changes in settings this shift. Pt breaths 2-3 breaths over set rate of 18. Lungs coarse, Sxd copious thick yellow sputum. RSBI-168. Pt leaking around trach at tines. Cuff pressure 30cmH20***\n" }, { "category": "Nursing/other", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 1553820, "text": "NURSING MICU NOTE 7A-7P\n\nPT MADE AT 1500 S/P FAMILY MEETING WITH PT'S 4 CHILDREN AND WIFE . PT WAS FROM VENT AND PLACED ON MORPHINE GTT AT 3MG/HR. PT AT THIS TIME APPEARS COMFORTABLE. FAMILY IS AT BEDSIDE.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-27 00:00:00.000", "description": "Report", "row_id": 1553821, "text": "Resp Care\nPt made . Pulled off vent support.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-28 00:00:00.000", "description": "Report", "row_id": 1553822, "text": "THE PT EXPIRED AT 0233. FAMILY AT BEDSIDE.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-20 00:00:00.000", "description": "Report", "row_id": 1553791, "text": "npn 7A-7p\n**DNR**\nPlease see fhp and carevue for additional data.\nOf NOTE: Pt with bilateral hearing aides needed for neuro asessments*\n\nNeuro: Pt continues to be alert, however, not following commands. opens eyes to voice. Intermittently follows command to shake head. Neuro continues to follow PT 2-3mm/bsk. turns head side to side. No outward signs of seizure noted. grimaces to nailbed pressure. Prior EEG and MRI unrevealing.\nResp: Trach #8 portex. No vent changes made today. RR 18-20. Sats 98-100%. Sxn'd Q4/hrs for small amounts of greenish/tan, thick, sputum. Will hold off on any further weaning until attempts at correcting metabolic state are made.\n\nCV: HR SB-NSR 52-63, no ectopy noted. sbp 107-127. Dialysis implemented at 16:00 this evening with goal of 2hrs/2L removal. Also plans for HD tomorrow and Monday. CVP ~. Continues with Right arm edema, elevated on pillow. volume overload in general.\n\nGI/GU: Peg site benign, TF back on at noon. abd, soft distended, +BS. No stool today. Foley patent, adequate, clear, yellow urine out. HD today goal as aforementioned. Plans for HD tomorrow and Monday as well.\nEndo: Insulin sliding scale ordered today. Follow fingerstick per order. consider implemented standing dose insulin if sugars trend high.\nSkin: Reportedly stage one to right buttock. Douderm intact not visualized by this RN.\nID: afeb. On Vanco and Aztreonem.\nSocial: spoke with wife today, updated and questions answered by this RN.\nA/P: to monitor MS. Neuro continues to follow. HD today, goal 2L off, and planned for tomorrow, and Monday. to follow BUN/CRE. Plans to attempt to correct metabolic state prior to attempt another vent wean. on abx. f/u with ? need for SD insulin. providing supportive care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-20 00:00:00.000", "description": "Report", "row_id": 1553792, "text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex extra long trach on full mechanical support. Travelled to IR for placement of R IJ dialysis catheter line w/out incident. See resp flowsheet for specifics.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2193-12-21 00:00:00.000", "description": "Report", "row_id": 1553793, "text": "NPN 1900-0700\nNeuro: Pt. alert but does not follow commands consistently. Pt. does make eye contact for short time but does not follow commands. Pt. noted to mouth words few times this shift but than goes into blank stare. No purposful movements noted.\n\nResp: Pt. trached and . on same vent settings with no change made this shift. LS dim. O2 sat 98-100%. Pt. suctioned few times this shift for small amount of yellow sputum. Pt. unable to wean off vent. on . No further attempts to vean off vent at this time.\n\nCV; VSS. HR 59-75 NSR with no ectopy noted. BP 140's/40's. Generalized edema. Dialysis cath to R IJ with bleeding under dressing. R SC TLC intact but order to d/c TLC in AM prior to rounds.\n\nGI: Nepro TF at 45cc/hr with no residuals. Small loose stool this shfit. Abd soft, distended, BS+. FS >200 covered by RISS.\n\nGU: Pt. had HD on with 2L of fluid off. Will have HD again in AM for creatnine of 4.5 on . Foley cath in place and draining urine 30-50cc/hr. Fluid balance +22L for LOS.\n\nSkin: Pt. has stageI to coccyx. Duoderm off and skin cleansed and barrier cream applied. Pt.on Kinair bed and repositioned Q2-4 hR.\n\nSocial; Pt. is a DNR. Pt.'s son in to visit this shift and updated on plan of care.\n\nPlan: . HD to see if MS improves.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-25 00:00:00.000", "description": "Report", "row_id": 1553813, "text": "micu npn 0700-1900\nplease see carevue flowsheet for all objective data\n\n\nslow bleeding continued to r ear from laceration in canal. ent in to place in ear canal, bleeding has subsided. pt also received one dose of ddavp. **please have pt's wife take hearing aids home when she comes in tomorrow.\n\nneuro- essentially unchanged. emg done this am showing severe global polyneuropathy. no movement noted to extremeties. opens eyes to stim/voice.\n\ncv/resp- hr 60-70's bp 130-160's sys, conts on labetelol home regimine of 600 . k 3.3 today, repleted w/80meq per dr . also received 4 g calcium for serum of 7. pt on this am briefly, he appeared very uncomfortable and tachypnic, same result w/increased ps, so we switched him back to his original a/c settings where he remains. suctioning thick yellow secretions q4hrs.\n\ngi/gu- tube feeds nepro at goal of 45cc/hr. sm amts of formed stool x2. uop has been at times 5-15cc/hr, other times he will put out 50-60cc/hr.. team awre. renal is following but has opted for no further dialysis at this time.\n\nsocial- this rn spoke w/pt's wife and daughter today. we talked some about the pt not being a candidate for dialysis at this point and his overall much unchanged condition and lack of progress. the wife will be coming in tomorrow, team is to arrange for a family meeting to discuss neuro findings and renal's imput on his lack of improvement\n" }, { "category": "Nursing/other", "chartdate": "2193-12-20 00:00:00.000", "description": "Report", "row_id": 1553789, "text": "NPN 1900-0700\nNeuro; Pt. awake but not responding to any commands. EEG from is inconclusive. ? etiology of encephalopathy. Neuro team is following Pt.\n\nCV: VSS. BP ranging from 116-131/32-44, HR 50-64 SR with no ectopy noted. R subclavian TLC intact. Pt. has R arm edema with no redness or warmth. R arm elevated uo on pillow to decrease swelling.\n\nResp: Pt. trached and on A/C 550x28 Peep of 5 and FiO2 50%. O2 sat 100%. Minimal secretions. MRSA in sputum. LS dim. No vent changes overnight. Pt. did not tolerate trach callor on day shift with drop in pH and secretions.\n\nGI: Pt. on Nepro TF @45cc/ht stopped at 0220 for procedure in IR in AM. Adb soft distended, BS+. No stools at this time. TF will be restarted after procedure.\n\nGU; Foley cath in place and draining adequate amount of clear yellow urine. Urine output> 30cc/hr. BUN 178 creat. 4.5 on AM. BUN and creat. has been rising over the past couple of days with no clear reason. Dialysis line to be placed on in IR for trial of dialysis for period of 1 week to see if mental status improves. Pt. was diuriesed with Lasix and Diurel and did well but fluid balance is stil+.\n\nSkin: Pt. has stage I to R buttock covered with duoderm that's CDI.\n\nSocial: Pt. is HOH and has hearing aids taken out for the night and placed in a case. Pt.'s wife is with contact with nurses and MD. I did not speak with family this shift. Pt. is a DNR.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-20 00:00:00.000", "description": "Report", "row_id": 1553790, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for mod amts thick yellow secretions.Will probably wean to t-collar today. RSBI done on 0 peep/ 5ips 34. Will to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-26 00:00:00.000", "description": "Report", "row_id": 1553814, "text": "NPN 7P-7A:\n\nENT IN TO SEE PT . A EAR WICK WAS PLACED IN THE RIGHT EAR. THEIR HAS NOT BEEN BLOODY DRAINAGE NOTED.\n\nNEURO: UNCHANGED. EDG WAS DONE ON . SHOWING SEVERE GLOBAL POLYNEUROPATHY. NO MOVEMENT NOTED FORM BILAT UPPER AND LOWER EXT.\n\nRESP: WITH WHITE SPUTUM IN MOD AMOUNTS. AC 40% 550/18/5. WITH MV 12.5.\n\nGI/GU: NEUPRO 45/ML HOUR VIA PEG TUBE. + BS. ABD LAREG ROUND AND SOFT. NO BM. THE RANLA TEAM IS FOLLOWING THE PT. NO HD @ THIS TIME. FOLEY CATH WITH 20-30CC OF BROWN URINE A HOUR. ICU TEAM AWARE.\n\nPOC: HOLD ON HD. VENT SUPPORT.MEETING WIFE TO TO DISCUSS THE LACK OF PT PROGRESS.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-26 00:00:00.000", "description": "Report", "row_id": 1553815, "text": "RESP. CARE:\n PT. REMAINS TRACH'D AND ON VENT. SUPPORT. BS- COARSE AND DIMINISHED. SX'D THICK YELLOW/TAN SPUTUM IN SM-MOD. AMOUNT. ABG7.47/42/65/31. RSBI=125 THIS A.M. PT. TO GO BACK TO C-PAP/PS MODE TODAY AS TOLERATED.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-26 00:00:00.000", "description": "Report", "row_id": 1553816, "text": "Respiratory Therapy\n\nPt remains w/ extra long portex on full mechanical support. No vent changes made this shift. Currently on A/C w/ PIP/Pplat = 25/15. SpO2 remained 90s. BLBS slightly coarse, suctioned for moderate amounts of thick tan pluggy sputum. See resp flowhsheet for specifics.\n\nPlan: maintains support; continue to assess readiness to wean...\n" }, { "category": "Nursing/other", "chartdate": "2193-12-19 00:00:00.000", "description": "Report", "row_id": 1553786, "text": "npn 7p-7a (see also carevue flownotes for objective data)\n\ndx: ARF, hypotension, hyperkalemia\n\nPt w/ neuropathy of unclear etiology, admitted from rehab to for ARF; pt also was failure to wean from mech ventilation, currently remains trached w/ A/C;\n\nneuro:\ncontinues to not move extremities, does move head side to side; no meaningful communication exchanged per gestures of any kind; eye tracking not confirmed, though does appear to gaze at caregiver at times, unable to confirm;\n\nc-v:\nnormotensive this night; hrt rhythm SB, no ectopy;\n\nresp:\nno attempts to wean on A/C ventilation per trach; lung sounds coarse bilat; occasional positional air leak heard from trach; MV's decrease when pt sleeping, but remain adequate;\n\ng-i:\ntube feeding turned off an midnight, (NPO MN) for planned placement of HD line today;\n recieved new order for insulin gtt during the night, will clarify start of ins gtt re tube feeding turned off;\n continues to ooz soft brownish-goldenish stool;\nabd obese; PEG patent;\n\ng-u:\nreceived ordered scheduled diuretics at 01:00; small diuretic effect noted, though did have increased from baseline urinary output;\n\nskin:\non -air bed; duoderm on coccyx;\n\na.m. labs:\nNa and K+ wnl's; Ca remains low, receiving alum hydrox for elevated phosphate;\n\nPLAN:\n1) HD line today\n2) MRA and MRI kidneys today(?)--need consent from family\n3) SSI vs ins gtt re NPO at this time\n4) prophylaxis ppi and hep sq, skin cares\n5) trach care\n" }, { "category": "Nursing/other", "chartdate": "2193-12-19 00:00:00.000", "description": "Report", "row_id": 1553787, "text": "respiratory care\npt was weaned to trach for several hours today tol fairly well pt was placed back on the vent for MRI of the kidneys. plane to go to L2 on . see resp page of care veiw for more vent information.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-19 00:00:00.000", "description": "Report", "row_id": 1553788, "text": "NPN\n\nNeuro: Pt does not respond to painful stimuli though his eyes are often open and he will open them to stimuli if they are closed. He does not track nor follow commands. His wife brought in is hearing aids today and they are now in.\n\nCV: BP 110-140s/40s-60s, HR 40s-60s, sinus rhythm.\n\nResp: He was placed on and his 02 SATs were in this mid 90s, he was then put on a trache mask but is venous pH was 7.16 - he was placed back on A/C 550x28/., his pH was 7.27 with these settings. He had a huge amount of secreations this morning requiring q15 min suctioning at times, since he was placed back on pos pressure ventilation he has had very few secreations.\n\nGI: Tube feeding were on hold today for the MRI, he has had 3 liquid stools today, they were OB neg.\n\nGU: He had his 3rd dose of lasix and diuril today with little effect. He has an MRI/MRA of his renal artery and per verbal report he does have flow to his renal arteries. Pt to have a dialysis placed today.\n\nSoc: His wife, grandson and daughter were in today.\n\nID: Temps have been in the 96 range, his vanco level was high and he will be given a dose when his level drops below 15.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1553807, "text": "Resp Care: Pt continues trached and on ventilatory support with a/c, no vent changes overnoc, abg drawn from LRA >> acceptable oxygenation/ventilation; bs coarse crackles, msxn thick yell secretions, rsbi 122, will wean as tol.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1553808, "text": "micu npn 0700-1900\nplease see carevue flowsheet for all objective data\n\nbeuro- remains essentially unchanged from neurological perspective. neuro to re-consult pt today post dialysis treatments to give further imput in regard to his lack of improvement in mental stauts. team gathering information to present to pt's wife and family in family meeting hopefully to be scheduled w/in the next few days.\n\near continues to ooze throughout the day at good clip. ent in this pm, noted was a sm laceration probably form inserting hearing aid to r ear. pt is to get ear drops, to be written for this pm. ear to be left open to drain and form clot, also less chance for infection rather than pack per ent. if the bleeding becomes an issue and does not subside, ent will come back to pack the ear\n\n**Please do not insert hearing aids in either ears for now**\n\ncv/resp- hypertensive at times today, home dose of labetelol restarted, tolerated dose this am. bp creeping up again to 160's this pm, range 1teens-160 sys, sinus 60-70's nsr no ectopy. k was 3.3, team did not want to replete at this point. pt switched from a/c to cpap+ps 10/5, appears to be tolerating well rr 20, stv's450cc. suctioning q4 for thick yellow secretions.\n\ngi/gu- nepro tube feeds continue at goal rate of 45cc/hr to peg. sm amts of stool x3 today. uop remains o.k. 15-50cc/hr.\n\nsocial- wife called for update, no family in to visit today.\n\n to follow bleeding, await neuro team consult and recs. hopeful for fam mtg in next few days.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1553809, "text": "Resp Care\n\npt remains trached currently on PSV 10/5 tol well with vt around 450-550cc and RR in the mid to low 20s. BS slightly course sxing for small amts of thick yellow to white secretions Q3-Q4 hours. Attempted to wean PS 5 however Vt low 300s with increased RR noted following change. WIll with vent support and reassess later this evening for further weaning trials.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-25 00:00:00.000", "description": "Report", "row_id": 1553810, "text": "NPN 7A-7P:\n\nNEURO: PT ALERT . UNABLE TO MOVE UPPER AND LOWER EXT. HE IS NOT ABLET TO MAKE HIS NEEDS KNOWN.\n\nRESP: COURSE BILAT. SX FOR THICK YELLOW SPUTUM IN MOD AMOUNTS. VENT SETTINGS ARE UNCHANGED. TRACH SITE DRAINING YELLOW SPUTUM.\n\nCV: NSR HR 70'S. PVC NOTED. SBP 140'S.\n\nGI/GU: NEPRO AT 45CC/HR. WHICH IS GOAL RATE. ABD LARGE ROUND SOFT. + BS. LIGHT BROWN SMALL STOOL. FOLEY CATH WITH BROWN URINE.\n\nENDO: FS Q6H W/ RISS.\n\n\nSKIN: HIS RIGHT EAR IS OZZING BRIGHT RED BLOOD. ICU TEAM AWARE. HIS EAR WAS PACKED WITH ABSORBABLE HEMOSTAT.\n\nPOC: MONITOR RIGHT EAR BLEEDING. LABS IN AM.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-25 00:00:00.000", "description": "Report", "row_id": 1553811, "text": "RESPIRATORY CARE:\n\nPt remains , vent supported. No changes made overnight. BS's coarse, sxing thick tan secretions from trache. See flowsheet for further pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-25 00:00:00.000", "description": "Report", "row_id": 1553812, "text": "micu npn 0700-1900\naccess- conts to have r dialysis line w/side port for meds. team aware that new line needs to be placed.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-22 00:00:00.000", "description": "Report", "row_id": 1553800, "text": "NURSING MICU NOTE 7A-7P\n\nNEURO: PT SLIGHTLY MORE ALERT TODAY. STILL NOT FOLLOWING COMMANDS, NO SPONTANEOUS MVT IN ANY EXTREMITIE. PT WILL OPEN HIS EYES TO VOICE AND TOUCH. BUT WILL NOT TRACK. MRI DONE OF SPINE, WET READ NO SIGN OF ABCESS. PT WAS PLACED ON PROPOFOL FOR SHORT TIME FOR MRI.\n\nRESP: NO CHANGES MADE IN VENT. LS DIMINSHED AT BASES, COARSE IN UPPER. PT SUCTIONED FOR THICK YELLOW SECREATIONS MODERATE AMT. PT HAS THICK YELLOW SECREATION THAT COME UP AROUND TRACH. TRACH CARE DONE FREQUENTLY.\n\nCV: HR 40-60'S NSR. SBP 130-160'S. AFEBRILE. K+ ABD CA+ REPLEATED TODAY.\n\nGI/GU: ABD SOFT, +BS, SMALL AMT LOOSE STOOL. TF AT GOAL 45CC/HR NEPRO VIA PEG. FOLEY INTACT DRAINING AMBER CLOUDY URINE 10-30CC/HR.\n\nENDO: BS 169, 202. IMPROVING. EVENING DOSE NHP INCREASED TODAY.\n\nSKIN: DUODERM TO GLUT. PT ON MATTRESS. PT W/ +3 EDEMA THROUGH OUT.\n\nDISPO: WIFE CALLED IN FOR UPDATE TODAY. PLAN TO TO MONITOR MS. SB TRIAL IN AM. HD IN AM. PT IS A DNR.\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-23 00:00:00.000", "description": "Report", "row_id": 1553801, "text": "Pt 78 yr old admitted from Northwest rehab facility with encephopathy, of unknown origin, emphysema possible , neuroleptic maglignant syndrome which was ruled out by neurology. Admitted therre on , Pt received Haldol and developed movements, failure to wean from vent, and disorientation.\n\n According to wife pt had no previous medical HX was Taking depakote for 20 yrs for bipolar disorder. Admitted to with cardiomyopathy, hypercholesterolemia, extensive PVD with occl of SFA LCI LCF COPD with bullous emphysema Chronic resp failure recent MRSA with stenotrophomas and pseudomonas in sputum Pt present with ARF. Course over alst month at NE speciality unknown, team is trying to gather more medical information. Pt lab results from rehab CR2.7 with BUN over 100.\n Pt t-max @108 for 3 dys at rehab\n\nNeuro Pt appears to be alert. Will respond to voice by following with head motion. Appeared to attempt to mouth words a few times throughout shift/ No movement in uppper or lower extremities. Unable to follow simple commands. CT head and MRI spine done negative\n\nCV Pt edemous throughout espcially upper extremities. Had been receiving diuretics previously. vital signs are stable with HR @ 70 and B/p 156/43 Remained a-febrile throughout shift.\n\nGI/ GU Pt receiving dialysis had session on friday, and saturday removing 2-3 L Renal to review pt on Monday to approve continuation of Dialysis. Pt was voiding small amts of amberurine with sediment about 30 cc was anuria for few hrs (see carevue) and then started to produce urine again in small amts 20/30 cc Team aware. Abdomen is soft/dist with positive bowels sounds. PEG in place and Nepro @45/hr. Pt passed small amt of stool brown/soft.\n\nResp no changes in vent settings. Continues to have moderate amts of thick yellow sputum being suctioned and coming out around trach. Trach care done frequently. Pt to have spontaneous breathing trial today.\n\nENDO BS @ 149 rec'd 2 units reg/insulin @ midnight. B/S better controlled since pt receiving dose of AM and PM insulin.\n\nSKIN Pt on mattress. Duoderm on coccyx and pt does has some skin tears with barrier cream applied\n\n IV Dialysis with brown side port being used for blood draws and presidone administration . ABG sent with AM labs.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-23 00:00:00.000", "description": "Report", "row_id": 1553802, "text": "RESPIRATORY CARE NOTE\n\nPt remains trached with 8.0 Portex Ex-length blue line trach tube. BLBS are coarse. Sxn for thick pale yellow secretions. ABG drawn at 0430 shaows adequate ventilation and oxygenation.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2193-12-23 00:00:00.000", "description": "Report", "row_id": 1553803, "text": "> Labs @ 5Am results WBC 12.4 HCT 26.4 HGB 9.2 PLTS 139\nCREAT 3,0 BUN 124 Type and Screen sent 6AM for possible transfusion. ABG 's 7.45/39/111/28.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-23 00:00:00.000", "description": "Report", "row_id": 1553804, "text": "Resp. Care Note\nPt received intubated and vented on AC settings as charted on resp flowsheet. RSBI 24 today so placed n PSV5 peep 5 and did well with minute volume 9-10L. Placed on trache mask at 50%, after 4 hrs began to look somewhat labored with increased secretions. ABG drawn 7.29/59/59/ 30/0. Placed back on PSV 5 peep 5 and 40%.\n" }, { "category": "Nursing/other", "chartdate": "2193-12-23 00:00:00.000", "description": "Report", "row_id": 1553805, "text": " 4 ICU NPN 0700-1900\nOpens eyes spont. Does not follow commands or respond to deep pain. Extremities flacid. L facial droop.\nCurrently receiving HD. Tol well. Goal negative fluid balance 4 liters. UO 30-100 cc hr. BUN124, cr 3.0. Phos 5.7 Renagel started.\nTol PS trial. On TM X 3.5 hrs. Sats dropping to 87%. Pt working slightly harder to breath, slightly diaphoretic & pale. ABG 59/59/7.29. Placed back on PS. Had subsequent drop in sats to 82% with slightl improvement after suctioning HR up to low 100's ST.. Put on A/C. Appears more comfortable at present. Suctioned q1 to 3 hrs for thin, white to light yellow, tan secretions.\nTF-nepro at goal. Receiving free water boluses. Oozing small amts loose, brown OB negative stool X3.\nInsulin & SS covaerage increased.\nCrit 26.4. Given one unit PRB's with HD\nCalciun repleted\nWife in to visit. Updated on pt's condition & plan of care by this nurse.\n\nA/P:\nNO change in neuro, MS, clinical picture. Follow\n Tiring on TM trial. Assess overnight. Check RSBI in AM ?. TM trial againf in AM.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2193-12-24 00:00:00.000", "description": "Report", "row_id": 1553806, "text": "78 Yr old male admitted from rehab with encepalopathy,of unknown origin end stage renal, PNA, dementia, bipolar. on depakote for past 20 yrs. cardiomyopathy, extensive PVD right SFA, LCI, LCF COPD bullous emphysemaChronic resp failure recent MRSA with pseumondas in sputum failure to wean off vent.\n\nNeuro pt does not respond to commands or pain, Open eyes spontaneously. ALert at times to treatment or voice but unable to track. No movement in extremities and are extremely flaccid.\n\nResp pt remained on vent A/C 550cc x18 FIo .4 peep5cm spont rr 0-7, at times minute ventilation up to 15 liters.. now resting at 9-10 liters/minute Pt blood gases 7.41/47/45.Pt suctioned q 3hrs for white secretions. TM trial to be done this Am\n\nCV HR85-90 B/P 139/48 to 180/48 (see carevue) Pt having occasional PVC's. Pitting edema 3+ throughout upper and lower extremities HCT currently @ 28.4 after receiving 1unit blood on previous shiftfor HCT of 26.4 .Brown dialysis port for IV prednisone and lab draws\n\nGI/GU Pt with Peg tube in place and tolerating Nepro 45/ml/hr with minimal residuals. Free water bolus 150 cc given every 8hrs. Finished dialysis last night at . Pt draining about 30-60 cc hr of brown urine. Abd soft distended postive B/S pt had soft brown stool X3 small amt overnight.\n\n\n\nSkin pt has dudoderm on coccyx area dressing changed this shift. Several skin tears throughout due to pitting edema.\n\nB/S 197 @1200 received 4 units insulin q 6hrs checks.\n\nPt has moderate to large amt of blood draining from right ear. Team aware. Possible consult with ENT. Wife called and wanted to speak with someone from team after rounds today. Concerned about blood secretions draining from ear. Also wants hearing aides to be removed each evening. Hearing aides in inside black foam box in room on table\nTo be turned of before storing in box at night by turning small wheel on back of hearing aide turn till clicks.\n\n Plan: attempt to wean today, follow bleeding from right ear, consult ENT, support wife.\n" }, { "category": "Echo", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 64408, "text": "PATIENT/TEST INFORMATION:\nIndication: Coronary artery disease.\nHeight: (in) 70\nWeight (lb): 220\nBSA (m2): 2.18 m2\nBP (mm Hg): 95/28\nHR (bpm): 50\nStatus: Inpatient\nDate/Time: at 13:54\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 report of the prior study (images not\navailable) of .\n\n\nLEFT ATRIUM: Mild LA enlargement.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Low normal LVEF.\n[Intrinsic LV systolic function likely depressed given the severity of\nvalvular regurgitation.] No resting LVOT gradient.\n\nAORTA: Normal aortic root diameter.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. Mild (1+) AR.\n\nMITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular\ncalcification. Mild thickening of mitral valve chordae. Moderate (2+) MR.\nEccentric MR jet.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate\n[+] TR. Moderate PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is mildly dilated. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. Overall left ventricular systolic\nfunction is low normal (LVEF 50-55%). [Intrinsic left ventricular systolic\nfunction is likely more depressed given the severity of valvular\nregurgitation.] The aortic valve leaflets (3) are mildly thickened but aortic\nstenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral\nvalve leaflets are moderately thickened. Moderate (2+) mitral regurgitation is\nseen. The mitral regurgitation jet is eccentric (posteriorly directed). The\ntricuspid valve leaflets are mildly thickened. There is moderate pulmonary\nartery systolic hypertension. There is no pericardial effusion.\n\nCompared with the report of the prior study (tape unavailable for review) of\n, the overall LVEF has probably improved. The degree of pulmonary\nhypertension detected has increased.\n\n\n" }, { "category": "ECG", "chartdate": "2193-12-20 00:00:00.000", "description": "Report", "row_id": 132664, "text": "Sinus bradycardia\nFirst degree A-V block\nPoor R wave progression - possible septal myocardial infarction\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2193-12-19 00:00:00.000", "description": "Report", "row_id": 132665, "text": "Sinus rhythm\nConsider old septal infarct\nInferior T wave changes are nonspecific\nIntraventricular conduction delay\nLow QRS voltages in limb leads\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2193-12-16 00:00:00.000", "description": "Report", "row_id": 132666, "text": "Regular supraventricular rhythm - probably sinus\nIntraventricular conduction defect\nAnteroseptal myocardial infarction\nLow QRS voltages in limb leads\nST-T wave abnormalities\nSince previous tracing of , no significant change\n\n" }, { "category": "ECG", "chartdate": "2193-12-15 00:00:00.000", "description": "Report", "row_id": 132667, "text": "Sinus bradycardia\nIntraventricular conduction defect\nConsider old septal infarct\nInferior T wave changes are nonspecific\nLow QRS voltages in limb leads\nSince previous tracing of , anterior T wave changes have resolved\n\n" }, { "category": "Radiology", "chartdate": "2193-12-16 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 896336, "text": " 5:01 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for bleed, mass.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o of ? NMS with altered mental status. Chronic ,\n vent\n REASON FOR THIS EXAMINATION:\n eval for bleed, mass.\n CONTRAINDICATIONS for IV CONTRAST:\n acute renal failure\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Change in mental status.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: There is a band-like area of hyperdensity in the anterior aspect of\n the brainstem, which most probably represents streak artifact from the skull\n base. There are no areas concerning for intra- or extra-axial hemorrhage.\n There is no mass effect or shift of normally midline structures. There is mild\n prominence of the ventricles and sulci consistent with age- appropriate\n involutional change. The ventricles are symmetric and the basal cisterns are\n well visualized. There is slight increase in hypodensity in the\n periventricular white matter consistent with chronic small vessel infarction.\n Apart from the areas described above, the density of the brain parenchyma is\n within normal limits and -white matter differentiation is well preserved.\n No fractures are identified. The mastoid air cells are opacified bilaterally,\n and the sphenoid air cells are partially opacified, right greater than left.\n The orbits appear unremarkable. In the subcutaneous fat of the right\n occipital region is a small soft tissue density which may represent a\n sebaceous cyst.\n\n IMPRESSION:\n 1. Hyperdensity in the anterior aspect of the brainstem likely represents\n streak artifact. If clinically indicated, short-term followup head CT could\n be performed.\n 2. Partial opacification of the sphenoid sinuses and mastoid air cells\n bilaterally.\n 3. Small soft tissue density in the right occipital region could represent a\n sebaceous cyst. Clinical correlation is advised.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-17 00:00:00.000", "description": "MR HEAD W/O CONTRAST", "row_id": 896459, "text": " 2:27 PM\n MR HEAD W/O CONTRAST Clip # \n Reason: please eval for cause of delta ms - ?anoxic brain injury, st\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with change in mental status, ?NMS vs brain injury\n REASON FOR THIS EXAMINATION:\n please eval for cause of delta ms - ?anoxic brain injury, stroke, etc.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI EXAMINATION OF THE BRAIN\n\n CLINICAL HISTORY: Mental status changes, assess for anoxic injury or stroke.\n\n Multiplanar T1- and T2-weighted images of the brain was obtained. There are\n no acute territorial infarcts seen within the brain on diffusion images.\n Generalized sulcal dilatation is noted suggestive of age-appropriate atrophy.\n There is moderate bitemporal atrophy as well. The ventricular system is\n symmetrical without hydrocephalus. There are no extra-axial fluid\n collections. Scattered T2 hyperintensities are noted along the\n periventricular white matter and centrum semiovale, suggestive of chronic\n microvascular ischemic or gliotic changes. Diffusion-weighted images were\n unremarkable for acute territorial infarcts. Small lacunar old infarcts are\n noted in the right basal ganglia and left external capsule. There is signal\n flow void along the intracranial portions of the carotid and basilar arteries.\n Mucosal thickening is noted within the ethmoid, maxillary and sphenoid\n sinuses. There is T2 hyperintensity within the mastoid sinuses suggestive of\n chronic inflammatory mastoiditis. The overall study was moderately degraded\n by motion artifact.\n\n IMPRESSION:\n 1. No acute territorial infarct seen within the brain.\n\n 2. Chronic periventricular microvascular ischemic changes.\n\n 3. Mild bitemporal atrophy.\n\n 4. Chronic inflammatory paranasal sinus disease and bilateral mastoid sinus\n disease.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 896220, "text": " 7:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate/chf\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with change in mental status, vent/trach dep\n REASON FOR THIS EXAMINATION:\n eval for infiltrate/chf\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Mental status change. This examination was reported at the time it\n was completed but that dictation is lost and this is redictation.\n\n AP BEDSIDE CHEST: Diffuse slight increased interstitial markings centrally.\n Probable bilateral pleural effusions layering in semi-erect position and more\n prominent on the left (where there apparently is chronic pleural thickening).\n I doubt the presence of focal consolidations although this cannot be excluded\n in the left lower lobe behind the heart where there is atelectasis. Previous\n CABG. There is an apparent tracheostomy tube. No hilar or mediastinal\n enlargement. The apparent interstitial edema and effusions have developed\n since last exam . Cardiac silhouette not enlarged.\n\n IMPRESSION: Interval apparent CHF/fluid overload.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-16 00:00:00.000", "description": "P RENAL U.S. PORT", "row_id": 896298, "text": " 1:11 PM\n RENAL U.S. PORT Clip # \n Reason: evaluate for obstruction\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with acute renal failure.\n REASON FOR THIS EXAMINATION:\n evaluate for obstruction\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Acute renal failure.\n\n Technique: Renal Ultrasound\n\n Findings: The right kidney measures 11.0 cm. The left kidney measures 11.8\n cm. There is no hydronephrosis, stones, or mass. The bladder appears emptied\n and unremarkable. A small to moderate amount of free fluid is seen within the\n pelvis.\n\n IMPRESSION: No evidence of hydronephrosis, stones, or masses. Free fluid\n within the pelvis, which may be secondary to third spacing from acute renal\n failure.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-22 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 897087, "text": " 8:14 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: please evaluate for pathology of spine including abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n FINAL ADDENDUM\n There is suggestion of pleural effusion noted bilaterally. If clinically\n warranted, radiograph of the chest may be performed.\n\n\n\n 8:14 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n Reason: please evaluate for pathology of spine including abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with mmp including paraplegia of unknown etiology.\n REASON FOR THIS EXAMINATION:\n please evaluate for pathology of spine including abscess\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n 77-year-old male with history of paraplegia of unknown etiology. To rule out\n spinal abscess.\n\n Sagittal T1, T2, STIR images and post-contrast images of the cervical and\n thoracic spine were performed with large field of view.\n\n FINDINGS:\n The study is limited study as the cervical, thoracic spine was performed with\n large field of view.\n\n The vertebrae are normal in height and alignment. Heterogeneous marrow noted\n within the vertebral bodies most probably physiologic of uncertain etiology.\n No abnormal enhancing lesions noted. No definite evidence of infection noted.\n\n Mild degenerative disc disease is noted in the lower cervical spine with mild\n spinal stenosis.\n\n IMPRESSION:\n No abnormal enhancing lesions noted to suggest epidural abscess.\n\n If symptoms persist, a followup MRI may be performed in one to two weeks with\n a small field of view in the area of interest.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-20 00:00:00.000", "description": "NON-TUNNELED", "row_id": 896829, "text": " 8:04 AM\n TEMP DIALYSIS LINE PLCT Clip # \n Reason: Please place a temporary IJ line for dialysis. Please place\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ********************************* CPT Codes ********************************\n * NON-TUNNELED FLUOR GUID PLCT/REPLCT/REMOVE *\n * C1752 CATH,HEM/PERTI DIALYSIS SHORT C1769 GUID WIRES INCL INF *\n * C1894 INT.SHTH NOT/GUID,EP,NONLASER *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with ARF with no improvement.\n REASON FOR THIS EXAMINATION:\n Please place a temporary IJ line for dialysis. Please place extra side port on\n dialysis line. If this is not viable, please also place PICC (page if you need\n an additional order)\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute renal failure not resolving with other management. Requires\n hemodialysis.\n\n PHYSICIANS: The procedure was performed by Drs. , \n with Dr. , the attending radiologist, being present and\n supervising throughout the procedure.\n\n PROCEDURE AND FINDINGS: Following written informed consent the patient was\n positioned supine on the angiography table. A preprocedure timeout was\n performed to confirm patient, procedure and site. Standard sterile prep and\n drape of the right base of the neck. Local anesthesia with 10 cc of 1%\n lidocaine subcutaneously. Using realtime ultrasound guidance a 21-gauge\n needle was used to puncture the right internal jugular vein. A 0.018-inch\n guide wire was advanced through the needle into the superior vena cava using\n fluoroscopic guidance. The needle was exchanged for a micropuncture sheath\n and the wire was exchanged for a 0.035-inch guide wire which was advanced into\n the inferior vena cava using fluoroscopic guidance. The sheath was then\n exchanged for a 12 French 16 cm long non-tunneled dual-lumen hemodialysis\n catheter with its third lumen (VIP port). The tip of the catheter was\n positioned in the superior vena cava. All three lumens of the catheter\n flushed and aspirated well, were capped and heplocked. The catheter was\n sutured in place with 2-0 silk sutures and a sterile transparent dressing was\n applied. A final limited chest radiograph confirmed catheter tip position in\n the superior vena cava above the right atrial junction. The catheter can be\n used immediately. There were no immediate complications.\n\n IMPRESSION: Successful placement of a 12-French 16 cm long non-tunneled\n triple lumen hemodialysis catheter by way of the right internal jugular vein\n with tip in the superior vena cava. The catheter can be used immediately.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-15 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 896230, "text": " 10:52 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: new right subclavian\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with change in mental status, vent/trach dep\n\n REASON FOR THIS EXAMINATION:\n new right subclavian\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Changes in mental status, new right subclavian tube placement.\n\n CHEST X-RAY, AP PORTABLE VIEW.\n\n COMPARISON: , done at 6:48 p.m.\n\n FINDINGS: The right subclavian catheter tip is at the mid SVC. There is no\n pneumothorax. There is asymmetric pulmonary edema more on the right with\n redistribution compared to the prior x-ray. The right CP angle is not\n included in the film. On the left, there is small left pleural effusion. The\n patient is status post median sternotomy and CABG. Cardiomediastinal\n silhouette is stable. Persistent left basilar atelectasis.\n\n IMPRESSION:\n\n 1. Asymmetrical pulmonary edema.\n\n 2. Peristent small left pleural effusion.\n\n 3. Persistent left basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-19 00:00:00.000", "description": "MRI ABDOMEN W/O & W/CONTRAST", "row_id": 896708, "text": " 10:59 AM\n MRI ABDOMEN W/O & W/CONTRAST; MRA ABDOMEN W&W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: Please eval for renal artery stenosis.\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: MAGNEVIST Amt: 40\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with h/o htn, CRI, now admitted with .\n REASON FOR THIS EXAMINATION:\n Please eval for renal artery stenosis.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE ABDOMEN WITH AND WITHOUT CONTRAST (RENAL MRA) DATED \n\n CLINICAL HISTORY: 77-year-old male with history of hypertension, now with\n acute-on-chronic renal failure. Please evaluate for renal artery stenosis.\n\n TECHNIQUE: HASTE, FIESTA, 2D time-of-flight, and respiratory-triggered post-\n gadolinium LAVA sequences were performed at 1.5 Tesla. Images were\n reformatted on a separate workstation.\n\n COMPARISON: Renal ultrasound dated .\n\n FINDINGS: Study is limited due to patient's inability to hold breath (patient\n is vented), patient's body habitus, and third spacing of fluid.\n\n There are two renal arteries on the right and two renal arteries on the left.\n A tiny accessory artery supplies the lower pole of the right kidney and a tiny\n accessory artery supplies the lower pole of the left kidney. No significant\n stenosis is identified.\n\n Both kidneys enhance symmetrically. A few tiny simple cysts are noted within\n each kidney. There is no hydronephrosis.\n\n There are bilateral pleural effusions, incompletely evaluated. There is a\n large amount of ascites, diffuse anasarca, and periportal edema.\n\n A partially visualized liver, pancreas, spleen, and adrenal glands are\n unremarkable. There is no significant lymphadenopathy within the visualized\n abdomen.\n\n IMPRESSION:\n 1. Technically limited study demonstrating two renal arteries on the right\n and two renal arteries on the left. No evidence for significant stenosis.\n 2. Ascites, anasarca, bilateral pleural effusions, and periportal edema.\n\n" }, { "category": "Radiology", "chartdate": "2193-12-22 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 897088, "text": " 8:14 AM\n MR W & W/O CONTRAST; MR CONTRAST GADOLIN Clip # \n Reason: please evaluate for pathology of spine including abscess\n Admitting Diagnosis: ACUTE RENAL FAILURE\n Contrast: MAGNEVIST Amt: 20\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with mmp including paraplegia of unknown etiology.\n REASON FOR THIS EXAMINATION:\n please evaluate for pathology of spine including abscess\n ______________________________________________________________________________\n FINAL REPORT\n CLINICAL HISTORY:\n\n 77-year-old male with a history of paraplegia of unknown etiology. To rule\n out a spinal abscess.\n\n MR of the lumbar spine was performed without and with administration of\n contrast.\n\n FINDINGS:\n\n The vertebrae are normal in height and alignment and signal intensity. The\n distal spinal cord is unremarkable. Disc desiccation is noted in all the\n lumbar disc spaces.\n\n At the level of L4-5: Diffuse disc bulge noted with facet and ligamentum\n flavum hypertrophy thereby causing mild central canal stenosis. No\n significant neural canal stenosis noted.\n\n There is a questionable increased signal noted within the L5-S1 disc, which\n appears to be faintly enhancing on contrast administration. This is a\n nonspecific finding.\n\n IMPRESSION:\n\n No definite evidence of epidural abscess noted.\n\n The L5-S1 disc appears to be faintly enhancing, a nonspecific finding. If\n symptoms persist, a followup MRI may be performed in one to two weeks to\n exclude subtle abnormality.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-12-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 896239, "text": " 5:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for CHF\n Admitting Diagnosis: ACUTE RENAL FAILURE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 77 year old man with change in mental status, vent/trach dep, acute renal\n failure\n REASON FOR THIS EXAMINATION:\n assess for CHF\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 6:43 A.M ON .\n\n HISTORY: Change in mental status. Tracheostomy. Acute renal failure.\n\n IMPRESSION: AP chest compared to :\n\n Moderate interstitial pulmonary edema and moderate-sized bilateral pleural\n effusion have increased. Heart size is normal. Tip of the right subclavian\n line projects over the SVC. Tip of the tracheostomy tube abuts the left\n tracheal wall and should be evaluated clinically for appropriate positioning.\n No pneumothorax. Large lung volumes suggest emphysema. The patient has had\n median sternotomy and coronary bypass grafting.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2165-10-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843050, "text": " 6:27 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o PTX/Effusion/Tamponade\n Admitting Diagnosis: MITRAL STENOSIS\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with AS/A. Fib. s/p AVR & MAZE procedure\n REASON FOR THIS EXAMINATION:\n r/o PTX/Effusion/Tamponade\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: An 84-year-old woman with aortic stenosis and AC. Now status\n post MAZE procedure.\n\n Comparison is made to preoperative chest radiograph from .\n\n AP SINGLE VIEW OF THE CHEST: There is an ET tube in good position located\n approximately 4 cm from the carina. There is an NG tube located in the\n stomach. Two left-sided chest tubes. There is one right-sided chest tube.\n There is a one mediastinal tube. Swan-Ganz catheter with the tip in the right\n pulmonary artery. Bibasilar atelectasis. No evidence of pneumothorax. No\n obvious pleural effusions.\n\n IMPRESSION: Tubes and lines in appropriate position. No evidence of\n pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2165-10-29 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843170, "text": " 6:12 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p AVR/aortic root enlargement w/increase in CT output-r/o\n Admitting Diagnosis: MITRAL STENOSIS\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with AS/A. Fib. s/p AVR & MAZE procedure\n\n REASON FOR THIS EXAMINATION:\n s/p AVR/aortic root enlargement w/increase in CT output-r/o effusion\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post aortic valve replacement. Increased chest tube\n output. Assess for effusion.\n\n FINDINGS: Compared with , lung volumes are decreased status post\n extubation. There is persistent collapse involving the left lower lobe, but\n no large/obvious pleural effusions are seen on this single projection. The\n remaining two chest and two mediastinal tubes are unchanged in position and\n unremarkable. No CHF.\n\n" }, { "category": "Radiology", "chartdate": "2165-10-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 843226, "text": " 11:10 AM\n CHEST (PORTABLE AP) Clip # \n Reason: sp ct dc, eval for ptx\n Admitting Diagnosis: MITRAL STENOSIS\\AORTIC VALVE REPLACEMENT/SDA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 84 year old woman with AS/A. Fib. s/p AVR & MAZE procedure\n\n REASON FOR THIS EXAMINATION:\n sp ct dc, eval for ptx\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 84-year-old woman with aortic stenosis, atrial fibrillation,\n status-post AVR. Status-post chest tube discontinuation. Evaluation for\n pneumothorax.\n\n COMPARISONS: Upright AP portable chest x-ray of .\n\n FINDINGS: The chest tubes have been removed. There is no evidence of\n pneumothorax. The cardiac and mediastinal contours are unchanged. Pulmonary\n vascularity is normal. A small linear subsegmental atelectasis is noted at\n the right lung base. There is a also persistent retrocardiac opacity on the\n left, consistent with atelectasis or consolidation, and a small left pleural\n effusion cannot be excluded on this view. The lungs are otherwise clear.\n There is no pleural effusion on the right. The osseous structures and soft\n tissues are unremarkable on this view.\n\n IMPRESSION\n\n 1. Removal of two (2) chest tubes, the mediastinal drain, and right IJ venous\n catheter, with no evidence of pneumothorax.\n\n 2. Persistent left lower lobe opacity suggesting atelectasis or\n consolidation.\n\n 3. Status-post aortic valve replacement surgery.\n\n 4. A small residual left-sided pleural effusion cannot be excluded on this\n view.\n\n" }, { "category": "Nursing/other", "chartdate": "2165-10-30 00:00:00.000", "description": "Report", "row_id": 1444636, "text": "Neuro: Pt was confused and restless occassionally. Easily reoriented. Cooperative and following commands. MAE. C/o Chest incision pain. tylenol ordered for pain.\n\nCV: Required Ntg gtt to keep Sbp 110-120's. Ntg gtt weaned off. Nsr 70's. No ectopy. Skin is warm and dry. Recieved 2 u pc w/o incident. Afebrile.\n\nResp: Lungs are clear. Diminished @ bases. Spo2 93% to 97%. 3L np. Encouraged to CDB/IS.\n\nGU: Uop 20-25cc/hr. Gave 20 iv lasix. Responded well. See flowsheet.\n\nSKIN: Oozing noted at CT site. Dsd change and reinforced. Oozing stopped.\n\nPLAN: Get oob to chair. Encourage to CDB/IS. Tylenol for pain. Monitor for safety.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-28 00:00:00.000", "description": "Report", "row_id": 1444632, "text": "Respiratory Care:\nPt from OR; placed on SIMV/PS settings as indicated on Carevue flowsheet. AGB pending. BS are equal & clr throughout. Plan to ventilate as ordered & wean when tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-29 00:00:00.000", "description": "Report", "row_id": 1444633, "text": "ADMISSION NOTE\nPT ADM TO CSRU ~ 1830 POST-OP AVR AND MAZE PROCEDURE. PT INTUBATED AND SEDATED ON PROPOFOL. AV PACED ON ARRIVAL.\n\nCV: CURRENTLY NSR, NO ECTOPY. PACER CHANGED TO A DEMAND, RATE 70. BP LABILE INITIALLY AND AGAIN WHEN WAKING UP AND AFTER TURNING. IV NEO NTG TITRATED TO KEEP SBP 120 RANGE. C.I. LOW BY TD, BUT WNL BY FICK. PT REPORTEDLY HAS SOME DEGREE OF TR. MVO2 68 AND 71%. MOD AMT OF FLUID BOLUS REQUIRED DUE TO STEADY DIURESIS. CT DRNG HAS SLOWED AND IS NOW SEROSANG. PROTAMINE GIVEN FOR ACT 140. INR 1.9. HCT 26->TRANSFUSED 2U PRBC, REPEAT 37. FEET WARM.\n\nRESP: LUNGS CLEAR. EXTUBATED ~ 0030 TO HUMIDIFIED .50 FT. C&DB DONE.\n\nNEURO: APPROPRIATE, FOLLOWS COMMANDS. VOICE WNL. RESTLESS, HAVING DIFFICULTY FALLING ASLEEP. MSO4 IN SM AMTS FOR INCISIONAL DISCOMFORT.\n\nG.I.: ONCE AWAKE, PT GAGGING ON ETT AND DRY HEAVING. REGLAN GIVEN W/O EFFECT. ZOFRAN GIVEN W/ SOME IMPROVEMENT. BETTER ONCE ETT OUT. OGT D/C'D W/ ETT.\n\nG.U.: BRISK DIURESIS FIRST FEW HRS AFTER ARRIVAL, NOW 50-100ML/HR. K+ AND IONCA+2 REPLACED.\n\nENDO: SSRI X 1 FOR GLUC IN 150'S.\n\nSKIN: INTACT. SM AMT SANG DRNG ON STERNAL DRSG.\n\nA/P: C.I. IMPROVED AFTER VOLUME REPLACEMENT. NEED MORE AS CVP NOW= 0 , FICK C.I. DECREASED AND LABILE BP. STABLE RESP STATUS POST- EXTUBATION. ENC PULM TOILET. PAIN MED PRN. MONITOR LYTES.\n\n" }, { "category": "Nursing/other", "chartdate": "2165-10-29 00:00:00.000", "description": "Report", "row_id": 1444634, "text": "Neuro: alert and oriented x 3, at times does get confused to place but eaisily reoriented, mae, oob to chair steady on feet, following commands correctly, percocets for pain.\n\nCardiac: nsr in the 70's no ectopy noted, sbp's in thr one teens goal to be 110-120, continues nitro gtt, low filling pressures did get 500cc that helped increase #'s, going by fick's for ci's due to tr all ci's greater than 2, palpible pedial pulses, skin warm dry and intact, afebrile.\n\nResp: weaned to 3 liters nc satting at 95%, no leak in ct system that is draining moderate amount of sero sang, lungs are dim in bases.\n\nSkin: chest with dsd with small amount of sang drainage from or, ct dsds cdi.\n\nGi/Gu: tolerating po's, abd soft round and nontender, hypoactive bowel sounds, did get reglan for c/o neausea, on riss, making just around 30cc/hr of u/o did not respond to 500cc bolus.\n\nPlan: wean o2, monitor blodd sugars, encourage to eat, increase activity as tolerates, continue nitro gtt wean as tolerates, monitor u/o.\n" }, { "category": "Nursing/other", "chartdate": "2165-10-29 00:00:00.000", "description": "Report", "row_id": 1444635, "text": "continueation of nsg note above: around 1800 pt dumped 190 of bloddy ct drainage and lost sbp from 130's to 70's at same time, pa nillson aware and came to assess, nitro off, pa took down ct dressing and milked on ct to dislodge any clots, drainage soon subsided with out any intervention, labs pending.\n" } ]

[ { "category": "Echo", "chartdate": "2193-02-12 00:00:00.000", "description": "Report", "row_id": 68221, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Hypotension, shock.\nHeight: (in) 68\nWeight (lb): 160\nBSA (m2): 1.86 m2\nBP (mm Hg): 131/66\nHR (bpm): 83\nStatus: Inpatient\nDate/Time: at 09:30\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH. Small LV cavity. Hyperdynamic LVEF >75%.\nMild resting LVOT gradient.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter. Normal aortic arch diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (?#). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. No MR.\n\nTRICUSPID VALVE: Tricuspid valve not well visualized. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. No PS.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy. The left ventricular cavity is unusually small. Left ventricular\nsystolic function is hyperdynamic (EF>75%). There is a mild resting left\nventricular outflow tract obstruction. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (?#) appear structurally\nnormal with good leaflet excursion. There is no aortic valve stenosis. No\naortic regurgitation is seen. The mitral valve leaflets are mildly thickened.\nNo mitral regurgitation is seen. The pulmonary artery systolic pressure could\nnot be determined. There is no pericardial effusion.\n\nIMPRESSION: Suboptimal image quality. Mild concentric LVH with small cavity\nand hyperdynamic left ventricular function resulting in mild outflow tract\nobstruction.\n\n\n" }, { "category": "Nursing", "chartdate": "2193-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622837, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile upon admit to MICU\n Action:\n Pt afebrile after Tylenol in EW\n u/o 80cc, and received NS 1l bolus\n K hemolysed, and repeat sent\n BRB with sm clots aspirated from PEG tube, team aware and repeat hct\n sent\n Abd soft and distended\n Lactate 6 in EW, repeat sent, 1.8\n Pt with irregular resp pattern, at times tachypnic to 38, with snoring\n like sounds, than rr decreases to 20\n Pt with no left eye, right eye pupil 4mm and NR, pt looks over to right\n side, does not track\n Withdraws both arms and right leg to pain, does not withdraw left leg\n Moans to painful stimuli, no words spoken\n Pt on NC 2l with o2 sats >95%\n Placed on droplet precautions and flu swabs sent\n Response:\n Improved lactate\n Plan:\n f/u flu swabs\n IVF as ordered\n Follow fever curve\n Follow cx data\n ------ Protected Section ------\n Pt hypotensive to 87/, received 2l NS with improvement. U/o remains\n poor. Intern placing aline.\n ------ Protected Section Addendum Entered By: , RN\n on: 19:21 ------\n" }, { "category": "ECG", "chartdate": "2193-02-12 00:00:00.000", "description": "Report", "row_id": 149886, "text": "Ectopic atrial rhythm. Delayed R wave progression. Modest ST-T wave changes are\nsuggested but unstable baseline makes assessment difficult. Since the previous\ntracing of ST-T wave changes are suggested but unstable baseline and\nbaseline artifact in both tracings make comparison difficult.\n\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623020, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Remains afebrile, hemodynamically stable off levophed drip.\n HCT dropped to 25.\n Remains on cefepime, vancomycin, ciprofloxacin, flagyl, and\n ampicillin.\n Unresponsive at baseline secondary to history of stroke.\n Remains on contact and droplet precautions.\n Action:\n Stool sent for c difficile.\n CT scan of head done to evaluate source of infection.\n Additional sample sent for flu which resulted negative and flu\n precautions discontinued.\n NT suctioned for sputum sample with no secretions obtained.\n Response:\n Remains hemodynaimcally stable.\n Plan:\n LP this pm after head CT negative.\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623084, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Altered mental status (not Delirium)\n Assessment:\n Pt is resting in bed. R pupil sluggish and reactive. Pt has seemingly\n non-purposeful movt of extremities. Does not follow commands, but was\n noted to squeeze my hand w/ her R hand during procedure (LP) this\n evening. Opens R eye spontaneously and inconsistently to voice. HR\n 80-90 NSR, RR 17-45, ABPs variable w/ range of 110/60\n 180 / 100.\n Head CT is neg.\n Action:\n Monitor MS. Perform LP. Admin abx as dir.\n Response:\n MS unchanged during shift.\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max overnight 98 F oral, then trending down overnight to 94.6 ax /\n 96.5 oral. WBC 7.2.\n Action:\n Warm bath given and warm blankets applied. Trend temps.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt is not hypotensive this shift (see range above). Flu and urine cx\n neg, blood and stool cx\ns pending.\n Action:\n Admin broad coverage abx: flagyl, vanc, ampicillin, cefipime, cipro,\n acyclovir.\n Response:\n Pt remains normo -> hypertensive. LP gram stain neg, cx pending.\n Lactate 3.3.\n Plan:\n Cont empiric abx tx. Follow cx data.\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622890, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Events:\n -Arterial line placed on right arm.\n -Bolused with 1l NS total of 5L\n -Levo gtt initiated currently off\n -Electrolytes repleted\n -Bair Hugger currently off\n Hypothermia\n Assessment:\n Patient with cool dry skin. Temp of 95 F, WBC 7.2, Lactic acid\n trending down currently 1.8 from 6.\n Action:\n Warm blanket provided but patient still was hypothermic. Bair Hugger\n initiated.\n Response:\n At 0200 am patient\ns temp started to rise at 98. Bair Hugger temp was\n brought down.\n At 0400 am patient\ns temp was 100.1. Bair Hugger was turned off.\n Plan:\n Continue to monitor temps and provide warming measures as needed.\n Follow up culture results.\n Hypotension (not Shock)\n Assessment:\n Patient\ns SBP trending down with MAP in the high 50s (56-58)\n Action:\n Patient bloused with Normal saline 1 liter\n Levophed started when patient did not respond with saline bolus\n (0.02mcg/kg/min)\n Response:\n MAP >70. Around 0200 am patient\ns MAP was in the 80\ns. Levophed was\n turned off and has since maintained her MAPs >65.\n Plan:\n Maintain MAP>65\n Fluid Bolus as needed\n Electrolyte & fluid disorder, other\n Assessment:\n Hypokalemic with K=3.1, Hypomagnesemic with Mg=1.6\n Action:\n Dr. informed. Sliding Scale provided\n Repleted with total of 60meqs Kcl and 4gms of magnesium\n Response:\n Plan:\n Monitor lytes and replete as needed.\n Hyperglycemia\n Assessment:\n Patient received with blood sugar 364mg/dl\n Action:\n Patient\ns blood sugar monitored q 2hours with Humalog insulin\n administered as needed. Lantus administered as ordered.\n Response:\n Patient\ns blood sugar started to trend down. Last blood sugar at\n 0400am was 156mg/dl and covered with 2 units of Humalog per sliding\n scale.\n Plan:\n Continue to monitor blood sugar and administer insulin as needed.\n Follow up with nutrition regarding recommendations for tube feeds.\n Monitor blood sugar response with tube feed.\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622891, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Events:\n -Arterial line placed on right arm.\n -Bolused with 1l NS total of 5L\n -Levo gtt initiated currently off\n -Electrolytes repleted\n -Bair Hugger currently off\n Precaution: Droplet and Contact\n Hypothermia\n Assessment:\n Patient with cool dry skin. Temp of 95 F, WBC 7.2, Lactic acid\n trending down currently 1.8 from 6.\n Action:\n Warm blanket provided but patient still was hypothermic. Bair Hugger\n initiated.\n Response:\n At 0200 am patient\ns temp started to rise at 98. Bair Hugger temp was\n brought down.\n At 0400 am patient\ns temp was 100.1. Bair Hugger was turned off.\n Plan:\n Continue to monitor temps and provide warming measures as needed.\n Follow up culture results.\n Hypotension (not Shock)\n Assessment:\n Patient\ns SBP trending down with MAP in the high 50s (56-58)\n Action:\n Patient bloused with Normal saline 1 liter\n Levophed started when patient did not respond with saline bolus\n (0.02mcg/kg/min)\n Response:\n MAP >70. Around 0200 am patient\ns MAP was in the 80\ns. Levophed was\n turned off and has since maintained her MAPs >65.\n Plan:\n Maintain MAP>65\n Fluid Bolus as needed\n Electrolyte & fluid disorder, other\n Assessment:\n Hypokalemic with K=3.1, Hypomagnesemic with Mg=1.6\n Action:\n Dr. informed. Sliding Scale provided\n Repleted with total of 60meqs Kcl and 4gms of magnesium\n Response:\n Plan:\n Monitor lytes and replete as needed.\n Hyperglycemia\n Assessment:\n Patient received with blood sugar 364mg/dl\n Action:\n Patient\ns blood sugar monitored q 2hours with Humalog insulin\n administered as needed. Lantus administered as ordered.\n Response:\n Patient\ns blood sugar started to trend down. Last blood sugar at\n 0400am was 156mg/dl and covered with 2 units of Humalog per sliding\n scale.\n Plan:\n Continue to monitor blood sugar and administer insulin as needed.\n Follow up with nutrition regarding recommendations for tube feeds.\n Monitor blood sugar response with tube feed.\n Patient with unknown source of infection, being covered with Zosyn,\n Cipro and Vanco. Patient with pending urine and blood cultures.\n Patient also being ruled out for flu. Please follow up results. Still\n need to obtain stool for cdiff and sputum.\n" }, { "category": "Nursing", "chartdate": "2193-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622827, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile upon admit to MICU\n Action:\n Pt afebrile after Tylenol in EW\n u/o 80cc, and received NS 1l bolus\n K hemolysed, and repeat sent\n BRB with sm clots aspirated from PEG tube, team aware and repeat hct\n sent\n Abd soft and distended\n Lactate 6 in EW, repeat sent, 1.8\n Pt with irregular resp pattern, at times tachypnic to 38, with snoring\n like sounds, than rr decreases to 20\n Pt with no left eye, right eye pupil 4mm and NR, pt looks over to right\n side, does not track\n Withdraws both arms and right leg to pain, does not withdraw left leg\n Moans to painful stimuli, no words spoken\n Pt on NC 2l with o2 sats >95%\n Placed on droplet precautions and flu swabs sent\n Response:\n Improved lactate\n Plan:\n f/u flu swabs\n IVF as ordered\n Follow fever curve\n Follow cx data\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622889, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Events:\n -Arterial line placed on right arm.\n -Bolused with 1l NS total of 5L\n -Levo gtt initiated currently off\n -Electrolytes repleted\n -Bair Hugger currently off\n Hypothermia\n Assessment:\n Patient with cool dry skin. Temp of 95 F, WBC 7.2, Lactic acid\n trending down currently 1.8 from 6.\n Action:\n Warm blanket provided but patient still was hypothermic. Bair Hugger\n initiated.\n Response:\n At 0200 am patient\ns temp started to rise at 98. Bair Hugger temp was\n brought down.\n At 0400 am patient\ns temp was 100.1. Bair Hugger was turned off.\n Plan:\n Continue to monitor temps and provide warming measures as needed.\n Follow up culture results.\n Hypotension (not Shock)\n Assessment:\n Patient\ns SBP trending down with MAP in the high 50s (56-58)\n Action:\n Patient bloused with Normal saline 1 liter\n Levophed started when patient did not respond with saline bolus\n (0.02mcg/kg/min)\n Response:\n MAP >70. Around 0200 am patient\ns MAP was in the 80\ns. Levophed was\n turned off and has since maintained her MAPs >65.\n Plan:\n Maintain MAP>65\n Fluid Bolus as needed\n Electrolyte & fluid disorder, other\n Assessment:\n Hypokalemic with K=3.1, Hypomagnesemic with Mg=1.6\n Action:\n Dr. informed. Sliding Scale provided\n Repleted with total of 60meqs Kcl and 4gms of magnesium\n Response:\n Plan:\n Monitor lytes and replete as needed.\n" }, { "category": "Nursing", "chartdate": "2193-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622825, "text": "Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-02-11 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622826, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Afebrile upon admit to MICU\n Action:\n Pt afebrile after Tylenol in EW\n u/o 80cc, and received NS 1l bolus\n K hemolysed, and repeat sent\n BRB with sm clots aspirated from PEG tube, team aware and repeat hct\n sent\n Lactate 6 in EW, repeat sent\n Response:\n Plan:\n" }, { "category": "Physician ", "chartdate": "2193-02-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 623060, "text": "Chief Complaint: fever\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n EKG - At 06:45 PM\n ARTERIAL LINE - START 08:00 PM\n - Admitted to ICU\n - Tmax 104 R in ED\n - Borderline BP --> given 4 L NS\n - aline placed\n - Levophed started at 10 PM, weaned off\n - Afebrile in ICU\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Ciprofloxacin - 10:23 PM\n Cefipime - 06:41 AM\n Metronidazole - 06:41 AM\n Vancomycin - 08:00 AM\n Ampicillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n RISS\n heparin sq\n cipro\n vanco\n amantadine\n colace\n levophed (OFF)\n flagyl\n ampicillin\n cefepime\n zosyn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 85 (65 - 98) bpm\n BP: 134/67(87) {88/46(57) - 134/67(87)} mmHg\n RR: 27 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,555 mL\n 961 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n 961 mL\n Blood products:\n Total out:\n 285 mL\n 580 mL\n Urine:\n 285 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,270 mL\n 381 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: L enucleation\n Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g\n Peripheral 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:\n Diminished: )\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Tactile stimuli, Movement: Non -purposeful,\n Tone: Increased\n Labs / Radiology\n 8.7 g/dL\n 223 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 25 mg/dL\n 118 mEq/L\n 146 mEq/L\n 26.4 %\n 7.2 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n WBC\n 7.2\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n Plt\n 223\n Cr\n 0.6\n TropT\n 0.11\n 0.09\n 0.11\n Glucose\n 117\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:3.2\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: 7.3/54/49 venous gas\n Imaging:\n CXR: ? R ML infiltrate\n Microbiology: Blood cx:\n Urine cx:\n Assessment and Plan\n Fever: Unclear source. DDx: PNA (? Blossoming RML infiltrate)\n flu swab\n sputum cx\n urine cx\n Unless additional data becomes apparent, CT head then LP\n ABX: cefepime+vanco+amp+flagyl+cipro\n hx Cdiff tx recently so resend\n serotonin syndrome in ddx, but dx of exclusion in her\n Hypotension: Likely septic shock, resolving. Lactate cleared after IVF,\n now off pressors.\n TTE\n follow lactates\n CVP = check from femoral line\n Bolus with LR given elevated chloride\n If hypotensive with Hct <30, transfuse x 1 \n : Cr up from baseline initially, resolved with fluids\n follow\n Anemia: likely diluational in setting of 5+ L NS\n follow hcts\n guaiac all stools\n transfuse to 30 if hypotensive, e/o poor perfusion\n CAD: restart statin\n trop indeterminate but CKs flat\n ICU Care\n Nutrition: NPO for now\n Nutrition recs for TF\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with husband\n status: Full code\n Disposition : ICU\n Total time spent: 35 mins\n" }, { "category": "Physician ", "chartdate": "2193-02-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 622959, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n EKG - At 06:45 PM\n ARTERIAL LINE - START 08:00 PM\n - Per nursing home (): B/l past 6 months she is nonverbal\n (in any language) though occasionally grunts/groans. No longer\n recognizing family or caregivers. , responds to painful stimuli at\n b/l.\n - A line\n - 6 Liters in at 22:00, still hypotensive, so starting Levophed\n - Levophed d/c'd at 02:00\n - Hct 37.5 -> 5 liters NS -> 26.1. Guiac -. Likely dilutional.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Ciprofloxacin - 10:23 PM\n Cefipime - 06:41 AM\n Metronidazole - 06:41 AM\n Vancomycin - 08:00 AM\n Ampicillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 85 (65 - 98) bpm\n BP: 134/67(87) {88/46(57) - 134/67(87)} mmHg\n RR: 27 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,555 mL\n 962 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n 962 mL\n Blood products:\n Total out:\n 285 mL\n 580 mL\n Urine:\n 285 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,270 mL\n 382 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 223 K/uL\n 8.7 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 25 mg/dL\n 118 mEq/L\n 146 mEq/L\n 26.4 %\n 7.2 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n WBC\n 7.2\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n Plt\n 223\n Cr\n 0.6\n TropT\n 0.11\n 0.09\n 0.11\n Glucose\n 117\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:3.2\n mg/dL, PO4:3.1 mg/dL\n Imaging: CXR: Pending\n TTE: Pending\n KUB (Prelim read): Evaluation limited by patient motion.\n Nonspecific bowel gas pattern with stool and gas in rectum. No dilated\n loops of bowel. Residual oral contrast throughout large bowel.\n CXR #2: No pneumothorax. Low lung volumes with probable left\n basilar\n atelectasis\n CXR #1: Markedly limited chest radiograph without definite signs\n of\n pneumonia or CHF. Probable left basilar atelectasis. If there is strong\n clinical concern, recommend repeat study with a more optimized\n technique to further assess.\n Microbiology: Influenza: DIRECT INFLUENZA A/B: inadequate sample\n Respiratory Viral Culture (Pending):\n Assessment and Plan\n HYPERGLYCEMIA\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n ELECTROLYTE & FLUID DISORDER, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-02-12 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 622960, "text": "Chief Complaint:\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n EKG - At 06:45 PM\n ARTERIAL LINE - START 08:00 PM\n - Per nursing home (): B/l past 6 months she is nonverbal\n (in any language) though occasionally grunts/groans. No longer\n recognizing family or caregivers. , responds to painful stimuli at\n b/l.\n - A line\n - 6 Liters in at 22:00, still hypotensive, so starting Levophed\n - Levophed d/c'd at 02:00\n - Hct 37.5 -> 5 liters NS -> 26.1. Guiac -. Likely dilutional.\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Ciprofloxacin - 10:23 PM\n Cefipime - 06:41 AM\n Metronidazole - 06:41 AM\n Vancomycin - 08:00 AM\n Ampicillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n Changes to medical and family history:\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 85 (65 - 98) bpm\n BP: 134/67(87) {88/46(57) - 134/67(87)} mmHg\n RR: 27 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,555 mL\n 962 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n 962 mL\n Blood products:\n Total out:\n 285 mL\n 580 mL\n Urine:\n 285 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,270 mL\n 382 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 223 K/uL\n 8.7 g/dL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 25 mg/dL\n 118 mEq/L\n 146 mEq/L\n 26.4 %\n 7.2 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n WBC\n 7.2\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n Plt\n 223\n Cr\n 0.6\n TropT\n 0.11\n 0.09\n 0.11\n Glucose\n 117\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:3.2\n mg/dL, PO4:3.1 mg/dL\n Imaging: CXR: Pending\n TTE: Pending\n KUB (Prelim read): Evaluation limited by patient motion.\n Nonspecific bowel gas pattern with stool and gas in rectum. No dilated\n loops of bowel. Residual oral contrast throughout large bowel.\n CXR #2: No pneumothorax. Low lung volumes with probable left\n basilar\n atelectasis\n CXR #1: Markedly limited chest radiograph without definite signs\n of\n pneumonia or CHF. Probable left basilar atelectasis. If there is strong\n clinical concern, recommend repeat study with a more optimized\n technique to further assess.\n Microbiology: Influenza: DIRECT INFLUENZA A/B: inadequate sample\n Respiratory Viral Culture (Pending):\n Assessment and Plan: 70 y/o F PMH DM, HTN, right CVA with residual\n aphasia and left sided hemiplegia admitted from nursing home for\n fevers, tachycardia and tachypnea.\n .\n # Fevers: Unable to obtain history from patient to narrow source. Ua\n negative. CXR no overt infiltrate, other than left basilar atelactasis.\n Blood cultures sent. Patient with recent C. Diff infection, abdominal\n exam soft but moderately distended. Moderate distension similiar to\n prior admission when CT scan was done. Unable to assess menigitic\n symptoms -mental status unresponsive at baseline (confirmed with\n nursing home), unable to assess nucchal rigidity on exam. Nasal swab\n for influenza was an inadequate swab.\n - Due to health care exposure broaden antibiotics to Vancomycin and\n Cipro. Anaerobic coverage with metronidazole due to aspriation risk and\n foul smelling breath on admission. Also c/w ampicillin and cefepime at\n meningitic doses\n - Follow-up blood culture and urine culture\n - Repeat CXR this afternoon following fluid resuscitation\n - Send sputum culture via nasotracheal suction\n - Order stool culture if has bowel movements\n - Repeat nasal swab for influenza\n - KUB to eval for megacolon in setting of recent c. diff infection and\n moderate distension on exam\n - Consider LP\n .\n # Hypotension: Evidence of shock with elevated lactate and creatinine.\n Lactate improved with 3 L NS. Differential most likely septic shock in\n setting of fevers vs. hypovolemic shock.\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Add pressors if MAP < 60\n - Awaiting TTE findings, trend troponins to eval cardiogenic shock\n - Trend lactate\n - Further resuscitation with RBC vs LR\n .\n # Acute kidney injury: Creatine returned to baseline, after aggressive\n fluid resusciation\n - Follow urine output\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Unlikely PE as patient on lovenox doses at nursing home for DVT ppx.\n CXR no overt infiltrate, effusions. No suggestion of heart failure on\n exam. While examining patient with notable upper airway sounds\n suggestive of sleep apnea. Based on VBG appears to be respiratory\n acidosis with compensation.\n - ABG to assess acid-base status\n - KUB to assess for abdominal etiology (obstruction, megacolon)\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 29 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam. However, clotted blood around PEG tube. Unlikely\n significant GI bleed resulting in tachypnea.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: Order sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: LFTs stable\n - Restart statin, ASA\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line, arterial line\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Nutrition:\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-02-12 00:00:00.000", "description": "Physician Attending Progress Note", "row_id": 622961, "text": "Chief Complaint: fever\n I saw and examined the patient, and was physically present with the\n for key portions of the services provided. I agree with his / her note\n above, including assessment and plan.\n HPI:\n 24 Hour Events:\n MULTI LUMEN - START 05:00 PM\n EKG - At 06:45 PM\n ARTERIAL LINE - START 08:00 PM\n - Admitted to ICU\n - Tmax 104 R in ED\n - Borderline BP --> given 4 L NS\n - aline placed\n - Levophed started at 10 PM, weaned off\n - Afebrile in ICU\n History obtained from Family / Medical records\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Ciprofloxacin - 10:23 PM\n Cefipime - 06:41 AM\n Metronidazole - 06:41 AM\n Vancomycin - 08:00 AM\n Ampicillin - 08:00 AM\n Infusions:\n Other ICU medications:\n Other medications:\n RISS\n heparin sq\n cipro\n vanco\n amantadine\n colace\n levophed (OFF)\n flagyl\n ampicillin\n cefepime\n zosyn\n Changes to medical and family history:\n PMH, SH, FH and ROS are unchanged from Admission except where noted\n above and below\n Review of systems is unchanged from admission except as noted below\n Review of systems:\n Constitutional: Fever\n Flowsheet Data as of 10:26 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 37.8\nC (100.1\n Tcurrent: 36.9\nC (98.4\n HR: 85 (65 - 98) bpm\n BP: 134/67(87) {88/46(57) - 134/67(87)} mmHg\n RR: 27 (18 - 35) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,555 mL\n 961 mL\n PO:\n TF:\n IVF:\n 4,555 mL\n 961 mL\n Blood products:\n Total out:\n 285 mL\n 580 mL\n Urine:\n 285 mL\n 580 mL\n NG:\n Stool:\n Drains:\n Balance:\n 6,270 mL\n 381 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: ///22/\n Physical Examination\n General Appearance: No acute distress\n Eyes / Conjunctiva: L enucleation\n Cardiovascular: (S1: Normal), (S2: Normal), no m/r/g\n Peripheral 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:\n Diminished: )\n Musculoskeletal: Muscle wasting\n Skin: Warm\n Neurologic: Responds to: Tactile stimuli, Movement: Non -purposeful,\n Tone: Increased\n Labs / Radiology\n 8.7 g/dL\n 223 K/uL\n 117 mg/dL\n 0.6 mg/dL\n 22 mEq/L\n 4.7 mEq/L\n 25 mg/dL\n 118 mEq/L\n 146 mEq/L\n 26.4 %\n 7.2 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n WBC\n 7.2\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n Plt\n 223\n Cr\n 0.6\n TropT\n 0.11\n 0.09\n 0.11\n Glucose\n 117\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:3.2\n mg/dL, PO4:3.1 mg/dL\n Fluid analysis / Other labs: 7.3/54/49 venous gas\n Imaging:\n CXR: ? R ML infiltrate\n Microbiology: Blood cx:\n Urine cx:\n Assessment and Plan\n HYPERGLYCEMIA\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n ELECTROLYTE & FLUID DISORDER, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n Fever: Unclear source. DDx: PNA (? Blossoming RML infiltrate)\n flu swab\n sputum cx\n urine cx\n Was covered overnight for CNS infection pending further discussion\n for CT/LP\n will hold for now\n ABX: cefepime+vanco+amp+flagyl+cipro\n hx Cdiff tx recently so resend\n Hypotension: Likely septic shock, resolving. Lactate cleared after IVF,\n now off pressors.\n TTE\n follow lactates\n CVP = check from femoral line\n Bolus with LR given elevated chloride\n If hypotensive with Hct <30, transfuse x 1 \n : Cr up from baseline initially, resolved with fluids\n follow\n Anemia: likely diluational in setting of 5+ L NS\n follow hcts\n guaiac all stools\n transfuse to 30 if hypotensive, e/o poor perfusion\n CAD: restart statin\n trop indeterminate but CKs flat\n ICU Care\n Nutrition: NPO for now\n Nutrition recs for TF\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT: sqh\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments: with husband\n status: Full code\n Disposition : ICU\n Total time spent: 35 mins\n" }, { "category": "Nutrition", "chartdate": "2193-02-12 00:00:00.000", "description": "Clinical Nutrition Note", "row_id": 622973, "text": "Subjective\n Patient nonverbal\n Objective\n Height\n Admit weight\n Daily weight\n Weight change\n BMI\n 172 cm\n 64 kg\n 21.6\n Ideal body weight\n % Ideal body weight\n Adjusted weight\n Usual body weight\n % Usual body weight\n 64 kg\n 100%\n kg\n kg\n %\n Diagnosis: PNA\n PMHx:\n DM type II\n Right CVA with Left residual hemiplegia and aphasia\n Hypertension\n Dysphagia\n Dementia with depression\n Food allergies and intolerances: none noted\n Pertinent medications: heparin, humalog insulin sliding scale, 2g\n Magnesium Sulfate, 40meq Potassium Chloride, others noted\n Labs:\n Value\n Date\n Glucose\n 117 mg/dL\n 04:16 AM\n Glucose Finger Stick\n 140\n 10:00 AM\n BUN\n 25 mg/dL\n 04:16 AM\n Creatinine\n 0.6 mg/dL\n 04:16 AM\n Sodium\n 146 mEq/L\n 04:16 AM\n Potassium\n 4.7 mEq/L\n 04:16 AM\n Chloride\n 118 mEq/L\n 04:16 AM\n TCO2\n 22 mEq/L\n 04:16 AM\n Calcium non-ionized\n 9.0 mg/dL\n 05:50 PM\n Phosphorus\n 3.1 mg/dL\n 05:50 PM\n Magnesium\n 3.2 mg/dL\n 04:16 AM\n Current diet order / nutrition support: NPO\n GI: Abdomen soft/distended with positive bowel sounds\n Assessment of Nutritional Status\n At risk for malnutrition\n Patient at risk due to: NPO / hypocaloric diet\n Estimated Nutritional Needs\n Calories: 1400-1800 (BEE x or / 22-28 cal/kg)\n Protein: 64-83 (1-1.3 g/kg)\n Fluid: per team\n Calculations based on: Admit weight\n Specifics:\n 70 year old female presenting from nursing home with fever, tachycardia\n and tachypnea. Patient non-verbal, had PEG. Consult received for tube\n feeding recommendations. Would suggest goal of Fibersource HN at\n 50ml/hr x 24 hours to provide 1440kcal and 64g protein.\n Medical Nutrition Therapy Plan - Recommend the Following\n Recommend Fibersource HN: start at 20ml/hr, advance by 20ml\n q6H to goal rate of 50ml/hr\n Monitor residuals q4H and hold tube feedings if greater than\n 200ml\n Will follow and make adjustments to formula PRN\n 12:24 PM\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623062, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623063, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Altered mental status (not Delirium)\n Assessment:\n Action:\n Response:\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n Action:\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Action:\n Response:\n Plan:\n Electrolyte & fluid disorder, other\n Assessment:\n Action:\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623103, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Altered mental status (not Delirium)\n Assessment:\n Pt is resting in bed. R pupil sluggish and reactive. Pt has seemingly\n non-purposeful movt of extremities. Does not follow commands, but was\n noted to squeeze my hand w/ her R hand during procedure (LP) this\n evening. Opens R eye spontaneously and inconsistently to voice. HR\n 80-90 NSR, RR 17-45, ABPs variable w/ range of 110/60\n 180 /100. Head\n CT is neg. Pt is wearing 2 L NC, no apnea noted, Sp02 100%. Increased\n tone all extremities.\n Action:\n Monitor MS. Perform LP. Admin abx as dir. ABG on RA\n 7.38/32/77/-.\n Response:\n MS unchanged during shift. Re-apply 2 L NC. ABG now\n 7.41/33/196/-.\n Plan:\n Monitor for changes.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max overnight 98 F oral, then trending down overnight to 94.6 ax /\n 96.5 oral. WBC 7.2.\n Action:\n Warm bath given and warm blankets applied. Trend temps.\n Response:\n Temp 97.1 F oral. WBC 4.8.\n Plan:\n Monitor fevers, cont abx tx.\n Hypotension (not Shock)\n Assessment:\n Pt is not hypotensive this shift (see range above). Flu and urine cx\n neg, blood and stool cx\ns pending.\n Action:\n Admin broad coverage abx: flagyl, vanc, ampicillin, cefipime, cipro,\n acyclovir.\n Response:\n Pt remains normo -> hypertensive. LP gram stain neg, cx pending.\n Lactate 3.3.\n Plan:\n Cont empiric abx tx. Follow cx data.\n Anemia, other\n Assessment:\n Hct trending down since admission: 26.4 to 25.1.\n Action:\n Monitor. Guiac stools.\n Response:\n Hct 25.3 at MN, then 24.9 at 4am. Stool is guiac neg.\n Plan:\n Transfuse PRBC if drops </= 21.\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623111, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Altered mental status (not Delirium)\n Assessment:\n Pt is resting in bed. R pupil sluggish and reactive. Pt has seemingly\n non-purposeful movt of extremities. Does not follow commands, but was\n noted to squeeze my hand w/ her R hand during procedure (LP) this\n evening. Opens R eye spontaneously and inconsistently to voice. HR\n 80-90 NSR, RR 17-45, ABPs variable w/ range of 110/60\n 180 /100. Head\n CT is neg. Pt is wearing 2 L NC, no apnea noted, Sp02 100%. Increased\n tone all extremities.\n Action:\n Monitor MS. Perform LP. Admin abx as dir. ABG on RA\n 7.38/32/77/-.\n Response:\n MS unchanged during shift. Re-apply 2 L NC. ABG now\n 7.41/33/196/-.\n Plan:\n Monitor for changes.\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max overnight 98 F oral, then trending down overnight to 94.6 ax /\n 96.5 oral. WBC 7.2.\n Action:\n Warm bath given and warm blankets applied. Trend temps.\n Response:\n Temp 97.1 F oral. WBC 4.8.\n Plan:\n Monitor fevers, cont abx tx.\n Hypotension (not Shock)\n Assessment:\n Pt is not hypotensive this shift (see range above). Flu and urine cx\n neg, blood and stool cx\ns pending.\n Action:\n Admin broad coverage abx: flagyl, vanc, ampicillin, cefipime, cipro,\n acyclovir.\n Response:\n Pt remains normo -> hypertensive. LP gram stain neg, cx pending.\n Lactate 3.3.\n Plan:\n Cont empiric abx tx. Follow cx data.\n Anemia, other\n Assessment:\n Hct trending down since admission: 26.4 to 25.1.\n Action:\n Monitor. Guiac stools.\n Response:\n Hct 25.3 at MN, then 24.9 at 4am. Stool is guiac neg.\n Plan:\n Transfuse PRBC if drops </= 21.\n" }, { "category": "Physician ", "chartdate": "2193-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 623181, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 10:30 AM\n repeat for influenza\n STOOL CULTURE - At 03:00 PM\n LUMBAR PUNCTURE - At 08:30 PM\n .\n - Influenza DFA neg\n - Head CT: No ICH or large territory infarct. Cephalomalacia and prom\n vent/sulci unchanged\n - CSF gram stain neg for organisms, but high protein/glucose -->\n started empiric acyclovir @ 10 mg/kg/dose Q8 hrs x 7 days. Added on HSV\n PCR\n - ECHO: Mild concentric LVH w/ small cavity and hyperdynamic left\n ventricular function resulting in mild outflow tract obstruction.\n Hyperdynamic, no akinesis/hypokinesis etc.\n - Hct 26.4 --> 25.1\n - Restarted simvastatin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:31 PM\n Cefipime - 11:41 PM\n Acyclovir - 12:18 AM\n Metronidazole - 01:31 AM\n Ampicillin - 04:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:40 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 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 87 (80 - 94) bpm\n BP: 137/58(81) {103/50(68) - 144/70(92)} mmHg\n RR: 29 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,266 mL\n 808 mL\n PO:\n TF:\n 130 mL\n 154 mL\n IVF:\n 2,136 mL\n 604 mL\n Blood products:\n Total out:\n 1,350 mL\n 420 mL\n Urine:\n 1,350 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 916 mL\n 388 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/33/196/21/-2\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 209 K/uL\n 8.2 g/dL\n 228 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.9 %\n 4.8 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n 11:43 AM\n 12:01 AM\n 12:24 AM\n 04:17 AM\n 04:31 AM\n WBC\n 7.2\n 4.8\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n 25.1\n 25.3\n 24.9\n Plt\n 223\n 209\n Cr\n 0.6\n 0.5\n TropT\n 0.11\n 0.09\n 0.11\n TCO2\n 20\n 22\n Glucose\n 117\n 228\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:3.3 mmol/L, Ca++:8.8 mg/dL, Mg++:2.1\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea.\n .\n # Fevers: Afebrile overnight. Ua negative. CXR no overt infiltrate,\n other than left basilar atelactasis. Blood and CSF cultures sent, as\n well as CSF HSV PCR. Had recent C. Diff infection. Nasal swab for\n influenza neg. KUB showed constipation. also represent serotonin\n syndrome.\n - Pull back meningitic dosing of antibiotics, as CSF studies not\n classic for bacterial infection\n - Due to health care exposure, continue with broad spectrum coverage\n (Cefepime, Vanc, Ampicillin, Flagyl, Cipro\n amp/cefepime doses). Added\n on Acyclovir yesterday given CSF findings.\n - Consider ID consult for guidance on antimicrobial choices\n - Consider toxicology recommendation for potential medication toxicity\n - Follow-up blood/urine/CSF cultures\n .\n # Hypotension: Resolved\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Trend lactate\n .\n # Acute kidney injury: Creatine returned to baseline, after aggressive\n fluid resusciation\n - Follow urine output, BUN/creatinine\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Based on VBG appears to be respiratory acidosis with compensation.\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 24.9 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: C/w sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: LFTs stable. C/w statin, ASA\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line, arterial line. Consider PICC placement for\n long-term antibiotics\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU at this time, can call out to floor\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:30 PM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-02-13 00:00:00.000", "description": "Resident / Attending Notes", "row_id": 623282, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 10:30 AM\n repeat for influenza\n STOOL CULTURE - At 03:00 PM\n LUMBAR PUNCTURE - At 08:30 PM\n .\n - Influenza DFA neg\n - Head CT: No ICH or large territory infarct. Cephalomalacia and prom\n vent/sulci unchanged\n - CSF gram stain neg for organisms, but high protein/glucose -->\n started empiric acyclovir @ 10 mg/kg/dose Q8 hrs x 7 days. Added on HSV\n PCR\n - ECHO: Mild concentric LVH w/ small cavity and hyperdynamic left\n ventricular function resulting in mild outflow tract obstruction.\n Hyperdynamic, no akinesis/hypokinesis etc.\n - Hct 26.4 --> 25.1\n - Restarted simvastatin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:31 PM\n Cefipime - 11:41 PM\n Acyclovir - 12:18 AM\n Metronidazole - 01:31 AM\n Ampicillin - 04:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:40 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 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 87 (80 - 94) bpm\n BP: 137/58(81) {103/50(68) - 144/70(92)} mmHg\n RR: 29 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,266 mL\n 808 mL\n PO:\n TF:\n 130 mL\n 154 mL\n IVF:\n 2,136 mL\n 604 mL\n products:\n Total out:\n 1,350 mL\n 420 mL\n Urine:\n 1,350 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 916 mL\n 388 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/33/196/21/-2\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 209 K/uL\n 8.2 g/dL\n 228 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.9 %\n 4.8 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n 11:43 AM\n 12:01 AM\n 12:24 AM\n 04:17 AM\n 04:31 AM\n WBC\n 7.2\n 4.8\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n 25.1\n 25.3\n 24.9\n Plt\n 223\n 209\n Cr\n 0.6\n 0.5\n TropT\n 0.11\n 0.09\n 0.11\n TCO2\n 20\n 22\n Glucose\n 117\n 228\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:3.3 mmol/L, Ca++:8.8 mg/dL, Mg++:2.1\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea.\n .\n # Fevers: Afebrile overnight. Ua negative. CXR no overt infiltrate,\n other than left basilar atelactasis. and CSF cultures sent, as\n well as CSF HSV PCR. Had recent C. Diff infection. Nasal swab for\n influenza neg. KUB showed constipation. also represent serotonin\n syndrome.\n - Pull back meningitic dosing of antibiotics, as CSF studies not\n classic for bacterial infection\n - Due to health care exposure, continue with broad spectrum coverage\n (Cefepime, Vanc, Ampicillin, Flagyl, Cipro\n amp/cefepime doses). Added\n on Acyclovir yesterday given CSF findings.\n - Consider ID consult for guidance on antimicrobial choices\n - Consider toxicology recommendation for potential medication toxicity\n - Follow-up /urine/CSF cultures\n .\n # Hypotension: Resolved\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Trend lactate\n .\n # Acute kidney injury: Creatine returned to baseline, after aggressive\n fluid resusciation\n - Follow urine output, BUN/creatinine\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Based on VBG appears to be respiratory acidosis with compensation.\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 24.9 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: C/w sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: LFTs stable. C/w statin, ASA\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line, arterial line. Consider PICC placement for\n long-term antibiotics\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU at this time, can call out to floor\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:30 PM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n ------ Protected Section ------\n CRITICAL CARE ATTENDING ADDENDUM\n I saw and examined Ms. with the ICU team, whose note from\n today reflects my input. I would add/emphasize that this 70-year-old\n woman with complex past history (DM, HTN, CVA with aphasia and\n hemiplegia, nursing home resident) was admitted for profound fever and\n some quickly-resolving hypotension. LP yesterday evening, otherwise no\n major events and exam is unchanged from prior (as documented in Dr.\n \ns note). Meds, labs, and imaging reviewed.\n Assessment and Plan\n 70-year-old woman with perplexing case of high-grade fever, which has\n resolved quickly here. The etiology of this remains opaque. This was\n clearly not raging septic shock (as it first appeared) given the\n astounding rapidity of resolution. Our infectious workup has been\n relatively aggressive, including\n culture\n Urine culture\n Influenza DFA\n C diff x 1\n LP with 5 wbc, 0% PMNs, elevated protein\n Transthoracic echo\n Chest x-ray\n CT head\n So far, no diagnosis is apparent. I am not sure what to make of the\n elevated CSF protein, though it raises the possibility of some problem\n disrupting the -brain barrier.\n We will therefore plan:\n 1) de-escalate antibiotics away from bacterial meningitic doses\n 2) maintain acyclovir while awaiting HSV PCR\n 3) continue other antibiotics while awaiting culture\n 4) for further diagnostic help:\n a. consult toxicology: ?serotonin syndrome, ?NMS (doubt)\n b. consult infectious disease: ?other diagnostic or therapeutic\n considerations\n Other issues as per Dr. \ns note above. Transfer to floor.\n ------ Protected Section Addendum Entered By: , MD\n on: 20:54 ------\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Progress Note", "row_id": 623085, "text": "HPI: Pt is a 70 yo woman who lives at Care Center.\n Transferred to ED today for temp 103.5, sat 92% on RA, and tachycardia.\n In pt found to have temp 104, received Tylenol, and IV abx. TLCL\n placed in right fem after unable to obtain other peripheral access.\n Lactate 6. Blood and urine cx sent. Pt transferred to MICU for\n observation.\n Allergies: NKA\n PMH: CVA, pt minimally responsive at baseline per report, HTN, L eye\n enucleation, PEG tube.\n Code: Full\n Altered mental status (not Delirium)\n Assessment:\n Pt is resting in bed. R pupil sluggish and reactive. Pt has seemingly\n non-purposeful movt of extremities. Does not follow commands, but was\n noted to squeeze my hand w/ her R hand during procedure (LP) this\n evening. Opens R eye spontaneously and inconsistently to voice. HR\n 80-90 NSR, RR 17-45, ABPs variable w/ range of 110/60\n 180 / 100.\n Head CT is neg. Pt is wearing 2 L NC, no apnea noted, Sp02 100%.\n Action:\n Monitor MS. Perform LP. Admin abx as dir. ABG on RA\n 7.38/32/77/-.\n Response:\n MS unchanged during shift. Re-apply 2 L NC\n Plan:\n Fever, unknown origin (FUO, Hyperthermia, Pyrexia)\n Assessment:\n T max overnight 98 F oral, then trending down overnight to 94.6 ax /\n 96.5 oral. WBC 7.2.\n Action:\n Warm bath given and warm blankets applied. Trend temps.\n Response:\n Plan:\n Hypotension (not Shock)\n Assessment:\n Pt is not hypotensive this shift (see range above). Flu and urine cx\n neg, blood and stool cx\ns pending.\n Action:\n Admin broad coverage abx: flagyl, vanc, ampicillin, cefipime, cipro,\n acyclovir.\n Response:\n Pt remains normo -> hypertensive. LP gram stain neg, cx pending.\n Lactate 3.3.\n Plan:\n Cont empiric abx tx. Follow cx data.\n Anemia, other\n Assessment:\n Hct trending down since admission: 26.4 to 25.1.\n Action:\n Monitor.\n Response:\n Hct 25.3 at MN,\n Plan:\n Transfuse PRBC if drops </= 21.\n" }, { "category": "Physician ", "chartdate": "2193-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 623147, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 10:30 AM\n repeat for influenza\n STOOL CULTURE - At 03:00 PM\n LUMBAR PUNCTURE - At 08:30 PM\n .\n - Influenza DFA neg\n - Head CT: No ICH or large territory infarct. Cephalomalacia and prom\n vent/sulci unchanged\n - CSF gram stain neg for organisms, but high protein/glucose -->\n started empiric acyclovir @ 10 mg/kg/dose Q8 hrs x 7 days. Added on HSV\n PCR\n - ECHO: Mild concentric LVH w/ small cavity and hyperdynamic left\n ventricular function resulting in mild outflow tract obstruction.\n Hyperdynamic, no akinesis/hypokinesis etc.\n - Hct 26.4 --> 25.1\n - Restarted simvastatin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:31 PM\n Cefipime - 11:41 PM\n Acyclovir - 12:18 AM\n Metronidazole - 01:31 AM\n Ampicillin - 04:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:40 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 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 87 (80 - 94) bpm\n BP: 137/58(81) {103/50(68) - 144/70(92)} mmHg\n RR: 29 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,266 mL\n 808 mL\n PO:\n TF:\n 130 mL\n 154 mL\n IVF:\n 2,136 mL\n 604 mL\n Blood products:\n Total out:\n 1,350 mL\n 420 mL\n Urine:\n 1,350 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 916 mL\n 388 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/33/196/21/-2\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 209 K/uL\n 8.2 g/dL\n 228 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.9 %\n 4.8 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n 11:43 AM\n 12:01 AM\n 12:24 AM\n 04:17 AM\n 04:31 AM\n WBC\n 7.2\n 4.8\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n 25.1\n 25.3\n 24.9\n Plt\n 223\n 209\n Cr\n 0.6\n 0.5\n TropT\n 0.11\n 0.09\n 0.11\n TCO2\n 20\n 22\n Glucose\n 117\n 228\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:3.3 mmol/L, Ca++:8.8 mg/dL, Mg++:2.1\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n ELECTROLYTE & FLUID DISORDER, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:30 PM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Physician ", "chartdate": "2193-02-13 00:00:00.000", "description": "Physician Resident Progress Note", "row_id": 623149, "text": "Chief Complaint:\n 24 Hour Events:\n NASAL SWAB - At 10:30 AM\n repeat for influenza\n STOOL CULTURE - At 03:00 PM\n LUMBAR PUNCTURE - At 08:30 PM\n .\n - Influenza DFA neg\n - Head CT: No ICH or large territory infarct. Cephalomalacia and prom\n vent/sulci unchanged\n - CSF gram stain neg for organisms, but high protein/glucose -->\n started empiric acyclovir @ 10 mg/kg/dose Q8 hrs x 7 days. Added on HSV\n PCR\n - ECHO: Mild concentric LVH w/ small cavity and hyperdynamic left\n ventricular function resulting in mild outflow tract obstruction.\n Hyperdynamic, no akinesis/hypokinesis etc.\n - Hct 26.4 --> 25.1\n - Restarted simvastatin\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 08:00 AM\n Ciprofloxacin - 08:31 PM\n Cefipime - 11:41 PM\n Acyclovir - 12:18 AM\n Metronidazole - 01:31 AM\n Ampicillin - 04:44 AM\n Infusions:\n Other ICU medications:\n Heparin Sodium (Prophylaxis) - 11:40 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 07:46 AM\n Vital signs\n Hemodynamic monitoring\n Fluid balance\n 24 hours\n Since AM\n Tmax: 36.9\nC (98.4\n Tcurrent: 36.2\nC (97.1\n HR: 87 (80 - 94) bpm\n BP: 137/58(81) {103/50(68) - 144/70(92)} mmHg\n RR: 29 (18 - 40) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 2,266 mL\n 808 mL\n PO:\n TF:\n 130 mL\n 154 mL\n IVF:\n 2,136 mL\n 604 mL\n Blood products:\n Total out:\n 1,350 mL\n 420 mL\n Urine:\n 1,350 mL\n 420 mL\n NG:\n Stool:\n Drains:\n Balance:\n 916 mL\n 388 mL\n Respiratory support\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n ABG: 7.41/33/196/21/-2\n Physical Examination\n General Appearance: Well nourished, No(t) Thin\n Eyes / Conjunctiva: PERRL\n Head, Ears, Nose, Throat: Normocephalic\n Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)\n Peripheral Vascular: (Right radial pulse: Not assessed), (Left radial\n pulse: Not assessed), (Right DP pulse: Not assessed), (Left DP pulse:\n Not assessed)\n Respiratory / Chest: (Expansion: Symmetric), (Percussion: Resonant : ),\n (Breath Sounds: Clear : )\n Abdominal: Soft, Non-tender, Bowel sounds present\n Skin: Not assessed\n Neurologic: Responds to: Not assessed, Movement: Not assessed, Tone:\n Not assessed\n Labs / Radiology\n 209 K/uL\n 8.2 g/dL\n 228 mg/dL\n 0.5 mg/dL\n 21 mEq/L\n 4.1 mEq/L\n 13 mg/dL\n 113 mEq/L\n 141 mEq/L\n 24.9 %\n 4.8 K/uL\n [image002.jpg]\n 05:50 PM\n 09:02 PM\n 11:45 PM\n 04:16 AM\n 11:43 AM\n 12:01 AM\n 12:24 AM\n 04:17 AM\n 04:31 AM\n WBC\n 7.2\n 4.8\n Hct\n 29.1\n 26.1\n 26.3\n 26.4\n 25.1\n 25.3\n 24.9\n Plt\n 223\n 209\n Cr\n 0.6\n 0.5\n TropT\n 0.11\n 0.09\n 0.11\n TCO2\n 20\n 22\n Glucose\n 117\n 228\n Other labs: CK / CKMB / Troponin-T:89//0.11, ALT / AST:, Alk Phos\n / T Bili:53/0.2, Lactic Acid:3.3 mmol/L, Ca++:8.8 mg/dL, Mg++:2.1\n mg/dL, PO4:2.0 mg/dL\n Assessment and Plan\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea.\n .\n # Fevers: Unable to obtain history from patient to narrow source. Ua\n negative. CXR no overt infiltrate, other than left basilar atelactasis.\n Blood cultures sent. Patient with recent C. Diff infection, abdominal\n exam soft but moderately distended. Moderate distension similiar to\n prior admission when CT scan was done. Unable to assess menigitic\n symptoms -mental status unresponsive at baseline (confirmed with\n nursing home), unable to assess nucchal rigidity on exam. Nasal swab\n for influenza neg. Sputum unable to be induced sufficiently. Cdiff\n pending. CSF cultures pending. KUB showed constipation\n - Due to health care exposure, continue with broad spectrum coverage\n (Cefeime, Vanc, Ampicillin, Flagyl, Cipro\n amp/cefepime at meningitic\n doses). Added on Acyclovir yesterday given CSF findings.\n - Follow-up blood culture and urine culture (NGTD); also follow-up CSF\n cultures\n .\n # Hypotension: Evidence of shock with elevated lactate and creatinine.\n Lactate improved with 3 L NS. Differential most likely septic shock in\n setting of fevers vs. hypovolemic shock. Now resolved\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Add pressors if MAP < 60\n - Trend lactate\n - Further resuscitation with RBC vs LR\n .\n # Acute kidney injury: Creatine returned to baseline, after aggressive\n fluid resusciation\n - Follow urine output\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Unlikely PE as patient on lovenox doses at nursing home for DVT ppx.\n CXR no overt infiltrate, effusions. No suggestion of heart failure on\n exam. While examining patient with notable upper airway sounds\n suggestive of sleep apnea. Based on VBG appears to be respiratory\n acidosis with compensation.\n - ABG to assess acid-base status; improved with 2L NC\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 24.9 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam. However, clotted blood around PEG tube. Unlikely\n significant GI bleed resulting in tachypnea.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: Order sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: LFTs stable\n - Restart statin, ASA\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line, arterial line\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ANEMIA, OTHER\n RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF)\n ALTERED MENTAL STATUS (NOT DELIRIUM)\n HYPERGLYCEMIA\n HYPOTHERMIA\n HYPOTENSION (NOT SHOCK)\n ELECTROLYTE & FLUID DISORDER, OTHER\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n ICU Care\n Nutrition:\n Fibersource HN (Full) - 05:30 PM 20 mL/hour\n Glycemic Control:\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n Prophylaxis:\n DVT:\n Stress ulcer:\n VAP:\n Comments:\n Communication: Comments:\n Code status: Full code\n Disposition:\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 623259, "text": "Anemia, other\n Assessment:\n Pt has had hct of 26-24 over past several days\n Action:\n Serial daily hcts, stool guiaced\n Response:\n Hct remains stable,\n Plan:\n Continue to monitor daily labs, checkstool for ob,\n Hyperglycemia\n Assessment:\n Pt on sliding scale, for hyperglycemic episodes\n Action:\n Fingerstick qid and rx per protocol\n Response:\n Bs range 225-258, pt rx with huumalong per sliding scale\n Plan:\n Continue to monitor and rx hyperlycemia\n Altered mental status (not Delirium)\n Assessment:\n Pt does not follow commands, and does not appear to track, although rt\n eye opens frequenty to stimuli (left eye enucleated), pt does not\n speak, frequent loud snorting respirations, withdraws marginally to\n nailbed stimuli\n Action:\n Micu team in to evaluate, ID in to evaluate, frequent attempts to\n interact and communicate with pt\n Response:\n Pt remains somnolent, occas hypertensive with stimulation, remains\n with noisy respirations that occas appear labored but 02 sats 97 and >\n Plan:\n Continue to monitor pt\ns cognitive state, ? underlying cause of\n lethargy in addition to past stroke\n" }, { "category": "Nursing", "chartdate": "2193-02-13 00:00:00.000", "description": "Nursing Transfer Note", "row_id": 623261, "text": "Anemia, other\n Assessment:\n Pt has had hct of 26-24 over past several days\n Action:\n Serial daily hcts, stool guiaced\n Response:\n Hct remains stable,\n Plan:\n Continue to monitor daily labs, checkstool for ob,\n Hyperglycemia\n Assessment:\n Pt on sliding scale, for hyperglycemic episodes\n Action:\n Fingerstick qid and rx per protocol\n Response:\n Bs range 225-258, pt rx with huumalong per sliding scale\n Plan:\n Continue to monitor and rx hyperlycemia\n Altered mental status (not Delirium)\n Assessment:\n Pt does not follow commands, and does not appear to track, although rt\n eye opens frequenty to stimuli (left eye enucleated), pt does not\n speak, frequent loud snorting respirations, withdraws marginally to\n nailbed stimuli\n Action:\n Micu team in to evaluate, ID in to evaluate, frequent attempts to\n interact and communicate with pt\n Response:\n Pt remains somnolent, occas hypertensive with stimulation, remains\n with noisy respirations that occas appear labored but 02 sats 97 and >\n Plan:\n Continue to monitor pt\ns cognitive state, ? underlying cause of\n lethargy in addition to past stroke\n HPI:\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea. Per nursing home records initial vital signs 103.5, HR 130,\n RR 48, BP 183/98, Os sat 92% RA. States she just completed antibiotic\n therapy for UTI (Bactrim) and C. Diff. According to nursing home her\n baseline is \"unresponsive\" requiring 100% assistance.\n .\n In the ED, initial vs were: T F P 96 BP 148/94 RR 14 O2 sat 100% on\n NRB. Tm in ED 104 F (rectal), SBP ranged 103-122 per documentation, but\n per report dropped to SBP 60 and required central line access (femoral\n placed). Patient sats high 90s on 2 L NC, but RR ranged as high as 41.\n Labs notable for elevated lactate and acute renal failure. Patient was\n given vancomycin, ceftriaxone, azithromycin and 2 L NS.\n .\n Patient had a recent admission for tachypnea,\n elevated lactate (3.6). Episodes of tachypnea and work-up revealed\n negative CXR, negative d-dimer and an ABG revealing mild respiratory\n alkalosis. Patient had excellent oxygenation per the discharge summary\n and episodes of dyspnea felt to be secondary to central process.\n Lactate improved to 3.6 on discharge. Infectious work-up involved\n negative urine, blood and CXR. CT abdomen demonstrated no acute process\n identified - no evidence of bowel ischemia, obstruction or colitis.\n Patient had additional admission for tachypnea and\n treated with community acquired pneumonia (CTA RLL PNA).\n Demographics\n Attending MD:\n D.\n Admit diagnosis:\n PNEUMONIA\n Code status:\n Full code\n Height:\n Admission weight:\n 64 kg\n Daily weight:\n Allergies/Reactions:\n No Known Drug Allergies\n Precautions: Contact, Droplet\n PMH:\n CV-PMH: CVA, Hypertension\n Additional history: Enucleated left eye, unresponsive at baseline \n CVA,, PEg tube, DM II, Pna, CHF, freq UTIs,\n Surgery / Procedure and date:\n Latest Vital Signs and I/O\n Non-invasive BP:\n S:93\n D:49\n Temperature:\n 96.8\n Arterial BP:\n S:167\n D:72\n Respiratory rate:\n 32 insp/min\n Heart Rate:\n 95 bpm\n Heart rhythm:\n SR (Sinus Rhythm)\n O2 delivery device:\n Nasal cannula\n O2 saturation:\n 93% %\n O2 flow:\n 2 L/min\n FiO2 set:\n 24h total in:\n 2,172 mL\n 24h total out:\n 955 mL\n Pertinent Lab Results:\n Sodium:\n 141 mEq/L\n 04:17 AM\n Potassium:\n 4.1 mEq/L\n 04:17 AM\n Chloride:\n 113 mEq/L\n 04:17 AM\n CO2:\n 21 mEq/L\n 04:17 AM\n BUN:\n 13 mg/dL\n 04:17 AM\n Creatinine:\n 0.5 mg/dL\n 04:17 AM\n Glucose:\n 228 mg/dL\n 04:17 AM\n Hematocrit:\n 24.9 %\n 04:17 AM\n Finger Stick Glucose:\n 225\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:\n Date & time of Transfer:\n" }, { "category": "Physician ", "chartdate": "2193-02-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 622851, "text": "TITLE: Admission Note\n Chief Complaint: fever, tachypnea\n HPI:\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea. Per nursing home records initial vital signs 103.5, HR 130,\n RR 48, BP 183/98, Os sat 92% RA. States she just completed antibiotic\n therapy for UTI (Bactrim) and C. Diff. According to nursing home her\n baseline is \"unresponsive\" requiring 100% assistance.\n .\n In the ED, initial vs were: T F P 96 BP 148/94 RR 14 O2 sat 100% on\n NRB. Tm in ED 104 F (rectal), SBP ranged 103-122 per documentation, but\n per report dropped to SBP 60 and required central line access (femoral\n placed). Patient sats high 90s on 2 L NC, but RR ranged as high as 41.\n Labs notable for elevated lactate and acute renal failure. Patient was\n given vancomycin, ceftriaxone, azithromycin and 2 L NS.\n .\n Patient had a recent admission for tachypnea,\n elevated lactate (3.6). Episodes of tachypnea and work-up revealed\n negative CXR, negative d-dimer and an ABG revealing mild respiratory\n alkalosis. Patient had excellent oxygenation per the discharge summary\n and episodes of dyspnea felt to be secondary to central process.\n Lactate improved to 3.6 on discharge. Infectious work-up involved\n negative urine, blood and CXR. CT abdomen demonstrated no acute process\n identified - no evidence of bowel ischemia, obstruction or colitis.\n Patient had additional admission for tachypnea and\n treated with community acquired pneumonia (CTA RLL PNA).\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Per nursing home record:\n ASA 81 mg\n Lisinopril 30 mg qd\n Lovenox 40 mg qd\n Amantadine 100 mg qd\n Metoprolol 50 mg \n Metoclopramide 10 mg QID\n Tylenol 325 mg \n Simvastatin 10 mg qhs\n Lantus 10 units qhs\n Novolog sliding scale starting 160-200 2 units\n Bisacodyl\n Milk of Magnesiua\n Maalox\n * Bactrim DS 10 days end date \n * Acidophillis 2 tabs TID for 40 days ending \n Past medical history:\n Family history:\n Social History:\n DM type II\n L eye trauma and enucleation, distant past\n Right posterior cerebral artery cerebrovascular accident\n Hypertension\n Dysphagia\n Dementia with depression\n unable to obtain\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems: Unable to obtain.\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.7\n HR: 73 (73 - 91) bpm\n BP: 112/52(67) {112/52(67) - 134/62(82)} mmHg\n RR: 23 (18 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,310 mL\n PO:\n TF:\n IVF:\n 4,310 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,060 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General: Responsive to pain only (withdraws). Does not follow\n commandds, nonverbal.\n HEENT: L eye enucleated, right eye permanently deviated R - not\n responsive to light. Sclera anicteric, dryMM, poor visualization of\n oropharynx.\n Neck: supple, JVP not elevated, no LAD\n Lungs: ronchirous breath sounds throughout.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\n gallops.\n Abdomen: soft, non-tender, distended, tympaninc, bowel sounds\n present, no rebound tenderness or guarding, no organomegaly,\n clean G-tube in place.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\n edema\n Neuro: severely hindered by baseline obtundation. unable to\n adequately assess cranial nerves. Increased tone in right arm>L\n arm. Some spontaneous movement in right arm. Legs flaccid, patellar\n reflexes intact. Toes equivocal.\n Labs / Radiology\n 3.9 mEq/L\n 29.1 %\n [image002.jpg]\n \n 2:33 A2/22/ 05:50 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 29.1\n Other labs: CK / CKMB / Troponin-T:61//, ALT / AST:, Alk Phos / T\n Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR on admission: Markedly limited chest radiograph without\n definite signs of pneumonia or CHF. Probable left basilar atelectasis.\n If there is strong clinical concern, recommend repeat study with a more\n optimized technique to further assess.\n .\n Repeat CXR: long lung volumes, left basilar atelectasis.\n Microbiology: Blood culture: ngtd\n Urine culture: ngtd\n .\n Prior micro data:\n URINE CULTURE (Final ):\n ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..\n GRAM NEGATIVE ROD(S). ~4000/ML.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ENTEROCOCCUS SP.\n |\n AMPICILLIN------------ <=2 S\n NITROFURANTOIN-------- <=16 S\n TETRACYCLINE---------- =>16 R\n VANCOMYCIN------------ <=1 S\n ECG: EKG: Normal axis. HR 79. No ST elevation or depression.\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n Assessment and Plan: 70 y/o F PMH DM, HTN, right CVA with residual\n aphasia and left sided hemiplegia admitted from nursing home for\n fevers, tachycardia and tachypnea.\n .\n # Fevers: Unable to obtain history from patient to narrow source. Ua\n negative. CXR no overt infiltrate, other than left basilar atelactasis.\n Blood cultures sent. Patient with recent C. Diff infection, abdominal\n exam soft but moderately distended. Moderate distension similiar to\n prior admission when CT scan was done. Unable to assess menigitic\n symptoms -mental status unresponsive at baseline (confirmed with\n nursing home), unable to assess nucchal rigidity on exam.\n - Due to health care exposure broaden antibiotics to Vancomycin, Zosyn\n and Cipro. Anaerobic coverage due to aspriation risk and foul smelling\n breath on admission.\n - Follow-up blood culture and urine culture\n - CXR in am following fluid resuscitation\n - Send sputum culture\n - Order stool culture\n - Nasal swab for influenza\n - KUB to eval for megacolon in setting of recent c. diff infection and\n moderate distension on exam\n - Consider LP\n .\n # Hypotension: Evidence of shock with elevated lactate and creatinine.\n Lactate improved with 3 L NS. Differential most likely septic shock in\n setting of fevers vs. hypovolemic shock.\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Add pressors if MAP < 60\n - ECHO in am, trend troponins to eval cardiogenic shock\n - Trend lactate\n - Place a-line\n .\n # Acute kidney injury: Creatine 1.3 from baseline 0.5 - 0.9. Secondary\n to hypovolemia vs. septic shock.\n - Aggressive fluid resusciation\n - Re-check K due to hemolysis\n - Follow urine output closely\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Unlikely PE as patient on lovenox doses at nursing home for DVT ppx.\n CXR no overt infiltrate, effusions. No suggestion of heart failure on\n exam. While examining patient with notable upper airway sounds\n suggestive of sleep apnea. Based on VBG appears to be respiratory\n acidosis with compensation.\n - ABG to assess acid-base status\n - KUB to assess for abdominal etiology (obstruction, megacolon)\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 29 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam. However, clotted blood around PEG tube. Unlikely\n significant GI bleed resulting in tachypnea.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: Order sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: Hold simvastatin until LFTs and ASA until stable HCT.\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n ------ Protected Section ------\n ICU Overnight Attending Coverage\n I saw and examined the patient with the medical ICU resident. The\n assessment and plan was discussed in detail and is detailed in Dr.\n \ns note above. I would emphasize and add the following. 70\n y.o. woman with DM, CVA with aphasia, presents with fever and\n hypotension requiring aggessive volume resusitation and now pressors\n added. Urine output ~35 cc/hr. Rhonchi on exam, foul smelling\n breath. No witnessed aspiration reported from nursing home. Abdomen\n distended but soft, occ. Bowel sounds. Suspect lung source of\n infection. Worrisome that now becoming hypothermic. Unstable for\n transfer from ICU to radiology for head CT, plan to empirically cover\n for CSF infection and hold on LP pending head CT. Hct drop in setting\n of volume resusitation, some clots noted by nursing around PEG site,\n flushing to evaluate for evidence of GIB. Type and cross, consider\n transfusion. Agree with detailed assessment and plan as above.\n Patient is critically ill\n Time spent: 40 minutes\n ------ Protected Section Addendum Entered By: , MD\n on: 23:23 ------\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622859, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Events:\n -Arterial line placed on right arm.\n -Bolused with 1l NS total of 5L\n -Levo gtt initiated\n -Electrolytes repleted\n Hypothermia\n Assessment:\n Patient with cool dry skin. Temp of 95 F\n Action:\n Warm blanket provided but patient still was hypothermic. Bair Hugger\n initiated.\n Response:\n Plan:\n Continue to monitor temps.\n Hypotension (not Shock)\n Assessment:\n Patient\ns SBP trending down with MAP in the high 50s (56-58)\n Action:\n Patient bloused with Normal saline 1 liter\n Levophed started when not responsive with saline (0.03mcg/kg/min)\n Response:\n MAP >70\n Plan:\n Maintain MAP>65\n Fluid Bolus as needed\n Wean off levo as tolerated\n Electrolyte & fluid disorder, other\n Assessment:\n Hypokalemic with K=3.1, Hypomagnesemic with Mg=1.6\n Action:\n Dr. informed. Sliding Scale provided\n Repleted with total of 60meqs Kcl and 4gms of magnesium\n Response:\n Plan:\n" }, { "category": "Nursing", "chartdate": "2193-02-12 00:00:00.000", "description": "Nursing Progress Note", "row_id": 622914, "text": "Pt is a 70 yo woman who lives at Care Center. Transferred to\n EW today for temp 103.5, sat 92% on RA, and tachycardia. In Ew pt found\n to have temp 104, received Tylenol, and IV abx. TLCL placed in right\n fem after unable to obtain other peripheral access. Lactate 6. Blood\n and urine cx sent. Pt transferred to MICU for observation\n Allergies\n \nCVA, pt minresponsive at baseline per report, HTN, Left eye\n enucleation, PEG tube.\n Events:\n -Arterial line placed on right arm.\n -Bolused with 1l NS total of 5L\n -Levo gtt initiated currently off\n -Electrolytes repleted\n -Bair Hugger currently off\n Precaution: Droplet and Contact\n Hypothermia\n Assessment:\n Patient with cool dry skin. Temp of 95 F, WBC 7.2, Lactic acid\n trending down currently 1.8 from 6.\n Action:\n Warm blanket provided but patient still was hypothermic. Bair Hugger\n initiated.\n Response:\n At 0200 am patient\ns temp started to rise at 98. Bair Hugger temp was\n brought down.\n At 0400 am patient\ns temp was 100.1. Bair Hugger was turned off.\n Plan:\n Continue to monitor temps and provide warming measures as needed.\n Follow up culture results.\n Hypotension (not Shock)\n Assessment:\n Patient\ns SBP trending down with MAP in the high 50s (56-58)\n Action:\n Patient bloused with Normal saline 1 liter\n Levophed started when patient did not respond with saline bolus\n (0.02mcg/kg/min)\n Response:\n MAP >70. Around 0200 am patient\ns MAP was in the 80\ns. Levophed was\n turned off and has since maintained her MAPs >65.\n Plan:\n Maintain MAP>65\n Fluid Bolus as needed\n Electrolyte & fluid disorder, other\n Assessment:\n Hypokalemic with K=3.1, Hypomagnesemic with Mg=1.6\n Action:\n Dr. informed. Sliding Scale provided\n Repleted with total of 60meqs Kcl and 4gms of magnesium\n Response:\n K=4.7 Mg=pending\n Sinus rhythm no ectopy\n Plan:\n Monitor lytes and replete as needed.\n Hyperglycemia\n Assessment:\n Patient received with blood sugar 364mg/dl\n Action:\n Patient\ns blood sugar monitored q 2hours with Humalog insulin\n administered as needed. Lantus administered as ordered.\n Response:\n Patient\ns blood sugar started to trend down. Last blood sugar at\n 0400am was 156mg/dl and covered with 2 units of Humalog per sliding\n scale.\n Plan:\n Continue to monitor blood sugar and administer insulin as needed.\n Follow up with nutrition regarding recommendations for tube feeds.\n Monitor blood sugar response with tube feed.\n Patient with unknown source of infection, being covered with Zosyn,\n Cipro and Vanco. Patient with pending urine and blood cultures.\n Patient also being ruled out for flu. Please follow up results. Still\n need to obtain stool for cdiff .\n" }, { "category": "Physician ", "chartdate": "2193-02-11 00:00:00.000", "description": "Physician Resident Admission Note", "row_id": 622847, "text": "TITLE: Admission Note\n Chief Complaint: fever, tachypnea\n HPI:\n 70 y/o F PMH DM, HTN, right CVA with residual aphasia and left sided\n hemiplegia admitted from nursing home for fevers, tachycardia and\n tachypnea. Per nursing home records initial vital signs 103.5, HR 130,\n RR 48, BP 183/98, Os sat 92% RA. States she just completed antibiotic\n therapy for UTI (Bactrim) and C. Diff. According to nursing home her\n baseline is \"unresponsive\" requiring 100% assistance.\n .\n In the ED, initial vs were: T F P 96 BP 148/94 RR 14 O2 sat 100% on\n NRB. Tm in ED 104 F (rectal), SBP ranged 103-122 per documentation, but\n per report dropped to SBP 60 and required central line access (femoral\n placed). Patient sats high 90s on 2 L NC, but RR ranged as high as 41.\n Labs notable for elevated lactate and acute renal failure. Patient was\n given vancomycin, ceftriaxone, azithromycin and 2 L NS.\n .\n Patient had a recent admission for tachypnea,\n elevated lactate (3.6). Episodes of tachypnea and work-up revealed\n negative CXR, negative d-dimer and an ABG revealing mild respiratory\n alkalosis. Patient had excellent oxygenation per the discharge summary\n and episodes of dyspnea felt to be secondary to central process.\n Lactate improved to 3.6 on discharge. Infectious work-up involved\n negative urine, blood and CXR. CT abdomen demonstrated no acute process\n identified - no evidence of bowel ischemia, obstruction or colitis.\n Patient had additional admission for tachypnea and\n treated with community acquired pneumonia (CTA RLL PNA).\n Patient admitted from: ER\n History obtained from Family / Medical records\n Patient unable to provide history: Unresponsive\n Allergies:\n No Known Drug Allergies\n Last dose of Antibiotics:\n Piperacillin/Tazobactam (Zosyn) - 08:34 PM\n Vancomycin - 09:00 PM\n Infusions:\n Other ICU medications:\n Other medications:\n Per nursing home record:\n ASA 81 mg\n Lisinopril 30 mg qd\n Lovenox 40 mg qd\n Amantadine 100 mg qd\n Metoprolol 50 mg \n Metoclopramide 10 mg QID\n Tylenol 325 mg \n Simvastatin 10 mg qhs\n Lantus 10 units qhs\n Novolog sliding scale starting 160-200 2 units\n Bisacodyl\n Milk of Magnesiua\n Maalox\n * Bactrim DS 10 days end date \n * Acidophillis 2 tabs TID for 40 days ending \n Past medical history:\n Family history:\n Social History:\n DM type II\n L eye trauma and enucleation, distant past\n Right posterior cerebral artery cerebrovascular accident\n Hypertension\n Dysphagia\n Dementia with depression\n unable to obtain\n Occupation:\n Drugs:\n Tobacco:\n Alcohol:\n Other:\n Review of systems: Unable to obtain.\n Flowsheet Data as of 09:36 PM\n Vital Signs\n Hemodynamic monitoring\n Fluid Balance\n 24 hours\n Since AM\n Tmax: 37.3\nC (99.1\n Tcurrent: 35.9\nC (96.7\n HR: 73 (73 - 91) bpm\n BP: 112/52(67) {112/52(67) - 134/62(82)} mmHg\n RR: 23 (18 - 29) insp/min\n SpO2: 100%\n Heart rhythm: SR (Sinus Rhythm)\n Total In:\n 6,310 mL\n PO:\n TF:\n IVF:\n 4,310 mL\n Blood products:\n Total out:\n 0 mL\n 250 mL\n Urine:\n 250 mL\n NG:\n Stool:\n Drains:\n Balance:\n 0 mL\n 6,060 mL\n Respiratory\n O2 Delivery Device: Nasal cannula\n SpO2: 100%\n Physical Examination\n General: Responsive to pain only (withdraws). Does not follow\n commandds, nonverbal.\n HEENT: L eye enucleated, right eye permanently deviated R - not\n responsive to light. Sclera anicteric, dryMM, poor visualization of\n oropharynx.\n Neck: supple, JVP not elevated, no LAD\n Lungs: ronchirous breath sounds throughout.\n CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,\n gallops.\n Abdomen: soft, non-tender, distended, tympaninc, bowel sounds\n present, no rebound tenderness or guarding, no organomegaly,\n clean G-tube in place.\n Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or\n edema\n Neuro: severely hindered by baseline obtundation. unable to\n adequately assess cranial nerves. Increased tone in right arm>L\n arm. Some spontaneous movement in right arm. Legs flaccid, patellar\n reflexes intact. Toes equivocal.\n Labs / Radiology\n 3.9 mEq/L\n 29.1 %\n [image002.jpg]\n \n 2:33 A2/22/ 05:50 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 29.1\n Other labs: CK / CKMB / Troponin-T:61//, ALT / AST:, Alk Phos / T\n Bili:53/0.2, Lactic Acid:1.8 mmol/L, Ca++:9.0 mg/dL, Mg++:1.9 mg/dL,\n PO4:3.1 mg/dL\n Imaging: CXR on admission: Markedly limited chest radiograph without\n definite signs of pneumonia or CHF. Probable left basilar atelectasis.\n If there is strong clinical concern, recommend repeat study with a more\n optimized technique to further assess.\n .\n Repeat CXR: long lung volumes, left basilar atelectasis.\n Microbiology: Blood culture: ngtd\n Urine culture: ngtd\n .\n Prior micro data:\n URINE CULTURE (Final ):\n ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..\n GRAM NEGATIVE ROD(S). ~4000/ML.\n SENSITIVITIES: MIC expressed in MCG/ML\n _________________________________________________________\n ENTEROCOCCUS SP.\n |\n AMPICILLIN------------ <=2 S\n NITROFURANTOIN-------- <=16 S\n TETRACYCLINE---------- =>16 R\n VANCOMYCIN------------ <=1 S\n ECG: EKG: Normal axis. HR 79. No ST elevation or depression.\n Assessment and Plan\n FEVER, UNKNOWN ORIGIN (FUO, HYPERTHERMIA, PYREXIA)\n Assessment and Plan: 70 y/o F PMH DM, HTN, right CVA with residual\n aphasia and left sided hemiplegia admitted from nursing home for\n fevers, tachycardia and tachypnea.\n .\n # Fevers: Unable to obtain history from patient to narrow source. Ua\n negative. CXR no overt infiltrate, other than left basilar atelactasis.\n Blood cultures sent. Patient with recent C. Diff infection, abdominal\n exam soft but moderately distended. Moderate distension similiar to\n prior admission when CT scan was done. Unable to assess menigitic\n symptoms -mental status unresponsive at baseline (confirmed with\n nursing home), unable to assess nucchal rigidity on exam.\n - Due to health care exposure broaden antibiotics to Vancomycin, Zosyn\n and Cipro. Anaerobic coverage due to aspriation risk and foul smelling\n breath on admission.\n - Follow-up blood culture and urine culture\n - CXR in am following fluid resuscitation\n - Send sputum culture\n - Order stool culture\n - Nasal swab for influenza\n - KUB to eval for megacolon in setting of recent c. diff infection and\n moderate distension on exam\n - Consider LP\n .\n # Hypotension: Evidence of shock with elevated lactate and creatinine.\n Lactate improved with 3 L NS. Differential most likely septic shock in\n setting of fevers vs. hypovolemic shock.\n - Infectious work-up as above\n - Aggressive fluid resuscitation\n - Add pressors if MAP < 60\n - ECHO in am, trend troponins to eval cardiogenic shock\n - Trend lactate\n - Place a-line\n .\n # Acute kidney injury: Creatine 1.3 from baseline 0.5 - 0.9. Secondary\n to hypovolemia vs. septic shock.\n - Aggressive fluid resusciation\n - Re-check K due to hemolysis\n - Follow urine output closely\n .\n # Tachypnea: Appears to be chronic problem, felt to be central process.\n Unlikely PE as patient on lovenox doses at nursing home for DVT ppx.\n CXR no overt infiltrate, effusions. No suggestion of heart failure on\n exam. While examining patient with notable upper airway sounds\n suggestive of sleep apnea. Based on VBG appears to be respiratory\n acidosis with compensation.\n - ABG to assess acid-base status\n - KUB to assess for abdominal etiology (obstruction, megacolon)\n - Consider CPAP treatment at night, however patient appears to be\n intermittently sleeping throughout the day.\n .\n # Anemia: 29 from 37.5 most likely dilutional. Guaiac negative on\n rectal exam. However, clotted blood around PEG tube. Unlikely\n significant GI bleed resulting in tachypnea.\n - Active type and screen\n - Repeat HCT to monitor stability\n .\n # DM type II: Order sliding scale.\n .\n # Hypertension: Hold outpatient Lisinopril, Metoprolol\n .\n # CVA: Hold simvastatin until LFTs and ASA until stable HCT.\n .\n # Dementia: Continue amantadine.\n .\n # Med Rec: Hold reglan for now.\n .\n # FEN: aggressive IVF, replete electrolytes, NPO\n - Nutrition recs for tube feeds\n # Prophylaxis: Subcutaneous heparin TID, bowel reg\n # Access: femoral line\n # Communication: Patient\n # Code: Full (discussed with HCP)\n # Disposition: ICU pending clinical improvement\n ICU Care\n Lines:\n Multi Lumen - 05:00 PM\n Arterial Line - 08:00 PM\n" }, { "category": "Radiology", "chartdate": "2193-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1122560, "text": " 2:41 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: r/o PTX\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with attempted L IJ placement. Assess for PTX\n REASON FOR THIS EXAMINATION:\n r/o PTX\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post left IJ attempt. Assess for pneumothorax.\n\n COMPARISON: Chest x-ray from earlier the same day.\n\n FINDINGS: Single frontal view of the chest reveals no evidence of\n pneumothorax. No line is visualized. Again the lung volumes are low and\n there is some probable left basilar atelectasis. Cardiomediastinal silhouette\n is unchanged.\n\n IMPRESSION: No pneumothorax. Low lung volumes with probable left basilar\n atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-11 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1122605, "text": " 7:49 PM\n PORTABLE ABDOMEN Clip # \n Reason: eval obstruction, megacolon\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with resp distress and moderately distended abdomen, history\n of c. diff\n REASON FOR THIS EXAMINATION:\n eval obstruction, megacolon\n ______________________________________________________________________________\n WET READ: EAGg MON 10:44 PM\n Evaluation limited by patient motion. Nonspecific bowel gas pattern with stool\n and gas in rectum. No dilated loops of bowel. Residual oral contrast\n throughout large bowel.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: A 70-year-old female with respiratory distress and moderately\n distended abdomen.\n\n COMPARISON: CT available from .\n\n FRONTAL RADIOGRAPH OF THE ABDOMEN. Dense material is present throughout the\n colon, including oval-shaped densities within the descending colon, compatible\n with dense stool. A moderate amount of dense stool is also present within the\n rectal vault. Loops of small and large bowel are not distended. A PEG tube\n is positioned with its origin overlying the area of the stomach, which is\n filled with gas. The included views of the chest are unremarkable. There is\n no acute fracture or dislocation.\n\n IMPRESSION:\n 1. No evidence of megacolon or obstruction.\n 2. Large amount of dense stool within the colon and rectal vault.\n\n" }, { "category": "Radiology", "chartdate": "2193-02-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1122743, "text": " 4:25 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: Please evaluate for head bleed, herniation, or other explana\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with altered mental status, may need LP\n REASON FOR THIS EXAMINATION:\n Please evaluate for head bleed, herniation, or other explanation of altered\n mental status, as well as other contraindications to LP\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: ARHb TUE 4:49 PM\n Severely limited by motion without new obvious intracranial hemorrhage or\n large territory infarct.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old female with altered mental status.\n\n COMPARISON: CT head .\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5-mm section\n thickness.\n\n FINDINGS: Overall, evaluation is severely limited by patient motion and head\n positioning. Right PCA territory hypodensity and encephalomalacia is again\n consistent with prior infarct. Prominent ventricles and sulci related to age-\n related parenchymal loss is again observed. Prominent periventricular white\n matter hypodensities are again the sequela of chronic small vessel\n microvascular infarction. Although motion limits evaluation, there is no new\n obvious large territory infarct or large intracranial hemorrhage.\n Atherosclerotic calcifications involving the cavernous carotid arteries again\n noted bilaterally. Mild mucosal thickening involving the sphenoid sinus and\n several ethmoid air cells. A left globe prosthesis is again noted.\n\n IMPRESSION: Severely limited study with evidence of prior infarcts and\n chronic small vessel ischemic changes. No obvious new large territorial\n infarct or large intracranial hemorrhage.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-14 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1123014, "text": " 11:38 AM\n CHEST (PA & LAT) Clip # \n Reason: ? new infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman withb fevers of unknown origin. Please assess for new\n infiltrate.\n REASON FOR THIS EXAMINATION:\n ? new infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 70-year-old woman with fevers of unknown origin. Please assess\n for new infiltrates.\n\n COMPARISON: Chest radiograph from .\n\n PA AND LATERAL CHEST RADIOGRAPH:\n\n The patient has low lung volumes. There is unchanged right minor fissural\n fluid. There is subtle opacity of the left lower lobe with obscuration of the\n underlying left hemidiaphragm, which may represent atelectasis, but pneumonia\n cannot be excluded.\n\n IMPRESSION:\n\n Subtle left basilar opacity, which may represent atelectasis versus\n early pneumonia. Follow- up radiographs are recommended.\n\n These findings were communicated to the referring physician at 3\n p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2193-02-14 00:00:00.000", "description": "CT ABDOMEN W/CONTRAST", "row_id": 1123019, "text": " 9:31 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for occult abscess\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman non-verbal at baseline with fever of unknown origin\n REASON FOR THIS EXAMINATION:\n please eval for occult abscess\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Fever of unknown origin. Evaluate for acute abscess.\n\n COMPARISON: CT .\n\n TECHNIQUE: MDCT acquired images through the abdomen and pelvis were obtained\n after administration of IV and oral contrast. Coronal and sagittal reformats\n were reviewed.\n\n CT ABDOMEN:\n\n Bilateral pleural effusions are small but new when compared to .\n There is mild bibasal atelectasis. The heart is normal in size. There is no\n pericardial or pleural effusion.\n\n A 5 mm hypodensity lesion in the left liver (segment II) is too small to\n characterize but likely represents a simple cyst. Otherwise, the liver\n enhance homogeneously. There is no intra-or extra-biliary dilatation. The\n gallbladder is normal in size, without radiopaque gallstones. The spleen,\n pancreas, adrenal glands are unremarkable. The kidneys enhance and excrete\n contrast symmetrically, without evidence of stones, masses, or hydronephrosis.\n The stomach, small and large bowel are normal without evidence of wall\n thickening, obstruction or mesenteric stranding. There is no free air, free\n fluid, or lymphadenopathy. G tube terminates in the stomach.\n\n There is mild atherosclerotic calcifion throughout the abdominal aorta and\n iliac arteries, without aneurysm formation or significant stenosis.\n\n CT PELVIS: The bladder, distal ureters, uterus and adnexa are normal. The\n sigmoid and rectum are unremarkable. There is no free air, free fluid, or\n lymphadenopathy.\n\n OSSEOUS STRUCTURES: There are mild multilevel degenerative changes through\n the thoracolumbar spine. There is no lytic or blastic lesion.\n\n IMPRESSION: No CT evidence to explain fever.\n (Over)\n\n 9:31 AM\n CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Clip # \n Reason: please eval for occult abscess\n Admitting Diagnosis: PNEUMONIA\n Contrast: OPTIRAY Amt: 130\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2193-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1122626, "text": " 2:45 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for infiltrate\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with resp distress and possible sepsis\n REASON FOR THIS EXAMINATION:\n eval for infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: Respiratory distress and possible sepsis, evaluation for\n pneumonia.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there is no relevant\n change. Minimally decreased lung volumes, newly appeared plate-like\n atelectasis at the right lung base. Otherwise, no relevant change. Normal\n size of the cardiac silhouette, no evidence of pneumonia. Minimal\n retrocardiac atelectasis. No pleural effusion. No pulmonary edema.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-13 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1122893, "text": " 2:14 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: pls assess tip of 43cm LUE cephalic; call w/ wet\n Admitting Diagnosis: PNEUMONIA\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with new LUE PICC\n REASON FOR THIS EXAMINATION:\n pls assess tip of 43cm LUE cephalic; call w/ wet read thanks\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Evaluation of PICC line placement.\n\n Portable AP chest radiograph was reviewed in comparison to .\n\n The left PICC line tip is at the level of low SVC. Heart size is normal.\n Mediastinal position, contour and width are unremarkable. Lungs are clear and\n there is no pleural effusion or pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2193-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1122502, "text": " 11:07 AM\n CHEST (PORTABLE AP) Clip # \n Reason: fever sob\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 70 year old woman with sob\n REASON FOR THIS EXAMINATION:\n fever sob\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH PERFORMED ON .\n\n Comparison is made with a prior chest radiograph from as well as a\n CTA chest from .\n\n CLINICAL HISTORY: Shortness of breath, fever.\n\n FINDINGS: AP portable upright view of the chest is obtained. Evaluation is\n markedly limited given the low lung volumes and patient's chin overlying the\n right upper chest. There is bibasilar atelectasis without definite signs of\n pneumonia or CHF. No large pleural effusion or definite evidence of\n pneumothorax is seen. Cardiomediastinal silhouette appears grossly stable.\n The previously noted density along the right mid lung is stable. Findings\n likely represent a small amount of scarring related to a prior infection.\n Bones appear grossly intact.\n\n IMPRESSION: Markedly limited chest radiograph without definite signs of\n pneumonia or CHF. Probable left basilar atelectasis. If there is strong\n clinical concern, recommend repeat study with a more optimized technique to\n further assess.\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2103-10-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163818, "text": " 6:26 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluation for any signs pulmonary edema, or aspiration pneu\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with acute onset of shortness of breath, wheezing after\n possible aspiration as well as being given lots of fluid in ICU.\n REASON FOR THIS EXAMINATION:\n evaluation for any signs pulmonary edema, or aspiration pneumonitis.\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Acute shortness of breath with possible aspiration.\n\n FINDINGS: In comparison with the study of , there are continued\n bilateral pleural effusions with compressive atelectasis and pulmonary edema\n in a patient with cardiomegaly. The degree of vascular engorgement may be\n slightly less prominent.\n\n\n" }, { "category": "Radiology", "chartdate": "2103-10-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1163616, "text": " 5:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pulmonary edema\n Admitting Diagnosis: SEPSIS\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with retropharyngeal phlegmon.\n REASON FOR THIS EXAMINATION:\n ? pulmonary edema\n ______________________________________________________________________________\n FINAL REPORT\n REASON FOR EXAMINATION: Shortness of breath in a patient with retropharyngeal\n phlegmon.\n\n COMPARISON: .\n\n As compared to the prior study, there is newly developed bilateral perihilar\n opacities continuing toward the lung bases accompanied most likely by small\n amount of bilateral pleural effusions, findings that given the rapid\n development and radiological appearance are consistent with pulmonary edema.\n Evaluation of the patient after diuresis is recommended.\n\n ADDENDUM: Findings were discussed with Dr. over the phone by Dr.\n at approximately 8:30 a.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2103-10-10 00:00:00.000", "description": "CT NECK W/CONTRAST (EG:PAROTIDS)", "row_id": 1163527, "text": " 2:32 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for abscess collection\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with sore throat, TTP on right, no uvula deviation, no signs\n PTA on exam\n REASON FOR THIS EXAMINATION:\n please eval for abscess collection\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 4:14 PM\n Ill defined hypodensity, stranding and loss of fat planes in the right\n hypopharynx and deep spaces of the right neck extending to the carotid\n space with retropharyngeal fluid/edema. No definite organized abscess. DDx\n includes infectious process, much less likely longus tendinitis.\n Mild narrowing of airway at hypopharynx but airway patent. D/w Dr. \n on at 4pm.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with sore throat and tenderness to palpation on\n the right with no uvular deviation and no signs of peritonsillar abscess on\n examination.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the neck with the\n administration of IV contrast. Multiplanar reformats were generated and\n reviewed.\n\n FINDINGS: An ill-defined hypodensity, stranding and loss of fat planes is\n noted in the right hypopharynx and deep spaces of the right neck extending to\n the right carotid space. There is associated significant retropharyngeal\n fluid/edema. No definite organized abscess is seen. The underlying osseous\n structures are intact and without evidence of periosteal reaction or other\n involvement. There is mild narrowing of the airway at the hypopharynx but the\n remainder of the airway appears patent. Visualized lung are clear.\n Visualized paranasal sinuses are unremarkable. Parts of the oropharynx are\n not well evaluated due to streak artifact, likely secondary to dental\n hardware. Right-sided cervical lymph nodes measure up to 9 mm (2, 39) and are\n likely reactive in nature. Visualized vessels are patent.\n\n IMPRESSION:\n 1. Ill-defined hypodensity, stranding and loss of fat planes in the right\n hypopharynx and deep spaces of the right neck extending to the carotid space\n with large amount of retropharyngeal fluid/edema. No definite organized\n abscess is present. The differential diagnosis includes infectious process vs\n much less likely longus tendinitis.\n 2. Mild mass effect on the right side of the hypopharynx with mild narrowing\n of the airway at the hypopharynx but the airway appears patent.\n\n Findings were discussed with Dr. at 4 p.m. on .\n (Over)\n\n 2:32 PM\n CT NECK W/CONTRAST (EG:PAROTIDS) Clip # \n Reason: please eval for abscess collection\n Contrast: OPTIRAY Amt: 70\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2103-10-10 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1163528, "text": " 2:32 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please eval r/o ICH\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with confusion identical to prior stroke symptoms\n REASON FOR THIS EXAMINATION:\n please eval r/o ICH\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: WED 4:08 PM\n hypodensity in the right posterior parietal region may represent subacute/old\n infarct, difficult to exclude vasogenic edema ; correlate clinically and may\n get MRI if clinically warranted for further evaluation. d/w Dr. \n at 4pm on .\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 62-year-old woman with confusion.\n\n COMPARISON: None.\n\n TECHNIQUE: Contiguous axial images were obtained through the brain without\n the administration of IV contrast.\n\n FINDINGS: There is no evidence of acute hemorrhage, discrete masses, mass\n effect, or shift of normally midline structures. A hypodensity in the right\n posterior parietal region may represent subacute or old infarct, underlying\n vasogenic edema may be present. There is no evidence of volume loss or mass\n effect.\n\n The ventricles and sulci are normal in size and configuration. Visualized\n osseous structures and paranasal sinuses appear unremarkable.\n\n IMPRESSION:\n 1. Hypodensity in the right posterior parietal region may represent\n subacute/old infarct, underlying vasogenic edema may be present; no evidence\n of volume loss or mass effect. Findings could be further evaluated on MRI.\n\n Findings discussed with Dr. at 4 p.m. on .\n\n" }, { "category": "Radiology", "chartdate": "2103-10-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1163529, "text": " 2:46 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval r/o intrathoracic process\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 62 year old woman with fever, tachycardia, hypotension\n REASON FOR THIS EXAMINATION:\n please eval r/o intrathoracic process\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 60-year-old woman with fever and tachycardia, evaluate for\n intrathoracic process.\n\n COMPARISON: None.\n\n PA AND LATERAL CHEST RADIOGRAPH: The cardiac, mediastinal and hilar contours\n appear unremarkable. Both lungs appear grossly clear with no focal\n consolidation, pleural effusion or pneumothorax.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n" }, { "category": "Echo", "chartdate": "2103-10-15 00:00:00.000", "description": "Report", "row_id": 75184, "text": "PATIENT/TEST INFORMATION:\nIndication: Evaluate systolic function/Pulmonary edema/aggressive volume resuscitation without prior history of heart failure.\nHeight: (in) 64\nWeight (lb): 210\nBSA (m2): 2.00 m2\nBP (mm Hg): 132/69\nHR (bpm): 93\nStatus: Outpatient\nDate/Time: at 09:17\nTest: TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Moderate LA enlargement.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.\n\nLEFT VENTRICLE: Normal LV wall thickness, cavity size and regional/global\nsystolic function (LVEF >55%). Doppler parameters are indeterminate for LV\ndiastolic function. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Normal ascending aorta\ndiameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification. Eccentric MR jet. Mild (1+) MR.\n\nTRICUSPID VALVE: Mild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: Trivial/physiologic pericardial effusion. No echocardiographic\nsigns of tamponade.\n\nConclusions:\nThe left atrium is moderately dilated. Left ventricular wall thickness, cavity\nsize and regional/global systolic function are normal (LVEF >55%). Doppler\nparameters are indeterminate for left ventricular diastolic function. There is\nno ventricular septal defect. Right ventricular chamber size and free wall\nmotion are normal. The aortic valve leaflets (3) appear structurally normal\nwith good leaflet excursion and no aortic regurgitation. The mitral valve\nleaflets are mildly thickened. An eccentric, posteriorly directed jet of mild\n(1+) mitral regurgitation is seen. There is mild pulmonary artery systolic\nhypertension. There is a trivial/physiologic pericardial effusion. There are\nno echocardiographic signs of tamponade.\n\nIMPRESSION: Normal global and regional biventricular systolic function.\nIndeterminate indices for diastolic function assessment. Mild mitral\nregurgitation.\n\nCompared with the prior study (images reviewed) of , the findings are\nsimilar.\n\n\n" }, { "category": "ECG", "chartdate": "2103-10-10 00:00:00.000", "description": "Report", "row_id": 195373, "text": "Nearly regular tachycardia of uncertain mechanism but is probably atrial\nflutter with rapid ventricular response. Early precordial lead QRS transition.\nDiffuse ST-T wave abnormalities are non-specific. Since the previous tracing\nof findings as outlined are now present.\n\n" } ]

[ { "category": "Echo", "chartdate": "2171-10-16 00:00:00.000", "description": "Report", "row_id": 96354, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 160\nBSA (m2): 1.84 m2\nBP (mm Hg): 101/65\nHR (bpm): 85\nStatus: Inpatient\nDate/Time: at 10:32\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nThis study was compared to the prior study of .\n\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Moderate global LV\nhypokinesis.\n\nRIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall\nhypokinesis.\n\nAORTA: Normal diameter of aorta at the sinus, ascending and arch levels.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular\ncalcification.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nBorderline PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. There is mild symmetric left ventricular\nhypertrophy with normal cavity size. There is moderate global left ventricular\nhypokinesis (LVEF = 30-35 %) with relative sparing of the function of the\nbasal lateral and basal inferior walls. The right ventricular cavity is mildly\ndilated with mild global free wall hypokinesis. The diameters of aorta at the\nsinus, ascending and arch levels are normal. The aortic valve leaflets (3) are\nmildly thickened but aortic stenosis is not present. No aortic regurgitation\nis seen. The mitral valve leaflets are mildly thickened. There is borderline\npulmonary artery systolic hypertension. There is no pericardial effusion.\n\nIMPRESSION: Moderate to severe global left ventricular hypokinesis. Mild right\nventricular cavity dilation and global systolic dysfunction. Borderline\npulmonary hypertension.\n\nCompared with the prior study (images reviewed) of , left ventricular\nsystolic function has declined substantially. Estimated pulmonary artery\npressure is borderline elevated. Right ventricular function can be assessed\nand is globally hypokinetic.\n\n\n" }, { "category": "Echo", "chartdate": "2171-10-15 00:00:00.000", "description": "Report", "row_id": 96355, "text": "PATIENT/TEST INFORMATION:\nIndication: Cardiac arrest. Evaluate left and right ventricular function. Evaluate for pulmonary embolus.\nHeight: (in) 69\nWeight (lb): 200\nBSA (m2): 2.07 m2\nBP (mm Hg): 112/49\nHR (bpm): 89\nStatus: Inpatient\nDate/Time: at 21:28\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Suboptimal\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA and RA cavity sizes.\n\nLEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Suboptimal\ntechnical quality, a focal LV wall motion abnormality cannot be fully\nexcluded. Overall normal LVEF (>55%). No resting LVOT gradient.\n\nRIGHT VENTRICLE: Dilated RV cavity. Cannot assess RV systolic function.\nParadoxic septal motion consistent with conduction abnormality/ventricular\npacing.\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: Normal mitral valve leaflets. Mild mitral annular calcification.\nNo MR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to moderate [+] TR.\nMild PA systolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS.\nPhysiologic PR.\n\nPERICARDIUM: No pericardial effusion. There is an anterior space which most\nlikely represents a fat pad, though a loculated anterior pericardial effusion\ncannot be excluded.\n\nGENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal\nimage quality as the patient was difficult to position. Suboptimal image\nquality - ventilator. Suboptimal image quality - patient unable to cooperate.\nEmergency study performed by the cardiology fellow on call.\n\nConclusions:\nThe left atrium and right atrium are normal in cavity size. There is mild\nasymmetric left ventricular hypertrophy with normal cavity size. Global left\nventricular wall motion is normal. A focal wall motion abnormality cannot be\nexcluded. The right ventricular cavity is mildly dilated. Right ventricular\nfunction is difficult to assess. The aortic valve leaflets (3) appear mildly\nthickened with good leaflet excursion and no aortic stenosis or aortic\nregurgitation. The mitral valve leaflets are structurally normal. No mitral\nregurgitation is seen. There is mild pulmonary artery systolic hypertension.\nThere is no pericardial effusion. There is an anterior space which most likely\nrepresents a prominent fat pad.\n\nIMPRESSION: Suboptimal image quality. Focused views post-cardiac arrest.\nNormal global left ventricular function. Cannot exclude focal wall motion\nabnormality. Mild right ventricular cavity dilation. Mild pulmonary artery\nhypertension.\n\nCompared with the findings of the prior study (images reviewed) of ,\nthe heart rate is faster. The severity of tricuspid regurgitation has\nincreased. The right ventricle appears mildly dilated. Right ventricular\nfunction cannot be assessed. Pulmonary artery systolic pressure can now be\naccurately measured.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-10-17 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1252486, "text": " 8:29 AM\n PORTABLE ABDOMEN Clip # \n Reason: assess for interval progression\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with megacolon\n REASON FOR THIS EXAMINATION:\n assess for interval progression\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with megacolon. Evaluation for progression.\n\n COMPARISON: Comparison is made to abdominal radiograph from .\n\n FINDINGS: There has been interval improvement in the dilatation of the\n transverse colon which is now normal in caliber. There is no evidence of\n pneumatosis or thumbprinting. No large intraperitoneal free air is seen on\n this radiograph. Overall, the bowel gas pattern is unremarkable.\n\n The previously seen G-tube, nasogastric tube, femoral catheter and flatus tube\n are unchanged in appearance or position since the previous radiograph.\n\n IMPRESSION: Interval improvement in the dilatation of the transverse colon\n which is now normal in caliber.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252292, "text": " 5:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: STAT CXR TO ASSESS FOR PTX\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with loss of pulses\n REASON FOR THIS EXAMINATION:\n STAT CXR TO ASSESS FOR PTX\n ______________________________________________________________________________\n WET READ: MDAg TUE 8:34 PM\n ETT ends 3.9cm above carina. NGT ends below diaphragm. no definite\n pneumothorax on this supine radiograph. heterogeneous opacity in the right\n lung may be infection, aspiration or asymmetric edema.\n ______________________________________________________________________________\n FINAL REPORT\n CHEST RADIOGRAPH\n\n INDICATION: evaluation for pneumothorax.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, the patient has received an\n endotracheal tube. The tip projects 4 cm above the carina. Tip of the\n nasogastric tube ends below the diaphragm, there is no evidence of\n complications, notably no pneumothorax. A heterogeneous opacity at the right\n lung base might result from aspiration or reflect early pneumonia. A wet read\n was delivered. Borderline size of the cardiac silhouette. Minimal fluid\n overload.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-15 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252280, "text": " 3:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ett placement, infiltrate\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 71F with post arrest\n REASON FOR THIS EXAMINATION:\n ett placement, infiltrate\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Post arrest.\n\n TECHNIQUE: Supine AP view of the chest.\n\n COMPARISON: None.\n\n FINDINGS:\n\n Endotracheal tube tip terminates approximately 5.5 cm from the carina.\n Orogastric tube tip terminates within the stomach. A percutaneous gastrostomy\n tube is noted, with balloon projecting over the region of the stomach. The\n heart size is normal. The aortic knob is calcified. The lung volumes are\n low. Hazy ill-defined opacity is noted in the right lung, primarily the right\n perihilar region, findings which could reflect asymmetric pulmonary edema\n though infection, aspiration, or hemorrhage is not excluded. No large\n pneumothorax is identified though a trace right pleural effusion may be\n present. Linear lucency through the posterior aspect of the right 1st rib is\n suggestive of a nondisplaced fracture.\n\n IMPRESSION:\n\n 1. Support lines and tubes are in standard positions.\n\n 2. Hazy opacification primarily within the right perihilar region could\n reflect asymmetric pulmonary edema though aspiration, hemorrhage or infection\n is not excluded.\n\n 3. Possible nondisplaced fracture of the right 1st rib.\n\n DFDdp\n\n" }, { "category": "Radiology", "chartdate": "2171-10-17 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252513, "text": " 11:11 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for free air under diaphram\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with C. diff and large bowel, concern for performation,\n please with semi-upright looking for air\n REASON FOR THIS EXAMINATION:\n assess for free air under diaphram\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: To assess for free intraperitoneal gas.\n\n FINDINGS: In comparison with the study of , the monitoring and support\n devices remain in place. There is decreased opacification bilaterally,\n consistent with improving aspiration pneumonia. Some indistinctness of\n vessels could reflect some elevated pulmonary venous pressure.\n\n Specifically, there is no evidence of free intraperitoneal gas. However, this\n is not truly an upright image, so that small pneumoperitoneum could easily be\n missed. If this is a serious clinical concern, a true upright view could be\n obtained or CT performed.\n\n\n" }, { "category": "ECG", "chartdate": "2171-10-15 00:00:00.000", "description": "Report", "row_id": 265628, "text": "Probable sinus tachycardia with atrial and ventricular premature beats. Marked\nleft axis deviation. Intraventricular conduction delay of left bundle-branch\nblock type. Since the previous tracing of the rate is faster, atrial\nand ventricular premature beats are new, QRS width is wider. Clinical\ncorrelation is suggested.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-16 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1252327, "text": " 2:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate line placement, ET tube placement, r/o infiltrates\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n evaluate line placement, ET tube placement, r/o infiltrates\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 2:00 A.M. ON \n\n HISTORY: Cardiac arrest. Evaluate line and tube placements.\n\n IMPRESSION: AP chest compared to at 5:59 p.m.:\n\n ET tube is in standard placement. Nasogastric tube ends near the pylorus.\n Esophageal probe ends in the low third of the esophagus. Left lung is clear.\n Heterogeneous opacification projecting over the right lung is more pronounced\n today than yesterday, most likely large scale aspiration pneumonia. Heart\n size is larger and mediastinal veins more dilated suggesting intervening\n volume reconstitution. No pneumothorax. Pleural effusion is small if any.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-17 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 1252557, "text": " 4:48 PM\n CHEST PORT. LINE PLACEMENT; -77 BY DIFFERENT PHYSICIAN # \n Reason: Right IJ line in place\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n Right IJ line in place\n ______________________________________________________________________________\n WET READ: 10:04 PM\n R IJ ends in the region of the cavoatrial junction. ETT is 5.5cm above the\n carina. NGT goes below the diaphragm. no pneumothorax. mild bibasilar\n opacities may be small pleural effusions and atelectasis\n\n ______________________________________________________________________________\n FINAL REPORT\n SINGLE FRONTAL VIEW OF THE CHEST\n\n REASON FOR EXAM: Status post cardiac arrest, assess right IJ line.\n\n Comparison is made with prior study performed five hours earlier.\n\n Right IJ tip is in the cavoatrial junction. ET tube tip is 5.5 cm above the\n carina. There is no pneumothorax. Cardiomediastinal contours are unchanged.\n NG tube tip is out of view below the diaphragm. Bibasilar opacities are a\n combination of pleural effusions and atelectasis, larger on the right,\n probably unchanged allowing the difference in positioning of the patient.\n\n\n" }, { "category": "Radiology", "chartdate": "2171-10-16 00:00:00.000", "description": "PORTABLE ABDOMEN", "row_id": 1252326, "text": " 1:46 AM\n PORTABLE ABDOMEN Clip # \n Reason: r/o toxic megacolon\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 76 year old woman with profuse diarrhea\n REASON FOR THIS EXAMINATION:\n r/o toxic megacolon\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 76-year-old female with profuse diarrhea.\n\n COMPARISON: Comparison is made to radiographs of the chest from and .\n\n FINDINGS: Two supine radiographs of the abdomen demonstrate marked gaseous\n distention of the transverse colon, measuring 13 cm. There is no evidence of\n edema, thumbprinting, or pneumatosis or free air. However, the gaseous\n distention is concerning for toxic megacolon, given the patient's symptoms.\n There is a nasogastric tube in the stomach and a right femoral catheter is\n seen. There is a flatus tube overlying the lower pelvis.\n\n IMPRESSION: Gaseous distention of the transverse colon, concerning for toxic\n megacolon.\n\n These findings were communicated to Dr. by, Dr. via telephone\n at 17:30, 5 minutes after the discovery was made.\n\n" }, { "category": "Radiology", "chartdate": "2171-10-15 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1252281, "text": " 4:39 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: ? head bleed\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 76F with witnessed fall\n REASON FOR THIS EXAMINATION:\n ? head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: SVMc TUE 4:49 PM\n no evidence of bleed\n\n WET READ VERSION #1\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 76-year-old female with a witnessed fall, question head bleed.\n\n COMPARISON: head CT\n\n TECHNIQUE: Multidetector CT scan of the head was performed without\n administration of IV contrast.\n\n FINDINGS: There is no evidence of hemorrhage, mass effect, or edema.\n -white matter differentiation is preserved throughout. The ventricles and\n sulci are mildly prominent, consistent with age-related global atrophy.\n Periventricular and deep white matter hypodensities are suggestive of sequela\n of chronic small vessel ischemic disease. No fractures are identified. No\n significant soft tissue swelling is seen. Mastoid air cells are partially\n opacified bilaterally. Imaged portions of the paranasal sinuses appear\n unremarkable.\n\n IMPRESSION: No evidence of an acute intracranial process.\n\n" } ]

[ { "category": "Radiology", "chartdate": "2117-07-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 966780, "text": " 2:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: ? aspiration event\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with CVA now with IPH\n REASON FOR THIS EXAMINATION:\n ? aspiration event\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST X-RAY OF \n\n INDICATION: Possible aspiration.\n\n Heart size, mediastinal and hilar contours are within normal limits, and lungs\n and pleural surfaces are clear on this single portable view.\n\n IMPRESSION: No evidence of acute aspiration.\n\n\n" }, { "category": "Radiology", "chartdate": "2117-07-12 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 966842, "text": " 9:01 AM\n CT HEAD W/O CONTRAST Clip # \n Reason: f/u exam in pt with parenchymal bleed and decreased mental s\n Admitting Diagnosis: INTRACRANIAL HEMORRHAGE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with\n REASON FOR THIS EXAMINATION:\n f/u exam in pt with parenchymal bleed and decreased mental status\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: CT of the abdomen without contrast.\n\n INDICATION: 78-year-old female with parenchymal bleed and decreased mental\n status.\n\n COMPARISONS: .\n\n TECHNIQUE: Non-contrast head CT.\n\n FINDINGS: Once again there is a focus of intraparenchymal hemorrhage along\n the left aspect of the superior falx cerebri which on today's examination\n measures 18 x 10 mm and is largely unchanged in size when compared to the\n examination from one day prior. There are small components of subarachnoid\n hemorrhage as well. In addition, there is surrounding hypodensity and\n effacement of the sulci consistent with edema. A small, hyperdense focus\n along the right frontal lobe looks slightly more pronounced on today's\n examination. No new areas of hemorrhage are identified. There is no shift of\n normally midline structures or significant mass effect from the above\n described hemorrhage. The visualized portions of the soft tissues, osseous\n structures, paranasal sinuses, and mastoid air cells are unremarkable.\n\n IMPRESSION: Interval evolution of left parietal lobe intraparenchymal\n hemorrhage/subarachnoid blood and right frontal hemorrhage compared to\n examination from one day prior. Details as above.\n\n" }, { "category": "Nursing/other", "chartdate": "2117-07-11 00:00:00.000", "description": "Report", "row_id": 1674467, "text": "ADMISSION NOTE/CONDITION UPDATE:\nPT ARRIVED FROM ALERT, MAE'S WITH PLATELETS INFUSING. PLEASE SEE FHP FOR HISTORY.\n\nD/A: T MAX 98.8\n\nNEURO: PT ALERT, ORIENTED TO PERSON, , \".\" MAE'S TO COMMAND. VERY IMPULSIVE, ATTEMPTING TO GET OOB. CONTINUOUSLY REMINDED TO BE SAFE. WRIST RESTRAINTS APPLIED AND 1:1 OBSERVER REQUESTED. DENIES PAIN. SMALL LACERATION OVER RIGHT EYE WITH SUTURES. EEG DONE.\n\nCV: HR 50'S-100 SB-ST, OCCASSIONAL PVC'S. NBP ~ 120/60. +PPP BILAT. GOAL SBP 100-140 MET WITHOUT INTERVENTION. PLATELET INFUSION COMPLETED, GIVEN PER EW NURSE DUE TO PLATELET AGGREGATE INHIBITORS PT WAS ON FOR PREVIOUS CVA.\n\nRESP: LS CLEAR. CHEST X-RAY DONE. ON 2 L/M NC WITH O2 SATS ~ 100.\n\nGI: NPO DUE TO ? ABILITY TO SWALLOW. +PPP BILAT.\n\nGU: FOLEY-BSD WITH CLEAR YELLOW URINE.\n\nSX: SON AND VISITED, SEVERAL CHILDREN APPARENTLY. DAUGHTER IS THE CONTACT PERSON.\n\nR: CONTINUE TO FOLLOW NEURO STATUS. HEAD CT IN AM. CONTINUE TO KEEP PATIENT SAFE WITH 1:1 OBSERVER AND/OR RESTRAINTS AS NEEDED. PT AND FAMILY SUPPORT. SBP GOAL 100-140.\n\n" }, { "category": "Nursing/other", "chartdate": "2117-07-12 00:00:00.000", "description": "Report", "row_id": 1674468, "text": "Update\nSee careview for details...\nNeuro: Pt 2, restless and attempting to get OOB at times, sitter at bedside for pt safety. MAE, good strengths, pupils 2-3mm and react\n\nCV: NSR with occas PVC's, afebrile, BP<150\n\nResp: O2 2lnc, sats 99-100%, lungs clear\n\nGI: Abd soft. no BM, tol PO without difficulty swallowing\n\nSkin: sm lac to forehead OTA, no dng, sutures intact\n\nPlan: Neuro checks, sitter at bedside, monitor BP\n" }, { "category": "Nursing/other", "chartdate": "2117-07-12 00:00:00.000", "description": "Report", "row_id": 1674469, "text": "NURSING NOTE\nPost-HCT d/c'd per SICU fellow, f/u w/AM labs sufficient. Mag repleted for 1.6\n" }, { "category": "Nursing/other", "chartdate": "2117-07-12 00:00:00.000", "description": "Report", "row_id": 1674470, "text": "NURSING NOTE\nPLEASE SEE CAREVUE FOR DETAILS\nNEURO: PT LETHARGIC MOST OF DAY, ORIENTED X , FOLLOWS COMMANDS CONSISTENTLY, MAES. NO C/O PAIN, HEAD CT DONE.\n\nCVS: HR 80S-100S, NSR, OCCAS PVC'S, AFEBRILE. SBP MAINTAINED<150 PER NEURO. TRANSFUSED 1UNIT PRBCS FOR HCT 24.8, POST-HCT PENDING.\n\nRESP: NARD/SOB, O2 SATS 99-100% ON 2L N/C, LUNGS CLEAR.\n\nGI/GU: ABS SOFT, +BS, TOL CLEARS WHEN AWAKE ENOUGH THIS PM. LGE AMT HUO.\n\nINTEG: SM LAC W/SUTURES TO FOREHEAD C/D/I\n\nPLAN: CONT FREQUENT NEURO CHECKS, PO'S AS TOL, 1:1 SITTER OVERNOC. FOLLOW-UP HCT, ?TRANSFER TO FLR.\n" }, { "category": "Nursing/other", "chartdate": "2117-07-13 00:00:00.000", "description": "Report", "row_id": 1674471, "text": "Update\nSee careview for details...\nNeuro: assessment unchanged, sitter at bedside\n\nCV: NSR-NST, BP <150\n\nResp: Lungs clear, tol RA\n\nGI: tol meds PO\n\nGU: clear yellow urine via foley\n\nPlan: transfer to floor in AM\n" }, { "category": "ECG", "chartdate": "2117-07-11 00:00:00.000", "description": "Report", "row_id": 228315, "text": "Sinus rhythm. Baseline artifact. Early R wave transition is probably a normal\nvariant. No previous tracing available for comparison.\n\n" }, { "category": "Radiology", "chartdate": "2117-07-11 00:00:00.000", "description": "CT HEAD W/ CONTRAST", "row_id": 966726, "text": " 5:10 AM\n CT HEAD W/ CONTRAST Clip # \n Reason: r/o sah\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p fall/found down\n REASON FOR THIS EXAMINATION:\n r/o sah\n CONTRAINDICATIONS for IV CONTRAST:\n shellfish\n ______________________________________________________________________________\n WET READ: ARHb SUN 6:19 AM\n A focus of subarrachnoid blood is noted along the left falx extending toward\n the vertex with intraparenchymal spread and surrounding edema. Another\n indistinct hyperdense focus at the right frontal lobe may also represent blood\n within the subarachnoid space. No intraventricular blood. No fracture.\n WET READ VERSION #1 ARHb SUN 6:05 AM\n A focus of subarrachnoid blood is noted along the right falx extending toward\n the vertex with intraparenchymal spread and surrounding edema. Another\n indistinct hyperdense focus at the right frontal lobe may also represent blood\n within the subarachnoid space. No intraventricular blood. No fracture.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 78-year-old woman found down after fall.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the head are obtained at 5 mm section\n thickness with 2.5 mm bone algorithm reconstructions.\n\n NON-CONTRAST HEAD CT: Hemorrhage along the left aspect of the falx extending\n towards the vertex is likely subarachnoid extending intraparenchymally with a\n mild amount of surrounding hypodensity, which may represent edema. This\n colleciton measures up to 16 x 11mm in axial dimensions. Indistinct\n hyperdensity at the right frontal lobe may also represent blood within the\n subarachnoid space, although this is less clear. There is no shift of normally\n midline structures or evidence of intraventricular blood. Surrounding osseous\n structures demonstrate no fracture. The mastoid air cells are well aerated. A\n small mucous retention cyst is seen within the right sphenoid air cell.\n\n IMPRESSION: Blood along the left aspect of the falx cerebri extending towards\n the vertex likely represents intraparanchymal and subarachnoid blood. A less\n distinct hyperdense collection in the right frontal lobe may also represent\n blood within the subarachnoid space, although this is less clear. No fracture\n is identified.\n\n" }, { "category": "Radiology", "chartdate": "2117-07-11 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 966727, "text": " 5:11 AM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: r/o fracture\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 78 year old woman with s/p fall\n REASON FOR THIS EXAMINATION:\n r/o fracture\n CONTRAINDICATIONS for IV CONTRAST:\n shellfish allergy\n ______________________________________________________________________________\n WET READ: DJD SUN 6:37 AM\n Multilevel moderate to severe cervical spondylosis without fracture or acute\n alignment abnormality.\n\n\n OVERREAD:\n Agree\n\n MD\n WET READ VERSION #1 ARHb SUN 6:14 AM\n Multilevel moderate to severe cervical spondylosis without fracture or acute\n alignment abnormality.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Fall, rule out fracture.\n\n COMPARISON: None.\n\n TECHNIQUE: Non-contrast axial images of the cervical spine are obtained with\n 5 mm section thickness with 2.5 mm bone algorithm reconstructions.\n\n NON-CONTRAST CT SPINE: There is no fracture or acute alignment abnormality.\n Atlanto-occipital and atlantoaxial articulations are preserved. No\n prevertebral soft tissue swelling. Multilevel moderate-to-severe cervical\n spondylosis is identified at all levels, with posterior osteophyte noted at\n multiple levels causing canal stenosis. Multilevel moderate foraminal\n stenosis is also noted. Imaged portions of the mastoid air cells are well\n aerated. Mucous retention cyst is identified within the right sphenoid air\n cell. Calcification is noted at the carotid bifurcation bilaterally.\n\n IMPRESSION: Moderate-to-severe cervical spondylosis without evidence of\n fracture or acute alignment abnormality.\n\n\n" } ]

[ { "category": "Echo", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 59755, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function. Syncope. S/p cardiac arrest.\nHeight: (in) 64\nWeight (lb): 135\nBSA (m2): 1.66 m2\nBP (mm Hg): 110/34\nHR (bpm): 40\nStatus: Inpatient\nDate/Time: at 10:09\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. Aneurysmal interatrial\nseptum.\n\nLEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Hyperdynamic LVEF\n>75%. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic diameter at the sinus level. Focal calcifications in\naortic root. Normal ascending aorta diameter. Focal calcifications in\nascending aorta.\n\nAORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. 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. Trivial MR. [Due to acoustic shadowing, the\nseverity of MR may be significantly UNDERestimated.] Prolonged (>250ms)\ntransmitral E-wave decel time. LV inflow pattern c/w impaired relaxation.\n\nTRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Thickened/fibrotic\ntricuspid valve supporting structures. No TS. Physiologic TR. Indeterminate PA\nsystolic pressure.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is elongated. The interatrial septum is aneurysmal. Left\nventricular wall thicknesses are normal. The left ventricular cavity is small.\nLeft ventricular systolic function is hyperdynamic (EF 70-80%). Tissue Doppler\nimaging suggests an increased left ventricular filling pressure (PCWP>18mmHg).\nThere is no ventricular septal defect. Right ventricular chamber size and free\nwall motion are normal. The aortic valve leaflets (3) are mildly thickened but\naortic stenosis is not present. Trace aortic regurgitation is seen. The mitral\nvalve leaflets are mildly thickened. There is no mitral valve prolapse.\nTrivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity\nof mitral regurgitation may be significantly UNDERestimated.] The left\nventricular inflow pattern suggests impaired relaxation. The tricuspid valve\nleaflets are mildly thickened. The supporting structures of the tricuspid\nvalve are thickened/fibrotic. The pulmonary artery systolic pressure could not\nbe determined. There is no pericardial effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-12 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006464, "text": " 7:41 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? tube placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with stroke, intubated\n REASON FOR THIS EXAMINATION:\n ? tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n As compared to the previous radiograph, there is no major change. Minimal\n increase in retrocardiac atelectasis. Otherwise, no relevant changes in the\n lung parenchyma. The monitoring and support devices are also unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-05 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005523, "text": " 2:51 PM\n CHEST (PORTABLE AP) Clip # \n Reason: r/o infiltrate, tube placement\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with s/p arrest, ? asp\n REASON FOR THIS EXAMINATION:\n r/o infiltrate, tube placement\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old female status post cardiac arrest. Evaluate for\n aspiration and endotracheal tube placement.\n\n PORTABLE SUPINE CHEST RADIOGRAPH:\n\n FINDINGS: No priors available for comparison. Today's examination is markedly\n limited by low lung volumes causing crowding of the bronchovascular\n structures. The right hemidiaphragm is asymmetrically elevated in comparison\n to the left hemidiaphragm. There is marked distention of the stomach and\n abdominal bowel likely related to resuscitative effort. Slightly increased\n spacing between the gastric bubble and the left hemidiaphragm may suggest a\n component of subpulmonic effusion. There is an ill-defined retrocardiac\n opacity which may reflect atelectasis and/or sequelae of aspiration.\n Endotracheal tube terminates 4.7 cm from the carina. The aorta is slightly\n ectatic and calcified and there is multilevel degenerative changes of the\n spine. No pneumothorax or large effusions are identified.\n\n IMPRESSION:\n\n 1) Appropriately positioned endotracheal tube. Gaseous distention of stomach\n and bowel likely related to resuscitative efforts. NGT may be of benefit.\n\n 2) Ill-defined retrocardiac opacity may represent atelectasis and/or sequelae\n from aspiration.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005602, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with syncope, s/p cardiac arrest\n REASON FOR THIS EXAMINATION:\n assess for change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Syncope with cardiac arrest.\n\n FINDINGS: In comparison with the study of , the elevation of the\n right hemidiaphragm is much less pronounced. Some prominence of interstitial\n markings could reflect chronic pulmonary disease, elevated pulmonary venous\n pressure, or both. Probable mild atelectatic changes at the bases, but no\n acute focal pneumonia.\n\n There is now an endotracheal tube in place with its tip about 4.5 cm above the\n carina. Nasogastric tube extends well into the stomach.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-05 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1005538, "text": " 4:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed, ischemia\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest\n REASON FOR THIS EXAMINATION:\n eval for acute bleed, ischemia\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:35 PM\n no acute path, post traumatic changes\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: -year-old female status post arrest. Apparent meniogioma removal\n in past.\n\n NON-CONTRAST HEAD CT\n\n No priors are available.\n\n Please note overall examination is markedly limited due to streak artifact\n from prior left frontal craniotomy. There is no evidence of intracranial\n hemorrhage, mass effect, shift of midline structures, hydrocephalus, or acute\n major vascular territorial infarct. There is ex vacuo dilatation of the left\n frontal and hypoattenuation of the adjacent white matter which is likely\n post-traumatic or ischemic in etiology. Dense parenchymal calcification is\n noted within the high left frontal lobe. -white matter differentiation is\n well preserved with chronic small vessel ischemic changes in the\n periventricular white matter.\n\n Soft tissues are unremarkable. No malignant- appearing osseous lesions are\n identified with degenerative changes noted involving the C1-C2 joint.\n Paranasal sinuses display mild mucosal thickening and some pooling of\n secretions within the oropharynx, likely related to intubation.\n Atherosclerotic disease is present within the anterior and posterior\n circulations.\n\n IMPRESSION:\n\n Slightly limited evaluation due to streak artifact from left frontal\n craniotomy and probable post-traumatic or ischemic changes involving the left\n frontal lobe. Left frontal calcification may be from prior trauma or possibly\n residual calcified tumor.\n\n No intracranial hemorrhage, mass effect, or shift of midline structures.\n\n\n (Over)\n\n 4:58 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: eval for acute bleed, ischemia\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Radiology", "chartdate": "2189-02-05 00:00:00.000", "description": "CTA CHEST W&W/O C&RECONS, NON-CORONARY", "row_id": 1005539, "text": " 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for acute pathology, PE\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest\n REASON FOR THIS EXAMINATION:\n eval for acute pathology, PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: 5:58 PM\n no etiology for code identified. no pe or dissection\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Status post arrest of unclear etiology.\n\n TECHNIQUE: MDCT acquired axial images were obtained through the chest,\n abdomen, and pelvis obtained using a PE protocol followed by runoff without\n oral contrast. Coronal and sagittal reformations were evaluated.\n\n CT OF THE CHEST WITHOUT AND WITH INTRAVENOUS CONTRAST: Non-contrast images\n display vascular calcifications within the coronary circulation and aorta.\n\n Contrast-enhanced images display no evidence of aortic dissection or pulmonary\n embolism. There is slight prominence to the right main pulmonary artery\n measuring 2.9 cm which may suggest underlying pulmonary hypertension. No\n pathologically enlarged axillary or central lymph nodes are identified. There\n is a hypoattenuating right thyroid lesion measuring 1.5 x 1.6 cm which is\n likely benign in a patient of this age.\n\n The lung parenchyma displays bilateral dependent atelectasis with regions of\n scattered subsegmental atelectasis, but no focal consolidations or worrisome\n nodules. The airways are patent to the subsegmental level with a moderate\n amount of secretions noted within the distal trachea proximal to the carina.\n Endotracheal tube and orogastric tube are noted to be in place and\n appropriately positioned.\n\n CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: Please note evaluation is\n slightly limited due to phase of contrast administration optimized for PE\n evaluation. There is evidence of cholelithiasis but no secondary findings of\n acute cholecystitis. The liver, gallbladder, spleen, stomach, small bowel,\n atrophic- appearing pancreas, and left adrenal gland are otherwise normal.\n There is a 10 x 25 mm incompletely characterized right adrenal lesion. There\n is a small 1- to 2-mm non-obstructive left upper pole renal calculi and a left\n interpolar 32 x 34-cm simple cyst. The right kidney displays a slightly\n prominent extrarenal pelvis but is otherwise normal. No free air, free fluid,\n or pathologically enlarged lymph nodes are present. There is moderate-to-\n severe atherosclerotic disease within the intra-abdominal aorta.\n\n CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: A moderate amount of stool is\n noted throughout the large bowel as well as colonic interposition between the\n right hemidiaphragm and liver. There is a densely calcified uterine mass\n (Over)\n\n 4:59 PM\n CTA CHEST W&W/O C&RECONS, NON-CORONARY; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST\n Reason: eval for acute pathology, PE\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n consistent with a fibroid uterus. A Foley catheter is noted within the\n decompressed urinary bladder. No free fluid or abnormal pelvic\n lymphadenopathy is present.\n\n BONE WINDOWS: There is multilevel degenerative joint and disc disease within\n the thoracic and lumbar spine. No malignant-appearing osseous lesions are\n identified. A small bone island is noted within the left femoral head.\n\n IMPRESSION:\n 1. No etiology for acute arrest identified. No PE or aortic dissection. Mild\n dilatation of the right main pulmonary artery may suggest underlying pulmonary\n arterial hypertension.\n\n 2. Moderate amount of secretions distal to the endotracheal tube within the\n trachea proximal to the carina may place the patient at risk for aspiration.\n\n 3. Non-obstructive left renal calculi and simple left renal cyst.\n\n 4. Incompletely characterized right adrenal lesion, likely benign on patient\n of this age. Hypoattenuating right thyroid lesion also likely benign in a\n patient's age.\n\n 5. Cholelithiasis without evidence of acute cholecystitis.\n\n 6. Extensive vasculopathy. Is there a history of diabetes?\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-07 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005759, "text": " 7:56 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ?acute cp process, i.e signs of aspiration or pulm overload\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p cardiac arrest and cooling protocol\n REASON FOR THIS EXAMINATION:\n ?acute cp process, i.e signs of aspiration or pulm overload\n ______________________________________________________________________________\n FINAL REPORT\n\n COMPARISON: . As compared to the previous radiograph, there is\n no relevant change. Unchanged position of monitoring and support devices.\n Unchanged fibrotic alterations at the lung bases bilaterally, right more than\n left. Unchanged size of the cardiac silhouette. No newly appeared\n parenchymal opacities.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-13 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006643, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? VAP\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with fever on ventilator\n REASON FOR THIS EXAMINATION:\n ? VAP\n ______________________________________________________________________________\n FINAL REPORT\n AP SINGLE VIEW OF THE CHEST\n\n REASON FOR EXAM: fever.\n\n Comparison is made with prior study performed a day earlier.\n\n There is persistent elevation of the right hemidiaphragm and bibasilar\n atelectasis. There is mild interstitial pulmonary edema. Cardiac size is\n top normal accentuated by the low lung volumes. NG tube and ET tube are in\n standard positions. There is a small right pleural effusion.\n\n DR. \n" }, { "category": "Radiology", "chartdate": "2189-02-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005873, "text": " 7:23 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval for ETT placement and interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p arrest, intubated\n REASON FOR THIS EXAMINATION:\n Eval for ETT placement and interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Followup.\n\n COMPARISON: .\n\n FINDINGS: As compared to the previous radiograph, there are no relevant\n changes. The tip of the endotracheal tube is located 5 cm above the carina.\n The nasogastric tube is in unchanged position. At slightly lower lung\n volumes, the size of the cardiac silhouette appears slightly larger than\n before. The left costophrenic sinus is not ideally distended. In the\n interval, no parenchymal opacities have newly occurred.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 1613830, "text": "CCU NPN 1900-2300\nS: Pt orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nCV: P HR 40's SB, rare PVC noted, ABP 115-130/38-39 MAPs 62-68. Bilat pedal pulses palp. 1 unit PRCBC's infusing.\n\nResp: Pt vent settings unchanged, pt sxn'd for no secretions, not overbreathing vent, O2 sats 95-100%. LS CTA.\n\nNeuro: Pt continues to not follow commands. Pt opens eyes to voice, stimuli-but does not open eyes to command. Pt does not withdraw BUE to nailbed pain stimulus. Nail bed pain stimulus applied to BLE-pt did not withdraw LE to pain stimulus, but moved legs away after stimulus removed. Pt eyes do track to voice. Pt started on IV keppra for epileptic activity noted on EEG.\n\nGI/GU: Pt abd soft, +BS x4, no stool this shift. Foley cath draining clear yellow u/o 10-100 cc's/hr.\n\nID: Pt afbrile, 95.1-96.4, warm blaket applied.\n\nSocial: Pt two sons and dtr-in-law's in at bedside this eve, spoke with RN and MD re. condition and POC.\n\nA/P: y/o female s/p artic sun, minimally responsive off sedation, 1 unit PRBC's infused for low Hct/hypotension. Cont to monitor pt hemodynamics, post transfusion HCt. Cont to monitor neuro status. Cont to provide emotional support to pt and family.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-07 00:00:00.000", "description": "Report", "row_id": 1613831, "text": "Resp Care\nPt remains on vent. pt stable. Settings changed based on abgs. Suctioned for small amt of thick white secretions. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-07 00:00:00.000", "description": "Report", "row_id": 1613832, "text": "Nursing Progress Note\n2300-0700\n Received patient orally intubated on full ventilatory support. ...Non-restrained.\n\nCV HR 40-50's..sinus ...SBP 140's/40's.\n\nResp AC Mode ..rate of 16.. increased to 18. No overbreathing noted. Lungs clear. Suctioned for scant amount of thin yellow sxns...40%//TV 400\n\nGI OGT clamped, No stool\n\nGU Minimal urine output 10-20 cc q1 hour. Dr aware.\n\nTurned q3 hours.\n\nNeuro\nOpens eyes to name when called. Does not track. Does not follow commands. Absent gag/cough. All sedation held.\n\nHeme Repeat hct 28\n\nAwait plan of care\nNeuro input.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-07 00:00:00.000", "description": "Report", "row_id": 1613833, "text": "CCU NPN 0700-1900\nS: Orally intubated and mechanically ventilated\n\nO: y/o F s/p witnessed collapse , CPR given by bystanders. Defib x1 for VF according to EMS-->NSR initally according to strips. Intubated in field, To ED, cooling protocol initiated. Given IVF and transiently on Levo for BP. Head CT- neg for hemmorrhage/infarct, CTA- no PE. Echo - EF 70-80%. Sedation weaned off -> unresponsive. EEG - ? epileptic activity--started on IV Keppra. EKGs and Cardiac enzymes flat.\n\nNEURO: Neuro following--? Pontine ischemic stroke. Opens eyes consistently to voice, blinking upon command. Attempted to use blinking as way of communicating (1 blink for no, 2 blinks for yes)--unable to use. +Tracking. Initally not moving BUE and BLE, although HR and BP noted to increase with noxious stimuli. Now withdrawing to pain BLE and moves BLE in bed spont. No movement noted in upper extremities. Moving head side-side -cough/gag. Initally not moving at all, now attempting to move torso, ?purposeful d/t being uncomfortable. Unable to assess pain, although grimaces during coughing/sxn. Sedation restarted at 1630 for comfort. Pupils irreg bilat--NR, thought to be surgical from cataracts. According to Son, pt did not have cataract surgery but has had \"laser surgery years ago because the doctor said she was going to go blind.\" To have head CT tomorrow per neuro recs (can not have MRI d/t h/o staples in head). PT/OT consult in for splints given possible paralysis.\n\nRESP: On full ventilatory support--no vent changes today. See careview. No resp effort.\n\nCV: Continues to be bradycardic 40-60s, SR, rare PVC. Hypertensive with SBP 130-160s--team aware. Not to treat until SBP >180. PM HCT stable 29.3. +2 pedal edema. Asa and simvastatin ordered.\n\nGI/GU/ENDO: TF Probalance started this afternoon--no residuals, GR 45cc/hr. No BM- sm, brown, guaic neg stool on rectal temp probe. Foley with min uop--500cc NS bolus given to increase uop with min response. Elevated FS- tx'd per HISS. SS changed to tighter scale.\n\nSOCIAL: Mult family members in today--updated by MDs and RN. Expressed concern re: pt's poor prognosis. Dtr-in-law asking many detailed questions, \"what's in the TF? is it soy? How long can she stay on the vent? What don't they do a cat scan now? Are there any side effects to the sz medication even though she doesn't have seizures?\" Sons very reasonable/appropriate.\n\nA/P: S/p ? cardiac arrest vs syncopal event of unknown cause. Pontine stroke with involvement of resp center.\n-daily wake-ups early every AM for rounds to assess neuro status.\n-advance TF as tol\n-Head CT tomorrow\n-monitor BP\n-reorient pt, emotional support to pt and family\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-07 00:00:00.000", "description": "Report", "row_id": 1613834, "text": "pt remained on full vent supprt through shift without incidence. she has woken somewhat through shift. sx'd for minimal secretions. plan to be revaluated in AM rounds.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-10 00:00:00.000", "description": "Report", "row_id": 1613844, "text": "NPN 7 PM-- 7 Am\n\nPT is S/P Pons infarct and hemorrage, awake, alert, does follow simple commands to open mouth or close eyes, has not been moving any extremities, even to pain, however moved right leg today to pain and it appeared to move leg spontaneously during turning. went to CT last night for c spine and CT without contrast, c spine showed no fracture,\nsevere canal narrowing and cord impingement, ct head pons infarct and hemorage as above ( wet ). Neuro met with family yesterday and discussed poor prognosis as pt has not been moving and has not been taking breaths on her own. Family decided to make pt DNR yesterday, and may discuss further decision SP test results today.\n\nNeuro- alert opens eyes to name, closes eyes and opens mouth to command, does not comunicate ? mouthing words, smiles does not nod,\nmoving right leg to pain this AM. no gag, no cough.\n\n\nCV- sinus brady to SR, BP 110/44--130/70 stable .\n\nrespiratory - lungs clear to coarse, suctioned for thick tan to yellow , send spec, oral ssecreations blood tinged, rusty, bleeding gums , q 4 hr mouthcare and prn. o2 weaned to 30 percent. ABg done in Am.\n\nGI- tolerating tube feeding at goal 45 cc, senna x 2 yesterday no BM.\nabd soft distended hypoactive BS.\n\nendocrine- insulin drip started, able to get glucose down to 150.\ncontinues on 5 units per hour.\n\nGU- urine output has been poor but dropping off to 5-10 cc per hour team updated NS 75 cc per hour to start.\n\nskin- multipodus boots on now off at 0600, no open areas buttocks back, changed ETT tape on bottom due to scab on upper lip.\n\nA: yo pt S/P pontine infarct/hemorrage, on vent, now DNR.\n\nP: MD to F/u with family regarding tests, follow labs, glucose, i/o, rhythm, support pt, keep pt and family updated on POC as discussed in CCU rounds\n" }, { "category": "Nursing/other", "chartdate": "2189-02-10 00:00:00.000", "description": "Report", "row_id": 1613845, "text": "Respiratory Care:\nPt remains orally intubated and vented. Attempted PS trial,but pt acutely became hypotensive, apneic and desated to 88%, Pt then placed back on AC. Lung sounds slightly coarse. Suctioned for moderate thick tan secretions. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-10 00:00:00.000", "description": "Report", "row_id": 1613846, "text": "CCU NPN 0700-1900\nS: Pt orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 42-55 SB, ABP 105-129/35-43. ABP dipped this afternoon at approx 1650 with SBP 80's-> 250 cc's IVF bolus given over 30 mins with SBP 90's-100's. Bilat pedal pulses palp.\n\nResp: Pt cont on AC 30% 400x16 5 peep. Pt trialed briefly on CPAP +PS-pt with several periods of apnea, pt also hypotensive at time-pt palced back on AC. Pt sxn'd for small to moderate amounts thick rusty sputum. Pt negative gag/negative cough. Pt LS clear to coarse at bases.\n\nNeuro: Pt opens eyes to name. Pt also opens/closes eyes to command. Communication between pt and staff decided as eyes closed means yes, eyes open mean no. Pt able to close eyes tightly and open eyes widely enough to communicate yes or no. At times pt with 10-20 second delay in clear response. Pt also sticks out tongue and puts tongue back in mouth to command. Pupils s/p surgical, NR. Pt able to track with eyes. Pt does not move nor withdraw BUE to pain. When pain stimulus applied to pt does not withdraw to pain nor move spontaneously. When pain stimulus applied to RLE then removed pt R foot moves upwards slightly and knee bends-MD's aware. Per neuro recs and as MD ordered, cervical collar applied. Pt to have MRI this eve, checklist needs to be completed.\n\nGI/GU: Pt abd soft, +BS x4, no stool this shift. Pt cont on TF 45 cc's/hr with no residuals. Foley cath draining clear yellow u/o 17-40 cc's/hr, pt + approx 1.1 L today (goal was even to negative)-> 10 mg IV lasix given with minimal effect-> then IVF bolus given for low BP.\n\nENDO: Pt cont on insulin gtt, see flowsheet for details, insulin gtt presently at 2 units/hr.\n\nID: Pt afebrile, hypothermic to 94.3 oral-96 rectal-> CCU MD aware, bair hugger applied with temps up to 98.6, bair hugger off.\n\nSkin: Pt skin intact, multipodus boots on.\n\nSocial: Pt son in at bedside briefly this afternoon.\n\nA/P: y/o female with pontine infarct/hemmorrhage, awaiting MRI. As discussed with CCU MD's, cont to monitor neuro status-pt to have MRI today. Cont to monitor hemodynamics, resp status, u/o. Cont to provide emotional support to pt and family, awaiting further POC per CCU Team.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-10 00:00:00.000", "description": "Report", "row_id": 1613847, "text": "CCU NPN 0700-1900\naddendum: Pt MRI checklist completed over phone with RN and son . Phone checklist witnessed by CCU intern. MRI checklist faxed to MRI.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-11 00:00:00.000", "description": "Report", "row_id": 1613848, "text": "Resp Care Note, Pt remains on current vent settings. See vent flow sheet for details. Suctioned for sml amts thin clear secretions. To MRI for head and spine.? results.Awake and alert most of the night.Now sleeping with no spont resp. Will cont to monitor resp status.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 1613826, "text": "Resp Care\nPt remains on vent. Intubated with #6 ett # 22, patent and secure. Suciotned for mod amt of yellow secreitons. No changes made. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 1613827, "text": "ADMISSION NOTE\n YR. OLD WOMAN WITH H/O HTN & IDDM WHO PRESENTS THROUGH ED WITH ?? CARDIAC ARREST. WHILE WAITING IN THE LOBBY OF HER BUILDING FOR HER SON TO TAKE HER TO ROUTINE VISIT WITH PCP, SUDDENLY COLLAPSED. RN IN LOBBY WITNESSED EVENT & INITIATED CPR. PER REPORT, EMS NOTED VFIB ON MONITOR & DEFIB X1 WITH 200J. REVIEW OF STRIPS BY HOUSE STAFF HERE--\nAPPEARS TO BE NSR WITH ARTIFACT FOLLOWED BY SHOCK & RESUMPTION OF NSR.\nBS 188. UNRESPONSIVE->INTUBATED IN FIELD. HYPOTENSIVE ON ARRIVAL TO ED WITH SBP 60'S. RECEIVED 1L NS. LEVOPHED STARTED WITH SBP->180'S. LEVO STOPPED. HEAD/CHEST/ABD CT SCANS DONE->ALL (-). PAN CX. ARCTIC SUN INITIATED IN ED. TRANSFERRED TO CCU .\n\nNEURO: SEDATED ON VERSED 5MG/HR & FENTANYL 50MCG/HR ON ARRIVAL TO CCU.\nUNRESPONSIVE TO ALL EXTERNAL STIMULI. DOES NOT OPEN EYES, MOVE EXTREMITIES, OR FOLLOW COMMANDS. PUPILS WITH CATARACTS. NO GAG, NO COUGH. SBP 170'S->INCREASED FENTANYL TO 200MCG/KG WITH SBP 150'S.\n\nRESP: ON VENT: 50%/TV 400/AC 16/PEEP 5. O2 SATS 97-100%. BS CLEAR. SX FOR SM.AMTS. THICK YELLOW SECRETIONS. RR 16/16. ABG 7.40/33/136/21 100%.\n\nCARDIAC: HR 58->40'S SB, NO ECTOPY. BP 130-150'S/50-60'S. ~0115 SBP SPONTANEOUSLY DROPPED TO 90'S WITH MAP<60. FENTANYL DECREASED TO 100MCG/HR. STARTED LEVO BRIEFLY WITH SBP 180'S. LEVO OFF. ARCTIC SUN ON & PT AT GOAL TEMP OF 34 DEGREES UNTIL ~1700 TODAY. HCT 28.7, PT 12.2, PTT 24.7, INR 1.0, K 3.7->KCL 20MEQ IVPB GIVEN X2. REPEAR K 4.7. MG 1.8-> MAG SULFATE 2GMS PB X1 GIVEN. REPEAT MG 2.8, CA 9.1, CK 192 WITH MB 10 & TROPONIN <0.01.\n\nGI: OGT IN PLACE FOR MEDS WHILE NPO. ABD. SOFT. BS+. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 25-105CC/HR.\nBUN/CREAT 27/0.7.\n\nID: T 33.8->34.1 PER TEMP PROBE OFF FOLEY CATHETER. PO T 92.5->93.8.\nBC X2 & URINE C&S PENDING IN LAB.\n\nENDO: BS 239->170. INSULIN PER SLIDING SALE.\n\nAM LABS SENT 0600.\n\nPLAN: ARCTIC SUN UNTIL 1700, THEN RE-WARM.\n REPLETE LYTED AS NEEDED UNTIL 4-6HRS PRIOR TO RE-WARMING.\n MONITOR T/BLADDER & T/PO Q1HR PER PROTOCOL.\n Q4HRS LYTES(CHEM 10) WHILE ON ARCTIC SUN\nGULFATE 2GMS\n" }, { "category": "Nursing/other", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 1613828, "text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele sinus brady with prolonged QT this am. Decision made to rewarm pt this am. Process started at 930 with body temp at 98.6 at 330pm. Pt remains bradycardic. SBP 80's- 110's. House staff aware. Given fluid boluses of 2 liters with some ^ in SBP. Echo done. Good LV function approx 70% EF. CK's remain flat.\n\nResp: Pt intubated A/C 40% 400 16 5. Please see flow sheet for abg's. Suctioned for minimal tan sputum. Lungs are clear.\n\nNeuro: Pt received on Versed at 5mg/hr and Fentanyl at 100mcgs/hr. both drips weaned off once pt was rewarmed. Presently opens here eyes to her name. Does not follow commands. Not noted to move extremeties. Seen by neuro.\n\nGI/GU: Pt remains NPO. Abd is soft with bowel sounds present. No BM. Foley draining minimal amts of CYU. creat .7. No response to fluid challenge yet.\n\nEndo: Pt is IDDM. RISSC needed. NPH is on hold.\n\nSocial: Pt has 3 sons 2 of which visited today. Spoke with this RN and MD's. Very anxous regarding prognosis. Spoke with neuro team as well. Pt remains a full code.\n\nA&P: yo s/p cardiac arrest ? vasal vagal event with artic sun cooling c/b bradycardia and prolonged QT. able to tolerate rewarming. Remains bradycardic and hypotensive for unclear etiology. cont with fluid resuscitation. Cont to monitor neuro status. check lytes. Support family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 1613829, "text": "pt remained on full vent support through shift, sx'd for minimal secretions. plan is to await clearance of sedation for neuro evaluation.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-11 00:00:00.000", "description": "Report", "row_id": 1613851, "text": "Respiratory care\nPt remains on a/c vent attempt to wean to cpap/psv failed Pt max breaths / min was 6 with mv 1.2l after 5 mins. Plan for family meeting tommorrow.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 1613852, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and ventilated on AC settings at this time. No vent changes made during the night. Attempted RSBI but patient has no spontaneous respirations. Will wean as tolerated.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 1613853, "text": "NPN 7 PM -- 7 Am\n\nS: pt intubated, awake, closes eyes for yes, opens for no, not able to blink.\n\no: Please see careview for vitals and other objective data\n\npt S/p CVA, intubated and failed Pressure support ventilation yesterday, not taking breaths on her own. pt had MRI yesterday please see wet report in careweb, pt neuro status is unchanged, moves right leg to deep pain other extremities flaccid.\n\nCV wise pt in SB when resting SR otherwise BP stable no issues.\n\n pt spiked temp to 101.4 last night Blood culture and urine CX\nsent, sputum sent this am Which was thick and tan, small amount.lungs clear to coarse at bases.\n\n pt continues on , colace, now passing flatus, no BM, hypoactive BS, tolerating tube feeds 0-5 cc residuals.\n\nendocrine- ON NPH and SS, glucose 255 last night 6 units given and glucose 145 this Am, no coverage.\n\nsocial- Family in every day to visit, family meeting planned for today at 1330, this is the second family meeting this week.\n\na: pt sp CVA, papralysis, not able to wean , family meeting planned.\n\np; continue Vap prevention, follow culture data, tylenonl for fever,\nfamily meeting, keep pt and family updated on POC as discussed in CCU rounds\n" }, { "category": "Nursing/other", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 1613854, "text": "CCU Nursing Progress Note 0700-1900\nS: does not mouth words. Had previously been squinting eyes closed to indicate \"yes,\" is not doing that today.\n\nO: see CCU flow sheet for complete objective data\n\nNeuro: R eyelid lagging behind L eyelid when eyes are open. Seen to raise eyebrows and squint. Does not open mouth when requested to do so. Does not respond to nail bed stimulation in any way. Also, opening eyes less frequently today. Face did light up when family in room.\n\nResp: sats >94%. Lungs with diminished breath sounds in bases. Remains on AC with no spontaneous resps.\n\nGI: TF remain @ 45 cc/hour, minimal residuals. Receiving NPH and SS regular, SS coverage broadened. Abd soft, +BS. No stool, on colace.\n\nGU: foley drainig clear, yellow urine.\n\nSkin: intact, turned side to side, heels up on pillows.\n\nID: T 102.6 , WBC 11.5 (10). Pan cultured on night shift. On Tyelnol ATC.\n\nCV: HR 60's sinus rhythm, SBP 100-120 via a-line\n\nAccess: PIV, L radial a-line.\n\nSocial: family meeting with son , wife and son -in-law. Dr. , Neurologist, , CCU team, social worker and RN present. Poor prognosis presented to family as well as options for future care (trache/peg; no escalation of care;withdrawal of care: comfort focused care). Son expresses concern re: withdrawing of care not being consistant with family's religious beliefs. Also concerned that only 7 days have passes, difficult to know pt's full prognosis. also states he needs to talk with his 2 siblings about the potential prospect of trache/peg. No further decision made at this point.\n\nA: neurological status slightly worsened today. Family not ready to make further decisions re: care direction at this point. Febrile, awaiting results of cultures.\n\nP: continue to assess T, tylenol for temp. Await culture results. Follow neuro status. Monitor BS. Support family.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 1613855, "text": "CCU Nursing Progress Note 0700-1900\nAddendum: pt's son in to visit, updated on discussion that took place during family meeting by CCU team--felt it \"made sense and was rationale\" and that he \"has to have a serious discussion with his brother.\" Pt. started on triple antibiotic coverage.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-12 00:00:00.000", "description": "Report", "row_id": 1613856, "text": "resp care - Pt remains intubated and on full vent support. No changes were made in vent settings this shift. Thick, yellow secretions were suctioned and BS were coarse t/o. Continued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-13 00:00:00.000", "description": "Report", "row_id": 1613857, "text": "RESPIRATORY CARE NOTE\n\nPatient remains intubated and fully ventlated on AC settings. No vent changes made during the night. Unable to complete RSBI d/t no spontaneous respirations.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2189-02-13 00:00:00.000", "description": "Report", "row_id": 1613858, "text": "RESPIRATORY CARE NOTE\nADDENDUM: Increased Peep to 10, FiO2 to 50% and RR to 18 d/t desaturation, acidosis which seems to be metabolic, PaO2 61. To have CXR this AM. Will wean support as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-09 00:00:00.000", "description": "Report", "row_id": 1613840, "text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT IS YOF S/P WITNESSED COLLAPSE , CPR, DEFIB X1 FOR VF ACCORDING TO EMS, NSR INITALLY ACCORDING TO STRIPS. INTUBATED IN FIELD. TO ED, ARTIC SUN HYPOTHERMIC THERAPY. RX W/ IVF AND TRANSIENLY ON LEVO FOR HYPOTENTION. HEAD CT NEG. CTA CHEST NEG. ECHO W/ EF 70-80%. SEDATION OFF EEG ?EPILECTIC ACTIVITY, IV KEPRA. CARDIAC EVENT R/O. POSS PONTINE STROKE.\n\nNEURO:OPENS EYES WHEN NAME CALLED, PUPIL 2MM NR. NO GAG/COUGH. ATTEMPTS TO MOUTH WORDS TO FAMILY WHEN ASKED TO OPEN MOUTH FOR MOUTH CARE, PT FOLLOWS COMMAND. NOT MOVING EXTREMITIES. DOES MOVE TORSO.\n\nCV:MHR 60-46SB NO VEA. DP WEAKLY PALP. SBP LESS LABILE THROUGH THE NOC. SBP 100S-150S. L RAD ALINE. 2PIVS INSERTED\n\nRESP:VENT AC/400/16/30/5, LUNGS CLR AND DIM. SX FOR TAN SECRETIONS. SATS 98.ETT ROTATED BY RESP TO R SIDE OF MOUTH.\n\nGI:TOL PROBALANCE AT GOAL MIN RESIDS. NO BM\n\nENDO:GLU HIGH 312 COV'D AS PER SS.\n\nGU:REMAINS OLIGURIC. SLT INCREASE IN U/O.\n\nA/P:FACILITATE FAMILY MEETING W/ SOC SVC/ETHICS/ AND MD/ RE: LONGTERM GOAL AND PROGNOSIS. FAMILY IN TO VISIT LAST EVENING. SEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-09 00:00:00.000", "description": "Report", "row_id": 1613841, "text": "pt remained on full vent support through shift without incidence, sx'd for minimal secretions. family meeting today, plan to be evaluated in AM rounds.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-09 00:00:00.000", "description": "Report", "row_id": 1613842, "text": "Nursing Progress Note:\n\nEvents: Family meeting took place with Neuro MD, CCU resident, palliative care and RN. Prognosis discussed (seen as being poor), further testing, and options for pt. were discussed. Family agreed to make pt. DNR and will follow up as to results of repeat CT scan (ordered for this evening) to make further decisions. Very productive meeting, family is very appropriate.\n\nNeuro: Sedation off since 0800. Pt. seems comfortablel. She is alert at times, arouses to voice at others, smiles, follows commands to shut her eyes and stick out her tongue. No movement to extremities in response to pain. She makes eye contact when spoken to and seemed to recognize her family. Repeat head CT ordered.\n\nCV: HR 40s-50s SB with no ectopy, ABP 100s-110s/30s. 2 PIVs and L R arterial line are all patent and WNL. Pt. has no edema.\n\nResp: Vent setttings AC 400X16/30%/5. Pt. had spontaneous breaths per minute without vent assistance. Lungs are clear for the most part with occ. crackles noted to bases. Suctioned for no secretions.\n\nGI: BSX4 although hypoactive, no BM on shift, TF at goal of 45cc/hour and are tolerated well.\n\nGU: UO is marginal but adequate.\n\nEndo: Blood glucose poorly controlled on sliding scale (around 300), insulin gtt started and is now and 5 units/hour, last BG 194.\n\nSkin: Intact\n\nSocial: Many very loving family members at bedside today.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-10 00:00:00.000", "description": "Report", "row_id": 1613843, "text": "Respiratory Care:\nPt remains intubated and vented. No parameter changes made this shift. Suctioned some bloody secretions. No RSBI due to lack of spont resp.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-15 00:00:00.000", "description": "Report", "row_id": 1613866, "text": "CCU NURSING PROGRESS NOTE\nS:INTUBATED\nO:PT IS A YOF S/P WITNESSED COLLAPSE , CPR, DEFIB, INTUBATED IN FIELD. TO ED, ARTIC SUN HYPOTHERMIC THERAPY. NOW W/ 1CM HEMORRHAGIC LESION OF THE CAUDAL MEDULLA.TINY HEMORRHAGIC LESIONS OF THEUPPER CERVICAL CORD T THE C2 AND C3 LEVEL W/ EXTENSIVE CORD EDEMA EXTENDING FROM THE CAUDA MEDULLA TO C6 LEVEL PER NEURO NOTE.\n\nNEURO:STILL OPENS EYES TO WHEN NAME CALLED, INCONSISTENT IN USE OF BLINKING TO ANSWER YES AND NO QUESTIONS. TRACKING LESS FREQUENTLY. SCRUNCHING OF EYES. AND FACIAL JAW MOTIONS NOTED. NOT RESPONDING TO NOXIOUS STIMULI. J COLLAR IN PLACE.\n\nRESP:PLAN FOR SPONTANEOUS BREATH TRIAL AROUND 10AM, THEN NOT TO PLACED BACK ON AC. VENT AC 400/18/40/10. SATS 99-100. NO SPONT RESP. SUCTIONED FOR THICK YELL SECRETIONS. LS CLR DIM, L BASE COARSE. SKIN PINK WARM AND DRY.\n\nCV:MHR 50S SB NO VEA. SBP 120S. DP WEAKLY PALP. LEFT RADIAL ALINE. 1PIV.\n\nID:T MAX 100. 9, REMAINS ON CIPOR VANCO AMTIBIOTICS, ?VAP, CX PENDING\n\nENDO;ON NPH, AND REG COVERAGE AS PER SS. LAST GLU 143.\n\nGI:+BS, TOL TF. NO BM\n\nGU;OLIGURIC.\n\nSKIN:INTACT.\n\nSOC:FAMILY IN VISITING LAST EVENING\n\nA/P:PT HAS SIZE 6ETT, BE TO SMALL FOR SPONT BREATHING TRIAL. SECONDLY APNEA ALARM WILL KICK IN WHEN PT DOES NOT BREATH. NEED TO CONSIDER OPTIONS, IE COOL AEROSOL T-PIECE TO ETT. OR EXTUBATION.\nSEE FLOW SHEET FOR ADDITIONAL INFORMATION.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-15 00:00:00.000", "description": "Report", "row_id": 1613867, "text": "Resp Care,\nPt. remains intubated on A/C overnoc. No vent changes this shift. Suctioned thick yellow sputum. No RSBI due to peep level. Maintain current vent settings at this time.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-11 00:00:00.000", "description": "Report", "row_id": 1613849, "text": "CCU NPN 1900-0700\nO: afeb.\nHR 40's SB. no VEA. BP 107/40-130/40's. BP higher with stimulation and staying elevated for longer periods after 0200.\n\nu/o 10-20cc/hr. lasix 40mg IV x1. 1L u/o responce.\nAM lytes pnd. HCT 27.6 (unchanged).\n\nTF at goal 45cc/hr no stool.\nMRI done of head and cervical spine. results pnd. J collar on.\npt. opens eyes spont. and to voice/name. looks around and looks for voice. good eye contact. appears to be trying to speak. no movement in upper extrem. and does not appear to have any sensation either.\nright lower extrem. withdraws to deep nail bed stimulation.\n\n3 family members visited for ~ 30min. in eve - son included - they did not ask to speak with MD.\n\nskin intact. multipodus boots on. turn/positioned q2-3 hours.\n\nendo: insulin gtt off at MN. FS 100-135. changed to SSRI but did not need coverage. NPH changed to .\n\nA/P: awaiting MRI results. bowel regiman. skin care regiman.\nfollow FS on SSRI and NPH .\nassess for pain, anxiety in pt. family support.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-15 00:00:00.000", "description": "Report", "row_id": 1613868, "text": "NURSING PROGRESS NOTE\n\nO: Pt started on MSO2 drip for pt comfort. Per family request pt was placed on spontaneous breathing trial using t-piece. No spontaneous respirations noted. Decision made by family to not place pt back on vent. Pt pronounced by MD at 1030.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-08 00:00:00.000", "description": "Report", "row_id": 1613835, "text": "CCU NURSING PROGRESS\nS:INTUBATED\nO:PT IS YOF S/P WITNESSED COLLAPSE , CPR, DEFIB X1 FOR VF ACCORDING TO EMS--NSR INITALLY ACCORDING TO STRIPS. INTUBATED IN FIELD. TO ED, ARTIC SUN HYPOTHERMIC THERAPY. RX W/ IVF AND TRANSIENTLY ON LEVO FOR HYPOTENTION. HEAD CT NEG. CTA NEG. ECHO W/EF 70-80%. SEDATION OFF EEG ?EPILECTIC ACTIVITY, IV KEPRA. CARDIAC EVENT R'D/O. ?PONTINE STROKE.\n\nNEURO:OPENS EYES, SOME TRACKING. PUPILS NON REACTIVE. BLINKING ON COMMAND. NOT MOVING LE ON BED THIS EVENING. NEG GAG/COUGH.\n\nCV:MHR 60-48SB, NO VEA. SBP HYPERTENSIVE UP TO 180,RECEIVED HYDRAL 10MG IV W/ ADEQUATE RESPONSE BP 120. 4HRS AFTER DOSE PT HYPOTENSIVE AND BRADYCARDIC, MAP 47, HR 47. 2ND NS 500CC BOLUS GIVEN W/ GOOD RESULTS. DR AWARE. FIRST BOLUS GIVEN FOR LOW U/O. PT HAD GOOD RESPONSE TO IVF BP UP TO MAP 66 HR 57SB. DP WEAKLY PALP. 2PIV, L RAD ALINE CORRELATING W/ CUFF.\n\nRESP:VENT AC/18/400/30%/5. LUNG DIM AND SLT COARSE AT BASES. SATS TRENDING LOW 90S. SKIN PALE WARM AND DRY. POSTERIOR PHARYNX W/OLD BLD.\n\nGI:TOL TF PROBALANCE UP TO 30CC/HR, MIN TO NO RESID, +BS,\n\nGU:URINE RESPONDED TO NS BOLUS.\n\nENDO: COVERED AS PER SS.\n\nSOC:FAMILY IN TO VISIT LAST EVENING. PT'S BP UP WHILE FAMILY TALKING TO PATIENT.\n\nA/P:CONTINUE W/ NEURO F/U, CT OF HEAD TOMORROW. MULTIPODUS BOOTS ORDERED FROM DISTRIBUTION. FOLLOW NEURO STATUS. IV FLUID BOLUS FOR HYPOTENTION. HOLD HYDRAL. PROVIDE EMOTIONAL SUPPORT. UPDATE FAMILY.\nSEE CARE VUE FOR ADDITIONAL INFORMATION.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-08 00:00:00.000", "description": "Report", "row_id": 1613836, "text": "Resp Care\nPt remains on vent. No changes made. Suctioned for small amt of thick blood-tinged secretions. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-08 00:00:00.000", "description": "Report", "row_id": 1613837, "text": "pt remained on full vent support through shift, wean to PSV attempted but Vm remained below 3L. sx'd for minimal secretions. plan to be revaluated in AM rounds.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-08 00:00:00.000", "description": "Report", "row_id": 1613838, "text": "CCU NPN 0700-1900\nPls see careview for further assessments\n\nNeuro: Spont mvmts noted only to BLE. Not following commands to move extremities however opened mouth upon command during mouth care. Blinks eyes, attempting to mouth words around ETT. F/b neuro- see note. Sedation off for neuro to assess.\n\nCV/RESP Bradycardic c stable BP. No spontaneous respiratory effort.\n\nGI/GU/ENDO: Started on bowel regime, TF at goal, no residual. Foley draining little to no urine. Repositioned and foley flushed with no response x4 hr. Renal fxn wnl. Team aware. Elevated FS, covered by HISS.\n\nSOCIAL: mult family members in today taking shifts to see pt. Updated by RN. Ethics consult ordered for life prolongation vs comfort/palliative care.\n\nA/P: poor neurological recovery, vent dependent. No uop. ? pontine ischemic stroke\n-SSEP to comfirm clinical dx of pontine/medullary stroke.\n-? family meeting to discuss goals of care\n\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-09 00:00:00.000", "description": "Report", "row_id": 1613839, "text": "Resp Care\nPt remains on vent. No changes made. Suctioned for small amt of blood-tinged secretions. repositioned ett. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-11 00:00:00.000", "description": "Report", "row_id": 1613850, "text": "CCU NPN 0700-1900\nS: Pt orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nCV: Pt HR 46-58 SB, no ectopy noted, SBP> 100. Bilat pedal pulses palp.\n\nResp: Pt cont on AC 40% 400 x16-pt placed briefly on PS-only 4 breaths noted per RT-pt placed back on AC. Pt sxn'd orally for scant amounts of white thick sputum, nothing via ETT. Pt LS clear to coarse throughout. Pt negative gag/cough.\n\nNeuro: Pt continues to open/close eyes to command and opens eyes to name. Pt able to close eyes tightly for yes, open eyes widely enough to communicate no. Pt tracks with eyes, continues with no movement in BUE, slight bend of R knee and R foot moves upwards slightly to nailbed stimulation, no movement of . MRI done last night/early this am-> see report-family meeting planned for tomorrow afternoon at 1330 to discuss pt condition/prognosis.\n\nGI/GU/ENDO: Pt abd soft, +BS x4, no stool this shift, pt cont on colace. TF continues at 45 cc's/hr with no residuals. Foley cath draining clr yellow u/o 20-70 cc's/hr. FS 211-252, ss insulin coverage and standing NPH given.\n\nID: Afebrile.\n\nSkin: Intact, collar care done.\n\nSocial: Several family members in at bedside today. Pt son spoke briefly with RN this afternoon.\n\nA/p: y/o female cont w/ poor prognosis, MRI done, family meeting tomorrow. Cont to monitor neuro status, resp status, hemodynamics. Cont to provide emotional support to family. Awaiting further POC per CCU Team.\n" }, { "category": "Radiology", "chartdate": "2189-02-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006293, "text": " 7:50 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? placement\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with pontine stroke, intubated\n REASON FOR THIS EXAMINATION:\n ? placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman, followup evaluation after pontine stroke.\n\n COMPARISON: at 8:15 a.m.\n\n SINGLE UPRIGHT PORTABLE VIEW OF THE CHEST AT 8:00 A.M.: There has been no\n interval change. An endotracheal tube and nasogastric tube are in unchanged\n position. Lung volumes remain low and bibasilar atelectasis persists.\n However, there is no consolidation or pleural effusion. Pulmonary vasculature\n is normal. The cardiomediastinal silhouette is unchanged.\n\n IMPRESSION: No interval change in bibasilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 1006101, "text": " 9:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: PONTINE STROKE, ASSESS FOR ISCHEMIA.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with presentation c/w pontine stroke, apneic and not moving\n extremities\n REASON FOR THIS EXAMINATION:\n please evaluate for areas of ischemia, edema\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with apnea and unresponsiveness. Please\n evaluate for ischemia or edema.\n\n TECHNIQUE: Non-contrast head CT.\n\n Comparison is made to the prior study of .\n\n FINDINGS: The densely calcified left frontal lesion and surrounding surgical\n clips are unchanged. No surrounding mass effect is visualized. The diffuse\n hypodensities surrounding the left frontal lesion and bilateral periatrial\n hypodensities, which are more prominent on the right than the left are\n unchanged.\n\n Small amount of intraventricular hemorrhage is noted bilaterally, which was\n not present on the prior images. No definite site of subarachnoid hemorrhage\n is visualized. The hyperdense focus noted in the distal pons and the proximal\n medulla might represent a focus of intraparenchymal hemorrhage. This is best\n seen on series 2, image 6.\n\n Mild mucosal thickening of the maxillary and ethmoid sinuses is visualized.\n Diffuse punctate calcification near the dens and transverse ligament is\n unchanged.\n\n IMPRESSION:\n\n 1. Interval development of small intraventricular hemorrhage, which is noted\n in the occipital horns of the lateral ventricles.\n\n 2. Questionable area of hyperdensity noted in the upper medulla might\n represent a focus of intraparenchymal hemorrhage/cavernous hemangioma.\n\n 3. Unchanged large lobulated calcification of the left frontal lobe.\n Differential possibilities include benign etiologies like prior embolization.\n The recurrent tumor or unusual intra-axial tumor is less likely based on the\n stable course of the lesion through four years.\n\n 4. Unchanged calcification near the tip of the dens, which most likely\n represents ligamentous calcification.\n\n These findings were discussed with Dr. at the time of dictation.\n (Over)\n\n 9:15 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: PONTINE STROKE, ASSESS FOR ISCHEMIA.\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n NOTE ON ATTENDING REVIEW:\n\n I AGREE WITH THE FINDINGS OF SMALL INTRAVENTRICULAR HEMOORHAGE IN THE\n OCCIPITAL HORNS AND SMALL FOCUS OF HEMORRHAGE IN THE UPPER MEDULLA. HOWEVER,\n THE CAUSE OF THIS IS UNCERTAIN FROM THE PRESENT STUDY. A CLOSE FOLLOW-UP\n EXAMINATION OR MR HEAD WITHOUT AND WITH IV CONTRAST, WOULD BE HELPFUL.\n\n\n THE LOBULATED CALCIFIED LESION APPEARS TO EXTEND INTO THE LEFT LATERAL\n VENTRICLE BUT UNCHANGED. THIS CAN BE BETTER ASSESSED WITH MR HEAD WITHOUT AND\n WITH IV CONTRAST FOR ANY ENHANCING TUMOR.\n\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-09 00:00:00.000", "description": "CT C-SPINE W/O CONTRAST", "row_id": 1006102, "text": " 9:17 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for acute pathology\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman not moving extremities\n REASON FOR THIS EXAMINATION:\n please evaluate for acute pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman with difficulty moving the extremities.\n\n No comparison is available.\n\n TECHNIQUE: Axial MDCT images of the cervical spine were obtained with no IV\n contrast administration. Sagittal and coronal reformatted images were then\n obtained.\n\n FINDINGS: No definite fracture or malalignment is detected. The dense\n calcification of the transverse ligament severely narrows craniocervical\n junction causing indentation on the thecal sac and possibly the cord.\n Multilevel degenerative changes of the cervical spine is noted with multilevel\n disc space narrowing and anterior and posterior osteophyte formation.\n\n At C3-C4 level, ligamentum flavum calcification and uncovertebral joint\n hypertrophy narrows the thecal sac.\n\n At the C4-C5 level, also calcification of the posterior longitudinal ligament\n and uncovertebral joint hypertrophy and ligamentum calcification narrows the\n spinal canal.\n\n At C6-C7 level, calcified posterior ligament and ligamentum flavum\n calcification narrow down the spinal canal.\n\n Neural foraminal narrowing is noted at multiple levels, which is most severe\n on the right side at the level of C3- C4 and on the left side at the level of\n C5-C6.\n\n Mild prevertebral soft tissue swelling is noted, most likely related to the\n endotracheal tube placement. The NG tube is also in place, as far visualized.\n Incidental note is made of calcified nodule within the left lobe of the\n thyroid, and an 18 mm hypodense nodule within the right lobe of the thyroid.\n The visualized portion of the lung apices reveal a punctate, 1-2mm\n calcified nodule in the right lung apex. (series3, im 62).\n Note is also made of a hyperdense area within the upper medulla\n corresponding to a focus of hemorrhage as describe the concurrent CT head.\n\n IMPRESSION:\n\n 1. No fracture or malalignment is detected.\n\n (Over)\n\n 9:17 PM\n CT C-SPINE W/O CONTRAST Clip # \n Reason: please evaluate for acute pathology\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n 2. Diffuse calcification of the transverse ligament adjacent to the dens\n causes severe canal narrowing and cord impingement. The thecal sac measures\n approximately 5 mm at this area.\n\n 3. Hyperdense focus within the lower pole of pons and upper medulla, might\n represent intraparenchymal hemorrhage or cavernoma.\n\n 4. Bilateral thyroid nodules which can be further evaluated on nonemergent\n basis.\n\n NOTE ON ATTENDING REVIEW:\n\n Multilevel degenerative changes in the cervical spine with variable levels of\n foraminal narrowing, most prominent at C3-4 and C5-6 as well as transverse\n ligament extensive calcification narrowing the canal and possible cord\n impingmeent. These can be better evaluated with MR Cervical spine for the\n intrathecal details.\n Pl. see the recommendation on CT head as well.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-14 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006790, "text": " 7:44 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman with ? VAP, intubated\n REASON FOR THIS EXAMINATION:\n ? interval change\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST OF \n\n COMPARISON: .\n\n INDICATION: Ventilator-associated pneumonia.\n\n Endotracheal tube and nasogastric tube remain in standard position.\n Cardiomediastinal contours are stable in appearance. Left basilar\n consolidation has slightly worsened, but right lower lobe atelectasis shows\n interval improvement. Small bilateral pleural effusions are probably\n unchanged.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1006136, "text": " 7:33 AM\n CHEST (PORTABLE AP) Clip # \n Reason: intubated patient, daily CXR\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman s/p CVA vs. cardiac arrest now intubated\n REASON FOR THIS EXAMINATION:\n intubated patient, daily CXR\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST, \n\n COMPARISON: .\n\n INDICATION: Status post cardiac arrest.\n\n Endotracheal tube and nasogastric tube remain in standard positions, and\n cardiomediastinal contours are stable in appearance. Worsening opacification\n is present in the left retrocardiac region. Additionally, there is a new area\n of increased opacity at the right lung base with associated volume loss\n suggestive of atelectasis. Small pleural effusions are present bilaterally.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1005988, "text": " 8:05 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Eval ETT placment and interval change\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman respiratory failure, possible pontine stroke\n REASON FOR THIS EXAMINATION:\n Eval ETT placment and interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: -year-old woman, followup evaluation of respiratory failure\n after possible pontine stroke.\n\n COMPARISON: at 8:25 a.m.\n\n SINGLE UPRIGHT PORTABLE VIEW OF THE CHEST AT 8:40 A.M.: There has been no\n interval change since the prior examination. The endotracheal tube is in\n unchanged position. The NG tube terminates below the level of the diaphragm,\n and the tip is not visualized.\n\n Lung volumes are low; however, the pulmonary vasculature is not engorged and\n there is no pleural effusion. There are no areas of consolidation. The\n cardiomediastinal silhouette is unchanged, with prominent calcification of the\n aorta.\n\n IMPRESSION: No interval change.\n\n" }, { "category": "Radiology", "chartdate": "2189-02-11 00:00:00.000", "description": "MR HEAD W & W/O CONTRAST", "row_id": 1006265, "text": " 12:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate further pontine lesion as well as interventr\n Admitting Diagnosis: CARDIAC ARREST\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman h/o meningioma s/p intervention in 's s/p syncopal\n episode now paraplegic, intubated, but conscious; CT shows pontine lesion.\n Reviewed in neuroradiology rounds, okay to MR w/clips per Dr. \n REASON FOR THIS EXAMINATION:\n Please evaluate further pontine lesion as well as interventricular hemorrhage,\n other pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN WED 3:36 AM\n please send recent CTof brain and/or c spine for comparison. multiple lesions,\n almost all extra axial, suspected to be multiple hematomas, including small\n lesions in right and left temporal lobes, high right parietal lobe of prior\n cva, pons, and the anterior epidural space at the level of the\n cervicomedullary junction which is moderately to markedly compressing the cord\n and is likely responsible for the patients paralysis. several of these lesions\n demonstrate only rim enhancement, which is more typical for subdural or\n epidural hematoma, rather than menigioma, but atypical menigiomas must be\n considered. the the cervical medullary junctional lesion measures\n 2.9x1.1x1.8cm and may require emergent surgical decompression. high signal in\n cord distal to the compressed area, representing either myelomalacia, infarct\n or transverse myelitis. cord contusion is also considered since there is\n multilevel moderate DDD with baseline narrowing of central canal, most\n significant at c5-6 (but still only mild canal narrowing). intraventricular\n hemorrahge is also present which is from either the left parietal hemorrhage\n or intrinsic from a bleeding diathesis. the left parietal hemorrhage in area\n of prior cva demonstrates heterogeneous enhancement, a bit more than typically\n expected from a hematoma, and neoplasm cannot be excluded. Overall DDX:\n bleeding diathesis, trauma, neoplasm. multiple meningiomas are considerd\n unlikely. amyloid and hemorrhagic infarct are unlikely. epidural hematoma\n compressing cord may need emergent decompression. please send CT's for\n comparison , MD\n ______________________________________________________________________________\n FINAL REPORT\n MR HEAD\n\n HISTORY: -year-old woman status post meningioma resection in the with\n syncopal episode, now paraplegic after intubation with a pontine lesion seen\n on CT scan.\n\n TECHNIQUE: Multiplanar multisequence MR images of the head were obtained\n before and after the administration of IV gadolinium.\n\n FINDINGS: Comparison is made to prior head CTs from and as\n well as concurrent MR of the cervical spine and a CT of the cervical spine\n from .\n\n (Over)\n\n 12:39 AM\n MR HEAD W & W/O CONTRAST Clip # \n Reason: Please evaluate further pontine lesion as well as interventr\n Admitting Diagnosis: CARDIAC ARREST\n Contrast: MAGNEVIST Amt: 11\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is a T1 and T2 hypointense lesion involving the caudal medulla with\n blooming and surrounding edema with expansion of the medulla consistent with\n an acute hemorrhage. No definite abnormal enhancement is seen correlating\n with this lesion. Better evaluated on the MR of the cervical spine is a large\n pannus posterior to the dens which is compressing the cervicomedullary\n junction.\n\n There is a large area of gliosis involving the left frontal lobe with a\n multilobulated calcified enhancing lesion consistent with a meningioma. This\n lesion measures approximately 3.4 cm in size.\n\n There is an enhancing calcified extra-axial mass measuring 1.4 cm adjacent to\n the left operculum consistent with a meningioma. Similar appearing enhancing\n calcified meningioma is seen along the left side of the falx cerebri measuring\n 0.7 cm and another lesion along the right temporal lobe measuring\n approximately 1.1 cm.\n\n There is an area of cystic encephalomalacia involving the right parietal lobe\n with overlying burr hole. Extensive T2 hyperintensities of the brain are seen\n suggestive of gliosis and chronic microangiopathic changes. The ventricles\n are dilated, likely due to atrophy and ex vacuo dilatation. Again seen is\n layering blood within the occipital horns of the lateral ventricles.\n\n Cataract surgical changes of the globes are seen. There is mucosal thickening\n involving paranasal sinuses bilaterally. There is an endotracheal tube and an\n orogastric tube in place.\n\n IMPRESSION: 1-cm hemorrhagic non-enhancing lesion of the caudal medulla with\n expansion and edema. This finding may represent a hemorrhagic infarct versus\n a cavernoma. Given the findings on the concurrent MR cervical\n spine, a hemorrhagic infarct is favored. Hemorrhagic neoplasm is thought to\n be less likely given the lack of contrast enhancement and no prior history of\n cancer.\n\n Multiple extra-axial partially calcified enhancing masses as described above\n consistent with meningiomas.\n\n Intraventricular blood as before.\n\n\n" }, { "category": "Radiology", "chartdate": "2189-02-11 00:00:00.000", "description": "MR CERVICAL SPINE W/O CONTRAST", "row_id": 1006266, "text": " 12:40 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please further evaluate dens/other c-spine/soft tissue patho\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n MEDICAL CONDITION:\n year old woman h/o meningioma s/p intervention in 's s/p syncopal\n episode now paraplegic, intubated, but conscious; CT c-spine shows thickening\n around dens. Reviewed in neuroradiology rounds, okay to MR w/clips per Dr.\n \n REASON FOR THIS EXAMINATION:\n please further evaluate dens/other c-spine/soft tissue pathology\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: KN WED 3:38 AM\n please send recent CTof brain and/or c spine for comparison. multiple lesions,\n almost all extra axial, suspected to be multiple hematomas, including small\n lesions in right and left temporal lobes, high right parietal lobe of prior\n cva, pons, and the anterior epidural space at the level of the\n cervicomedullary junction which is moderately to markedly compressing the cord\n and is likely responsible for the patients paralysis. several of these lesions\n demonstrate only rim enhancement, which is more typical for subdural or\n epidural hematoma, rather than menigioma, but atypical menigiomas must be\n considered. the the cervical medullary junctional lesion measures\n 2.9x1.1x1.8cm and may require emergent surgical decompression. high signal in\n cord distal to the compressed area, representing either myelomalacia, infarct\n or transverse myelitis. cord contusion is also considered since there is\n multilevel moderate DDD with baseline narrowing of central canal, most\n significant at c5-6 (but still only mild canal narrowing). intraventricular\n hemorrahge is also present which is from either the left parietal hemorrhage\n or intrinsic from a bleeding diathesis. the left parietal hemorrhage in area\n of prior cva demonstrates heterogeneous enhancement, a bit more than typically\n expected from a hematoma, and neoplasm cannot be excluded. Overall DDX:\n bleeding diathesis, trauma, neoplasm. multiple meningiomas are considerd\n unlikely. amyloid and hemorrhagic infarct are unlikely. epidural hematoma\n compressing cord may need emergent decompression. please send CT's for\n comparison , MD\n WET READ VERSION #1 KN WED 3:37 AM\n ______________________________________________________________________________\n FINAL REPORT\n MR CERVICAL SPINE\n\n HISTORY: A -year-old woman status post meningioma resection back in the\n with syncopal episode, and now paraplegia after intubation. Assess\n cervical spine and medullary lesion.\n\n TECHNIQUE: Sagittal post-gadolinium T1, T2, STIR of the cervical spine\n extending from the skull base to the T2/3 level and axial T2 and GRE images\n extending from the skull base to the C7/T1 levels were obtained.\n\n FINDINGS: This study is somewhat limited by patient motion. Comparison is\n made to a prior CT of the cervical spine from and head CT from that\n same date as well as a concurrent MR of the head.\n (Over)\n\n 12:40 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please further evaluate dens/other c-spine/soft tissue patho\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n There is an approximately 1-cm T1 and T2 hypointense lesion with blooming\n within the caudal medulla, which is expanding the medulla with surrounding\n edema. There is extensive T2 hyperintensity involving the caudal medulla and\n cord extending down to the T6 level. Within the cervical cord at the C2 and\n C3 levels are small areas of blooming suggestive of hemorrhage within the\n cord.\n\n There is a large pannus posterior to the dens, which is severely narrowing the\n spinal canal and compressing the cord.\n\n At C3/4, there is disc osteophyte complex and ligamentum flavum thickening\n combination of which is causing moderate canal stenosis and severe left and\n moderate right foraminal stenoses.\n\n At C4/5, there is ankylosis of the right facet joint.\n\n At C5/6, there is a disc osteophyte complex and ligamentum flavum thickening\n combination of which is causing moderately severe canal stenosis. There is\n moderate-to-severe bilateral foraminal stenoses.\n\n At C6/7, there is a disc osteophyte complex eccentric to the right and\n ligamentum flavum thickening, which is causing moderate canal stenosis with\n indentation of the right central side of the cord. There is likely mild\n bilateral foraminal stenosis.\n\n At C7/T1, there is central disc protrusion which is not contacting the ventral\n cord.\n\n There is an endotracheal tube and an orogastric tube in place. Mucosal\n thickening of the paranasal sinuses are seen.\n\n IMPRESSION: 1-cm hemorrhagic lesion of the caudal medulla. Tiny hemorrhagic\n lesions of the upper cervical cord at the C2 and C3 levels, with extensive\n cord edema extending from the caudal medulla down to the C6 level.\n\n There are also multilevel degenerative changes and a large pannus posterior to\n C1, which are causing high-grade canal stenosis with cord compression.\n\n These combinations of findings most likely represent hemorrhagic infarct of\n the medulla and cord.\n\n (Over)\n\n 12:40 AM\n MR CERVICAL SPINE W/O CONTRAST Clip # \n Reason: please further evaluate dens/other c-spine/soft tissue patho\n Admitting Diagnosis: CARDIAC ARREST\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n\n" }, { "category": "Nursing/other", "chartdate": "2189-02-13 00:00:00.000", "description": "Report", "row_id": 1613859, "text": " YR. OLD WOMAN S/P PONS INFARCT & HEMORRAGE & SEVERE CANAL NARROWING\n& CORD IMPINGEMENT IN CERVICAL AREA--NOW WITH POOR NEURO PROGNOSIS.\n\nNEURO: OPEN EYES TO VOICE, BUT NOT CONSISTENTLY. DOES APPEAR TO ENGAGE\n& TRACK WITH EYES. FOLLOWS SIMPLE COMMANDS(OPENS MOUTH FOR TEMP/MOUTH CARE). DOES NOT MOVE ANY EXTREMITIES. NO GAG/COUGH PRESENT.\n\nRESP: ON VENT: 40%/TV 400/AC 16/PEEP 5. BS CLEAR BUT SL. DIMINISHED AT BASES. SX FOR SMALL AMTS THICK YELLOW SPUTUM. RR 16/16. O2 SAT 97-99%.\n~0500->SPONTANEOUSLY DROPPED SAT TO 90%. LAVAGED & SX WITH NO IMPROVE-\nMENT. ABG 7.30/46/61/24 91%. FIO2 INCREASED TO 50%/AC 18/PEEP 10. RE-\nPEAT ABG 7.36/41/84/24 96%. LACTIC ACID 0.6. HO AWARE.\n\nCARDIAC: HR 56-62 SB/SR, NO ECTOPY. BP 97-123/30-37.\n\nGI: NPO. OGT IN PLACE. TF: FS PROBALANCE INFUSING AT GOAL RATE 45CC/HR. MINIMAL RESIDUAL. ABD. SL. DISTENDED, BUT SOFT. NO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 15-50CC/HR.\n\nID: T 101.8->101.3(PO). GIVEN TYLENOL 650MG PO Q4HRS. CX'S PENDING. RECEIVING IV VANCO, FLAGGYL, & CIPRO. WBC 11.5.\n\nENDO: BS 218->177. INSULIN COVERAGE PER SLIDING SCALE.\n\nAM LABS: WBC 10.5, HCT 24.8(26.4), PLAT CT 285K, K 4.9, CA 9.1, PO4 3.5, MG 2.6, BUN/CREAT 65/1.3.\n\nPLAN: CONT. TO ASSESS NEURO STATUS CLOSELY.\n SUPPORT FAMILY WITH DECISIONS\n" }, { "category": "Nursing/other", "chartdate": "2189-02-13 00:00:00.000", "description": "Report", "row_id": 1613860, "text": "resp care - Pt remains intubated and on full vent support. No vent changes were made this shift. BS were mostly clear. A small amount of thick, yellow/tan secretions sere suctioned. A sample was sent to the lab. Continued resp care planned.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-13 00:00:00.000", "description": "Report", "row_id": 1613861, "text": "Nursing Progress Note\n\nO: Please see flow sheet for objective data. Tele sinus rhythm. BP stable.\n\nResp: Remains intubated A/C 50% 400 x18 10. Suctioned for sm amts of thick tan sputum. Culture sent. Lungs are clear. O2 sats > 96%.\n\nNeuro: Pt conts to open her eyes to verbal stimulation. tracking at times. Able to follow commands intermittently. Not moving her extremities. No gag or cough. No spontaneous respirations noted.\n\nGI/GU: Pt conts on TF of promote with fiber at GR of 45cc/hr via OGT. Abd is soft with bowel sounds present. No BM. Foley draining dark yellow urine.\n\nID: Conts to be febrile throughout the day inspite of tylenol. To cont on present antibiotics pending cultures.\n\nSocial: Grandaughters and sons in to visit. Rabi here to assist with decision to move toward keeping pt comfortable. No change in status at this time.\n\nA&P: Cont with present management of care. Family to discuss options together possible decision over the weekend. Cont to support pt and family as needed.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-14 00:00:00.000", "description": "Report", "row_id": 1613862, "text": "Respiratory Care:\nPt remains intubated and vented. No parameter changes made this shift. Suctioned large amts white secretions. No RSBI done d/t peep level.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-14 00:00:00.000", "description": "Report", "row_id": 1613863, "text": " YR OLD WOMAN S/P PONS INFARCT & HEMORRAHAGE & WITH SEVERE CANAL NARROWING & CORD IMINGEMENT IN CERVICAL AREA--NOW WITH POOR NEURO PROGNOSIS.\n\nNEURO: OPENS EYES SPONTANEOUSLY & SOME TIMES TO VOICE. TRACKS AT TIMES, BUT NOT CONSISTENTLY. FOLLWS SIMPLE COMMANDS AT TIMES(OPEN MOUTH), BUT NOT CONSISTENTLY. DOES NOT MOVE EXTREMITIES. NO GAG/COUGH\nREFLEX.\n\nRESP: ON VENT: 50%/TV 400/AC 18/PEEP 10. BS CLEAR BUT DIMINISHED AT BASES. SX FOR SCANT THICK TAN SECRETIONS. RR 18/18. O2 SAT 100%. ABG\n7.36/40/145/24 98%. FIO2 DECREASED TO 40%.\n\nCARDIAC: HR 53-60 SB/SR, NO ECTOPY. BP 113-128/33-44.\n\nGI: NPO. OGT IN PLACE FOR MEDS & TF: FS PROBALANCE INFUSING AT GOAL RATE 45CC/HR. MINIMAL-NO RESIDUALS. ABD. SL. DISTENDED BUT SOFR. BS +.\nNO STOOL.\n\nGU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 35-55CC/HR.\n\nID: T 101.5->101.2(PO). TYLENOL Q4HRS. BC X2 & URINE C&S SENT. CONT. TO RECEIVE IV VANCO, FLAGGYL, & CIPRO.\n\nENDO: BS 159->176. INSULIN COVERAGE PER SLIDING SCALE.\n\nAM LABS PENDING.\n\nPLAN: WAITING FOR FAMILY TO MAKE DECISION RE: WITHDRAWING/CMO STATUS.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-14 00:00:00.000", "description": "Report", "row_id": 1613864, "text": "Respiratory Care\nPt remains on a/c settings without changes this shift. Plan to continue support as orderd.\n" }, { "category": "Nursing/other", "chartdate": "2189-02-14 00:00:00.000", "description": "Report", "row_id": 1613865, "text": "CCU NPN 0700-1900\nS: Pt orally intubated and mechanically ventilated.\n\nO: Please see careview for VS and additional data.\n\nNeuro: Pt neuro status unchanged. Pt with pons infarct and hemmorhage, also with severe canal narrowing and cord impingement in cervical area. Pt continues to only open and close eyes on command. Pt does not track consistently with eyes. Pt does not move extremeties, does not withdraw extremeties to pain stimulus (except for RLE knee and foot bend upward slightly to deep nailbed stimulus). J collar intact, collar care done-skin intact.\n\nCV: Pt HR 54-69 SB/NSR, no ectopy noted, ABP 114-140/34-44. Bilat pedal pulses palp.\n\nResp: Pt cont on AC 40% 400 x18 10 peep. Pt not noted to be overbreathing vent, no gag/no cough. Pt sxn'd via ETT for small amounts thick yellow secretions, orally suctioned for small to moderate amounts of yellow-while colored secretions. Pt LS clear to diminished.\n\nGI/GU/ENDO: Pt abd soft distended, +BS x4, no TF residuals-TF cont at 45 cc's/hr. Colace/senna given-no stool, +flatus. Foley cath draining clear yellow u/o 20-110 cc's/hr. FS 114-150 ss and standing dose insulin given as ordered.\n\nID: T max 101.2, cont on ceftriaxone, flagyl dc'd, bld and urine cx's from last night pending.\n\nSocial: Pt son in this evening. Spoke with RN re. talking to MD's about withdrawing care tomorrow am. Son spoke with CCU resident.\n\nA/P: y/o female with poor neurological prognosis cont intubated and unable to move extremeties. Cont to monitor pt hemodynamics, resp and neuro status. Awaiting family decision. Awaiting further POC CCU MD's.\n\n\n" }, { "category": "ECG", "chartdate": "2189-02-05 00:00:00.000", "description": "Report", "row_id": 105661, "text": "Sinus bradycardia. Low limb lead voltage. Q-T interval prolonged for rate.\nClinical correlation is suggested. Since the previous tracing of \nthe rate is slower. The Q-T interval is longer. Limb lead voltage is less\nprominent.\nTRACING #1\n\n" }, { "category": "ECG", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 105658, "text": "Irregular sinus bradycardia. Prolonged Q-T interval. Non-specific T wave\nchanges. Low QRS voltage in the limb leads. Compared to the previous tracing\nof the rhythm is now irregular.\n\n" }, { "category": "ECG", "chartdate": "2189-02-06 00:00:00.000", "description": "Report", "row_id": 105659, "text": "Sinus bradycardia. Q-T interval prolongation. Since the previous tracing\nof the rate has decreased and the Q-T interval is longer. Clinical\ncorrelation is suggested.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2189-02-05 00:00:00.000", "description": "Report", "row_id": 105660, "text": "Sinus bradycardia. Borderline low voltage. Prolonged Q-T interval. Artifact\nin lead V6 precludes assessment of ST-T waves in that lead. Since the\nprevious tracing earlier the same date probably no significant change.\nTRACING #2\n\n" } ]

[ { "category": "Radiology", "chartdate": "2179-05-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 1233610, "text": " 10:40 AM\n CHEST (PA & LAT) Clip # \n Reason: INFILTRATE?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 54F with hypotension and feverClinical Question: infiltrate?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, TWO VIEWS, .\n\n HISTORY: 54-year-old female with hypotension and fever. Question infiltrate.\n\n FINDINGS: Frontal and lateral views of the chest are compared to previous\n exam from . Again seen is elevation of the right hemidiaphragm.\n The lungs remain clear of consolidation or effusion. The cardiac silhouette\n is within normal limits. Osseous and soft tissue structures are unchanged.\n\n IMPRESSION: No acute cardiopulmonary process.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-04 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 1233628, "text": " 1:09 PM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: line placement?\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 54F with s/p R IJ line\n REASON FOR THIS EXAMINATION:\n line placement?\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n PORTABLE CHEST: \n\n HISTORY: 54-year-old female status post right IJ line placement.\n\n FINDINGS: Single portable view of the chest is compared to previous exam from\n earlier the same day. There is a new right IJ central line with tip in the\n mid SVC. Again seen is elevation of the right hemidiaphragm, similar to\n prior. There is no visualized pneumothorax. Cardiac silhouette is stable.\n\n IMPRESSION: New right IJ line in appropriate position. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2179-05-04 00:00:00.000", "description": "CT ABD & PELVIS W/O CONTRAST", "row_id": 1233624, "text": " 12:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n MEDICAL CONDITION:\n History: 54F with h/o chrohns, abd pain, most tender to Left of umbilicus,\n fever, hypotension. has ostomy, s/p mult bowel surgeries. +PO/IVClinical\n Question: abscess, fistula, or other acute process?\n REASON FOR THIS EXAMINATION:\n {See Clinical Indication Field}\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: PRib TUE 4:50 PM\n Stranding around herniated bowel and bowel wall thickening of remaining\n intra-abdominal colon. Could be due to crohns flare or infectious process or\n intramural hemorrhage. No fluid collections. Possible extraluminal air in soft\n tissues adjacent to colostomy site.\n\n WET READ VERSION #1\n WET READ VERSION #2 PRib TUE 3:14 PM\n Stranding around herniated bowel and bowel wall thickening of remaining\n intra-abdominal colon. Could be due to crohns flare or infectious process. No\n fluid collections. Possible extraluminal air in soft tissues adjacent to\n colostomy site.\n\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 54-year-old woman with Crohn's and abdominal pain and tenderness\n in the left umbilicus, fever and hypotension, status post multiple bowel\n surgeries. Question of abscess, fistula or other acute problem. INR over 8\n from coumadin for a. fib.\n\n COMPARISON: CT abdomen and pelvis on .\n\n TECHNIQUE: MDCT images were obtained through the abdomen and pelvis following\n the administration of oral contrast only. IV contrast was not administered\n secondary to patients acutely elevated creatinine.\n\n FINDINGS: Bibasilar atelectasis in the dependent portions of the lungs. The\n visualized heart and pericardium are unremarkable. Previously seen right\n paravertebral cystic structure is incompletely visualized.\n\n Evaluation of the intra-abdominal organs is slightly limited due to lack of IV\n contrast. Within the limitation, the liver, spleen, pancreas, kidneys and\n adrenal glands are unremarkable. The gallbladder is slightly enlarged and the\n common bile duct is dilated, however, this is unchanged compared to . The bladder is decompressed.\n\n Patient is status post sigmoidectomy with colostomy placed in the left lower\n quadrant. The remaining colon has diffuse cicumerferential wall thickening,\n in some areas with some hyperdensty (601b image 64) involving the cecum\n located in the cul-de-sac. There is a parastomal hernia which contains\n decompressed segment of colon but demonstrates surrounding fat stranding.\n (Over)\n\n 12:37 PM\n CT ABD & PELVIS W/O CONTRAST Clip # \n Reason: {See Clinical Indication Field}\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n There is also a focus of air in the adjacent soft tissues seen best on series\n 2, image 71 that is not definitively intra or extraluminal.\n\n There are scattered aortic artery calcifications, splenic artery calcification\n and -iliac arterial calcifications. There are scattered prominent lymph\n nodes in the pelvis, for example a lymph node measures 1.2 cm, best seen on\n series 6, image 69. There are also multiple prominent mesenteric lymph nodes.\n There is no free fluid in the pelvis or ascites. There is no free air nor\n drainable collection.\n\n There are multilevel degenerative changes mainly in the thoracic spine with\n disc space narrowing. There are no suspicious osseous lytic or sclerotic\n lesions.\n\n IMPRESSION:\n 1. Diffuse colonic wall thickening of the remaining colon. Differential\n considerations include changes from patients known Crohn's disease, infectious\n or inflammatory causes, or even hemorrhage given elevated INR and possible\n high density of the wall in certain areas.\n 2. Parastomal hernia with a focus of air within the soft tissues which is not\n clearly intraluminal and may be may be extraluminal. Close clinical followup\n suggested and repeat can be performed if desired.\n\n" }, { "category": "ECG", "chartdate": "2179-05-04 00:00:00.000", "description": "Report", "row_id": 303216, "text": "Baseline artifact marring interpretation of rhythm but probable atrial\nfibrillation with a rapid ventricular response rate of 101 beats per minute.\nLeftward axis. Delayed R wave transition. Non-specific ST segment changes\nin the inferolateral leads. Compared to the previous tracing of sinus\nrhythm is no longer apprecited and the ventricular rate has increased.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2124-02-08 00:00:00.000", "description": "Report", "row_id": 1348248, "text": "s/p cabg x4\nS: \"I'M NOT NAUSEOUS ANY MORE\"\nO: CARDIAC: APACED @ 80 WITH UNDERLYING RYTHYM 50'S-62 SB-SR, ISOLATED PVC'S NOTED, K 3.5 RECIEVED 40 MEQ KCL X1 WITH REPEAT K 4.9. CONTINUES ON NEO @ .5 MCQ TO KEEP SBP >100. CI>2. PADS FALL TO LO TEENS RESPOND NICELY TO LR. CT DRAINAGE TOTAL 385ML. DSGS D+I. PP VIA DOPPLER. EXTREMITIES WARM. HCT 32. HO'S AWARE.\n RESP: EXTUBATED @ 1715 WITHOUT INCIDENT, NP @ 3L WITH O2 SATS >97%, REPEAT ABG TO BE DRAWN, BS DIMINISHED BIBASILAR, CLEAR UPPER,FAIR COUGH NOT RAISING,IS WELL. NO CT LEAK.\n NEURO: SEDATE HOWEVER EASILY AROUSABLE, PERL, GRASPS STRONG AND EQUAL, MAE, ORIENTED X3, FOLLOWING COMMANDS, PLEASANT AND CALM.\n GI: CARAFATE X1, C/O NAUSEA AND RECIEVED REGLAN 10 MG X1- NO FURTHER COMPLAINTS.\n GU: GOOD UO UNTIL 1900 RECIEVED TOTAL 2 L LR WITH GOOD RESPONSE TO FLUID.\n ENDO: ARRIVED FROM OR ON INSULIN GTT, GLUCOSE 58 ON 3 UNITS-TURNED OFF+ RECIEVED AMP DEXTROSE REPEAT GLUCOSE 140'S THEREFORE INSULIN RESTARTED @ 1 UNIT, PRESENTLY @ 3 UNITS.\n PAIN: TORADOL AND 2 MG MSO4 X2 WITH GOOD EFFECT\n ID: VANCO 1 GM @ \n SOCIAL: SPOKE TO SISTER AND FRIEND OVER THE PHONE\nA: STABLE POST CABG\nP: MONITOR COMFORT, HR AND RYTHYM, SBP-WEAN NEO AS TOLERATED, CT DRAINAGE, DSGS, PP, RESP STATUS-PULM TOILET, NEURO STATUS,I+O-UO TO RECIEVE HESPAN IF NEEDED VOLUME NEXT, LABS-CONTINUE GLUCOSE CHECKS Q1HR. AS PER ORDERS.\n" }, { "category": "Nursing/other", "chartdate": "2124-02-09 00:00:00.000", "description": "Report", "row_id": 1348249, "text": "NEURO: SLEEPY BUT EASILY AROUSABLE. A&OX3, FOLLOWS COMMANDS. MAE\nCV: INITIALLY APACED. NSR 80'S. OCC PVC/PAC. LYTES REPLETED. NEO OFF. SBP 106-125. BP HIGHER W/ ACTIVTY OR VOMITING UP TO 190'S. ON ADEMAND 70. 2A 2V WIRES. PT RECEIVED ADDITIONAL 1L LR AND HESPAN 500 FOR TOTAL 4L LR AND HESPAN X1 SINCE OR. IVF GIVEN FOR LOW FILLING PRESSURES AND LOW U/O. DISTAL PULSES PALP. CT-SX NO LEAK MARG OUTPUT SANG DRNG. HCT THIS 25.7\nRESP: INITIALLY INCREASED NC TO 4L FOR PO2 74. REPEAT GAS PO2 157. CURRENTLY ON 2L NC W/SATS >97%. LUNGS DIM AT BASES. NON PROD COUGH. USING W/ ENCOURAGEMENT.\nGI: VOMITED X2 MOD AMT GREEN BILIOUS EMESIS. PT GIVEN REGLAN AND ZOFRAN W/ GOOD RESPONSE. NO BS. ABD SOFT.\nGU: U/O DECREASING THROUGHOUT SHIFT DESPITE FLUID BOLUSES. DR. AWARE. CREAT .6. FOLEY CHANGED. URINE YELLOW-LT AMBER CLEAR.\nENDO: ON AND OFF INSULIN GTT. BS LABILE.\nPAIN: PT C/O PAIN STERNAL INCISION W/ TURNING AND COUGHING. MSO4 2MG GIVEN X2 W/ SLIGHT RELIEF. PT AFRAID TO TAKE BECAUSE AFRAID MAKE NAUSEOUS.\nPLAN: CONT ASSESS U/O Q 1HR. ? TX VS. LASIX. ASSESS BS Q1HR TITRATE GTT PER PROTOCOL. CONT ASSESS HEMODYNAMICS AND RESP STATUS. ? DELINE , OOB ASN TX 2 THIS AM.\n" }, { "category": "ECG", "chartdate": "2124-02-08 00:00:00.000", "description": "Report", "row_id": 148668, "text": "Sinus rhythm. Diffuse low voltage, diminished compared to the previous tracing\nof . Prior anteroseptal and lateral myocardial infarction with less\nprominent T wave inversion in the anterolateral leads. Clinical correlation of\nthe diminished voltage is suggested.\n\n" }, { "category": "ECG", "chartdate": "2124-02-07 00:00:00.000", "description": "Report", "row_id": 148669, "text": "Sinus rhythm\nLong QTc interval\nAnterior infarct - age undetermined - may be acute/recent - clinical\ncorrelation is suggested\nSince previous tracing of : less suggestive of prior inferior myocardial\ninfarction\n\n" }, { "category": "ECG", "chartdate": "2124-02-05 00:00:00.000", "description": "Report", "row_id": 148670, "text": "Sinus rhythm. Left atrial enlargement. Prior inferior myocardial infarction.\nFurther evolution of recent or ongoing anteroseptal and lateral myocardial\ninfarction. Clinical correlation is suggested.\n\n" }, { "category": "ECG", "chartdate": "2124-02-04 00:00:00.000", "description": "Report", "row_id": 148671, "text": "Sinus rhythm. Prior anteroseptal myocardial infarction. T wave inversions in\nleads I, aVL and V4-V6. Question active lateral ischemia. There are\nQS delfections in leads III and aVF for prior inferior myocardial infarction as\nwell. No previous tracing available for comparison. Clinical correlation is\nsuggested.\n\n" } ]

[ { "category": "Nursing/other", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 1314070, "text": "Respiratory Care Note\nPt remains intubated and on the ventilator. Pt remains on A/C, unsuccessful attempts at PSV made. Pt has not required much suctioning. No other vent changes made. ETT withdrawn 2cm, good breath sounds bilaterally. Plan: continue full ventilatory support. See careview for vent settings and additional info.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 1314125, "text": "MICU B Nursing Progress Note (0700-1900)\n\nCNS: Pt. complaining of being \"anxious\" off and on all day. She has received her standing dose of ativan .5mg qid and haldol 2.5mg x 2 with good, but transient, effect. She is alert and cooperative. Concerned about some insurance issues and seems a bit discouraged and depressed relating to her illness and prolonged hospital course. Encouragement and emotional support given. Mother and S.O. both in to visit.\n\nPAIN: Pt. complaining of generalized body aches, esp. shoulders bilaterally. Pain service involved and they have suggested dc'ing MSO4 gtt, applying 25mcg fentanyl patch 72hr and starting PCA MSO4...1mg dosing...no basal rate...6min lockout...max dose of 10mg/hr. This was started at 1500.\n\nREHAB: Pt. OOB early and c/o being fatigued this AM, requesting to get back in bed. She has refused getting OOB to chair again, despite encouragement to do so.\n\nRESP: Lungs with coarse BS throughout. Suctioned frequently by RT for thick, blood tinged to white secretions. She has done well today on CPAP/PSV 5/5, 40% with RR 10-20, TV 400-500. Hopefully, will go for speech and swallow study tomorrow, ?start using passey-muir valve.\n\nHIT+: Agatroban held x 1hr for PTT of 91...restarted at 3mcg/kg/min (decreased by .25mcg/kg/min per protocol).\n\nGI: Tolerating tube feeds of promote with fiber at 30cc/hr. Abdomen soft and distended. Last BM (small), despite senna, lactulose, colace. Pt given dulcolax supp at 1600.\n\nSKIN: Intact. Sutures removed from left lateral CT site, although unable to remove 2 of them, will contact HO.\n\nID: Afebrile, off all antibiotics.\n\nSOCIAL: Pt. states she does have health insurance through her job at NWH. Per pt. and mother, they have retained an attorney due to issues surrounding her employment and prolonged absence from work due to serious illness.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 1314126, "text": "Addendum: Pt. very uncomfortable due to constipation. Received fleets enema without results. Attempt made at disimpaction...unsuccessful as stool is soft. Pt refusing SSE at this time.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 1314071, "text": "nursing note: 7a-7p\nneuro-propofol weaned to off and pt displayed significant weakness in all extremities. able to follow very simple commands but very weak. perla. pt communicating with eye movements and occasionally able to nod. pt indicating pain at hip at times, medicated with 1mg iv morphine x2 with slight releif. neurology consulted and is being considered. plasma pheresis planned for this evening.\n\nresp- remains intubated on ac mode 400x20 40% +5. attempts at weaning to pressure support unsuccessful due to poor efforts. suctioned for scant clear sputum. ett rotated and pulled back to 20cm at lip per am xray.\n\ncv- hr 80's sr no ectopy noted. bp stable 130-140's. ck and enzymes being followed. ekg and echo done at bedside today, prelim 3+ MR. IVF d51/2 ns at 75cc/h maintained\n\ngi- abd soft + bs no stool. ogt in place for meds.\n\ngu- foley patent for adequate u/o cloudy sedimentous yellow.\n\naccess- 2 #20g piv's in place. #16g piv placed today for possible pheresis but unable to place second large bore piv so presently a quinton catheter is being attempted to enable plasma pheresis tonight.\n\nsocial- mother is spokesperson, all calls are being refferred to her. fiance and father have called. fiance visited briefly, was updated by team.\n\ndispo- full code. continue to support.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314072, "text": "Resp Care\nPt remains on vent and intubated with # 8.0 ett @ 22, patent and secure. Ett had to be advanced according to x-ray, found @ 19 cm and placed to 22. Suctioned mod amt of thick yellow secretions. pt had desat spell to the mid 70s and required increase of O2 and pt repositon. Pt required higher fio2. Xrays and ctscan taken to R/o pnemos, came out negative. Overexpansion noted in xrays and vts decreased with rr increased to match Ve. Pt and sating in the 100s. Will continue to monitor.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314073, "text": "MICU NPN 7P-7A\nNEURO: RECEIVED PATIENT ON 75MCG PROPOFOL. BARELY RESPONSIVE. HAD RECEIVED 100MCG FENTANYL FOR LINE PLACEMENT @~1800. PERL @2MM AND BRISK. NOT MOVING. LATER IN SHIFT PATIENT AWAKE AT TIMES AND/OR AROUSABLE TO VOICE ON SAME 75MCG PROPOFOL. FOLLOWING COMMANDS. NOTED ONLY TO BE MOVING RIGHT SIDE. WILL SQUEEZE LEFT HAND. PERL @3MM AND BRISK. PATIENT WITH OVERALL WEAKNESS. WHEN ASKED OF SHE IS IN PAIN SHE WILL BLINK TWICE FOR YES. GIVEN 1MG MORPHINE IV WITH MOD EFFECT. RESTRAINTS LEFT OFF AS PATIENT BARELY ABLE TO PICK UP ARMS. PLASMA PHERESIS FOR OVER AN HOUR FOR POSSIBLE - AND TOLERATED WELL. **SHUT OFF PPF THIS MORNING AND PATIENT AWAKE IN A MATTER OF MINUTES. ABLE TO MOVE ALL EXTREMITIES TO COMMAND, MD AWARE AND PPF RESTARTED AS PATIENT UNCOMFORTABLE AND GAGGING ON ETT.** EMG TODAY.\n\nCARDIAC: HR 88-134 SR/ST WITH NO ECTOPY. HR HAD TRENDED UP TO 120 ON PHERESIS, ALSO HAD LOW GRADE TEMP. BLOOD RETURNED TO PATIENT WENT THROUGH A WARMER. THAT WAS TURNED OFF AND HR CAME BACK DOWN TO 100. HR INTO THE 130'S AFTER DESATURATION EPISODE. BP STABLE 114-145/63-94. EKG SHOWED ST AND WAS UNCHANGED FROM PREVIOUS EKG'S. AFTER PE WAS R/O PATIENT WAS GIVEN A 250CC FLUID BOLUS THIS MORNING FOR POSSIBLE DEHYDRATION ATTRIBUTING TO HER TACHYCARDIA. GENTLE REHYDRATION INLIGHT OF HER EF OF 50% AND SEVERE MR. HCT STABLE @42. PPP.\n\nRESP: RECEIVED ON A/C 400X20 40% +5PEEP. NOT OVERBREATHING VENT. SATS UPPER 90'S. ETT ADVANCED PER CXR. @0100 NOTED TO SPONTANEOUSLY DESAT TO 75% AND HR WENT FROM 100'S TO 130'S. RT NOTIFIED AND PATIENT NOTED TO HAVE AN AIR LEAK. SXTED FOR LITTLE. INCREASED FIO2 TO 100% AND ABG DRAWN. 7.33/55/132/30. SLOW RECOVERY BACK TO BASELINE SATS. ALSO NOTED TO BE DECREASED BS SOUNDS ON THE LEFT AND CHEST EXPANSION APPEARED TO BE ASYMMETRICAL WITH LITTLE MOVEMENT NOTED TO THE LEFT. CXR DONE WHICH SHOWED NO PNEUMOTHORAX. LATER SENT FOR CTA WHICH DID NOT SHOW A PE. FIO2 DECREASED TO 70% WITH ABG 7.35/52/87/30. LAST CXR SHOWED HYPERINFALTION OF THE LUNGS AND FLATTENED DIAPHRAGM. DECREASED TV TO 350 AND INCREASED RR TO 24. RT WILL GET AN ABG ON THIS, THIS AM. RSBI 183. LS COARSE AND DIMINISHED TO COARSE AND RHONCHEROUS. SXTED FOR THICK YELLOW SPUTUM.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. OGT IN PLACE. BILIOUS ASPIRATES. UOP 25-350CC/HR YELLOW AND CLEAR.\n\nFEN: CONTINUES ON D5.45NS @75CC/HR. EUVOLEMIC ON PAPER BUT ACTUALLY MIGHT BE DEHYDRATED LEADING TO TACHYCARDIA. GIVEN 250CC FB THIS MORNING WITH LITTLE CHANGE IN HR. LYTES PER CAREVUE. CURRENTLY NPO. INFORMED TEAM THEY NEED TO THINK ABOUT NUTRITION.\n\nID: LOW GRADE TEMPS 100.1. WBC AT 24. SEVERAL CX'S PENDING. NO ABX AS OF YET.\n\nSKIN: SEVERAL CHEST TUBES SCAR TO LEFT CHEST.\n\nACCESS: PIV X3, LSC QUENTIN.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. PLAN FOR CONTINUED PHERESIS X4 SESSIONS...DAILY WAKE UPS...F/U ON CX'S...NUTRITION... NEED MORE FLUID FOR TACHYCARDIA...F/U ABG DRAWN AT 0645 WEAN AS VENT TOLERATED...NEEDS BOWEL MEDS...\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314074, "text": "MICU B Nursing Progress Note (0700-1100)\n\nPlease see carevue for all objective data. Profofol dc'ed at 0845 per neuro request so that she could be evaluated more accurately. Pt. is able to nod appropriately, follows some requests and moves all four extremities, although weakly. EMG currently being done at the bedside.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-12 00:00:00.000", "description": "Report", "row_id": 1314080, "text": "MICU NPN 7P-7A\nNEURO: REMAINS ON 75MCG PROPOFOL. ALERT AT TIMES OR EASILY AROUSABLE. FOLLOWING COMMANDS. COMMUNICATING WITH ALPHABET BOARD. MOVING ALL EXTREMITIES. HAS SENASTION IN ALL EXTREMITIES. GAG/COUGH IMPAIRED. NO SIEZURE ACTIVITY. PERL @3MM AND BRISK. C/O NECK AND BACK DISCOMFORT WHICH WAS RELIEVED BY REPOSITIONING AND BACK RUB. + BY EMG.\n\nCARDIAC: HR 98-118 SR/ST WITH NO ECTOPY. PATIENT FEBRILE AND MOST LIKELY DEHYDRATED. GIVEN FLUID BOLUS WITH HR GOING FROM 110'S TO 100 BUT HR HAS SINCE RETURNED TO 110'S. BP 130-149/78-95. PPP. AM HC T PENDING.\n\nRESP: REMAINS ON A/C 350X24 50% +5. TEAM HAS BEEN REMINDED THAT SHE HAS NOT HAD AN ABG ON THIS FIO2. NO ART LINE. RR 26-32, DENIES SOB WHEN ASKED. SATS 95-100%. DID DESAT TO 92%, SXTED AND EVENTUALLY RETUNED TO BASELINE. ON OCCASION HAS DIPPED SATS TO LOWER 90'S AND THEN RETURNED. LS CLEAR TO COARSE/DIMINISHED BASES. SXTED FOR CREAMY, YELLOW, FOUL SMELLING, THICK SPUTUM. ALSO WITH FOUL SMELLING ORAL SECRETIONS. CXR YESTERDAY ?PNEUMONIA/ASPIRATION. RSBI 79.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. ON BOWEL MEDS. OGT IN PLACE. UOP 20-185CC/HR YELLOW AND CLEAR. UOP PICKED UP AFTER FLUID BOLUS.\n\nFEN: NS INFUSING @150CC/HR, ALSO RECEIVED 1L FB FOR TACHYCARDIA AND LOW UOP. +3.3L SINCE ADMIT. NA NOTED TO BE 147 WITH CHLORIDE OF 111. STOPPED NS INFUSION. MD AWARE. K+ 2.9, NO CENTRAL ACCESS. MD AWARE AND PATIENT TO RECEIVE IV/PO KCL. OTHER LYTES PER CAREVUE. TOLERATING TUBE FEEDS, NOW AT 30CC/HR WITH MINIMAL RESIDUALS. GOAL 80CC/HR.\n\nID: FEBRILE WITH TMAX 101. RECEIVED 650MG TYLENOL X2. WBC PENDING. ANY CX'S PENDING. SPUTUM GRAM STAIN WITH GNR. ON VANCO, LEVO, FLAGYL.\n\nSKIN: SEVERAL SCABBED AREAS TO LEFT CHEST FROM CHEST TUBE SITES.\n\nACCESS: PIV X2, LSC QUENTIN. **NEEDS ART LINE**.\n\nSOCIAL/DISPO: FULL CODE. FATHER/STEPMOM VISITED. UPDATED. PLAN ID FOR PLASMA PHERESIS AGAIN TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-12 00:00:00.000", "description": "Report", "row_id": 1314081, "text": "nursing note: 7a-7p\nneuro- received sedated on propofol gtt. shut off for exam and pt responded appropriately. following commands mae. communicating with alphabet board and nodding. able to lift all extremities off bed. cough improved. 2nd plasma pheresis session done today for -.\n\nresp- remains intubated on ac mode. no vent changes today. pt with likely asp pna from intubation. temp spike yesterday and consistently low grade temp today with copious thick creamy yellow sputum needing lavage. cpt done q4h\n\ncv- hr sr-st 90-110's no ectopy noted. bp stable 120-140's. k repleted with total of 120meq po, level to be rechecked at 1800. mag repleted. free water boluses started 250cc q6h for na 147\n\ngi- abd soft + bs + flatus, no stool. ogt in place for tf promote with fiber now at 50cc/h with goal of 80cc/h.\n\ngu- foley patent for adequate u/o clear yellow. ivf d51/2ns at 100cc/h.\n\naccess- 2 new piv's placed today, previous iv's infiltrated. quinton catheter in place, pheresis rn's changed dsg, site wnl.\n\nsocial- fiance visited, mom called for update.\n\ndispo- full code, remains in icu for more pheresis sessions, one qod.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-29 00:00:00.000", "description": "Report", "row_id": 1314143, "text": "NURSING PROGRESS NOTES 1900-0700\n\nREVIEW OF SYSTEMS:\n\nNEURO: ALERT AND ORIENTED X 3, MAE HG AND PEDAL PUSHES =. PERL 3MM\nAFEBRILE. PT HAS SLIGHT FOOT DROP. MULTIPODUS BOOTS ORDERED. PT IS VERY WONDERING \"WHY ME?\" EMOTIONAL SUPPORT GIVEN. SS CONSULT ORDERED. SHE HAS SEEN A PSYCHIATRIST WHO SHE SAYS DOES NOT HELP HER \"ALL HE CARES ABOUT IS HOW ARE MY MEDS WORKING\" SHE IS ALSO WILLING TO TRY A SUPPORT GROUP WHEN SHE LEAVES THE HOSPITAL.\n\nRESP: #8 TRACH W/ INNER CANNULA AT NIGHT, PASSE-MUIR VALVE DURING DAY. RESP THERAPY SUCTIONED DRK BLD SECRETIONS W/ CLOTS BEFORE PUTTING INNER CANNULA IN THIS EVENING. LS CLEAR W/ DIMINISHED BASE ON RIGHT AND DIMINISHED BS ON LEFT SIDE. TRACH MASK AT 70% 12LITERS O2. PT ABLE TO COUGH UP SOME SECRETIONS INTO MOUTH AND SHE SUCTIONS THEM W/ YANKEUR. PCXR DONE THIS AM. CT AND PLERODESIS ON HOLD FOR THIS AM D/T INR 9/11-2.7 (THIS AM INR PENDING) TEAM IS WAITING FOR INR TO GO DOWN GRADUALLY- GOAL 1.8, AS APPOSED TO USING PRODUCTS TO DECREASE INR D/T IT IS SHORT ACTING AND SHE WOULD BE AT RISK FOR BLEEDING, PT AWARE.\n\nCV: TELE SR 70-90 HRT SOUNDS S1S2 BP WNL. PEDAL PULSES +4. ACCESS- LEFT PERIPHERAL SL LEFT #20 AND PICC LINE W/ BLUE PORT CLOTTED OFF.\n\nGI: PT HAS PEDI TUBE IN RIGHT NARE W/ PROMOTE W/ FIBER AT GOAL 50CC/HR. ABD SOFT BS+. PT IS ON COLACE NO BM FOR 2 DAYS SHE STATES SOMETIMES SHE IS INC OF STOOL.\n\nGU: FOLEY CATH DRAINING YELLOW URINE\n\nCOMFORT: PT HAS LEFT SHOULDER AND LEFT CHEST PAIN \"PINCHING\" USUALLY # ON PAIN NUMBER SCALE. SHE HAS MS 2-4MG IV Q 4HRS. SHE DOES NOT LIKE THE FEELING OF GETTING MS . MS 4MG IS NOW PLACED IN 50CC OF NS GIVEN OVER 15MIN W/ 50CC FLUSH AFTER, IT WORKS VERY WELL FOR HER.\n\nSOCIAL: PT HAS 3 CHILDREN, FIANCE AND A VERY SUPPORTIVE MOTHER.\n\nCODE: FULL\n\nPLAN:\n1. AM LABS PENDING.\n2. IF INR 1. GO FOR SURGERY IF NOT CONT TO HOLD UNLESS SHE BECOMES UNSTABLE.\n3. SOCIAL SERVICE CONSULTED FOR EMOTIONAL SUPPORT. NEED ANTIDEPRESSANT.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 1314127, "text": "Patient remains on mechanical ventilation,suctioned for copious amount of thick rusty secretion.(L) shoulder pain,BS clear sound on (R),congested (L).Now on OPSV can rest on A/C over night,but rate should be decreased since patient does OK with low rate on PSV 5/5.No recent ABG drawn.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-27 00:00:00.000", "description": "Report", "row_id": 1314139, "text": "Nursing progress note (0700-1500)\n\nPt. waiting for CT placement for L pneumothorax requiring FFP to bring INR to 1.8 prior to procedure. PT. previous dx of Guillaume- requiring intubation and subsequent trach placement.\n\nNeuro:Pt. is alert,OX3 tends to be anxious but becomes calm when allowed to verbalize her concerns and is otherwise cooperative and pleasant. Mother has a calming influence and pt. has requested mother's presence while having CT placed today.Pt. c/o pain to L chest described as aching or sharp. 2mg Morphine given X2 today with relief of pain from . Pt. asks for Ativan and has routine doses ordered.Pt. MAE with no resp muscle compromise.\n\nCV:HR 92-101 sinus rhythm and sinus tach without ectopy.NBP 116-125/64-74. Pt. has 20g in L AC patent,and PICC to R AC with blue port clotted and other port patent,both WNL.Pt. received 4units FFP in am in prep for CT placement and desired INR of 1.8.Procedure delayed till pm, 4 more units FFPs ordered.Pt. also recieved 500cc NS bolus for UO<20/hr.\n\nResp:LS diminised on L, clear on R. RR 11-23, 02 sats 95%. Pt. does not c/o SOB or dyspnea but states that lying on L side is uncomfortable. CT to be placed in pm.Pt. has trach with Passe-Muir valve, able to mobilize and cough own secrtetions except for occasional need for suctioning.\n\nGI/GU: Pt. has BSX4, abdomen soft,non-tender.Pt. refused stool softeners because she went multiple times yesterday.Pt. NPO for procedure, nutrition changed orders for TF when restarted.NG tube in place, flushes well.Urine became bloody during am but cleared spontaneously, team aware. Bolused X1 500cc NS for UO <20/hr.\n\nSkin:Intact\n\nSocial: Mother in to see pt. and returned prior to procedure per pt. request. Fiance and son also in to see pt.\n\nPlan:Monitor resp status,coags, pain management.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-27 00:00:00.000", "description": "Report", "row_id": 1314140, "text": "ADDENDUM....RESP STATUS AND PREVIOUS CT SCAN REVIWED BY DR. / LIASED WITH THORACIC TEAM AND IN VIEW OF PATIENTS OVER ALL STABILITY NOT TO INSERT CHEST DRAIN AT THIS POINT AND TO AWAIT SURGERY ON LEFT LUNG SCHEDULED FOR MONDAY......\nHAS RECEIVED FURTHER X2 UNITS OF PLASMA THIS PM FOR PREVIOUS PENDING CHEST TUBE INSERTION, AWAITING REPEAT PTT/INR AS WILL BE PLACED BACK ON COUMADIN/ACTROBAN THIS FOR PREVIUOS PE IN RT LUNG.....\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314075, "text": "MICU B Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Positive diagnosis of Guillian- made by EMG.\n\nNEURO: Propofol dc'ed for thorough neuro exam and during EMG. Pt. nods appropriately, follows simple commands and is actually able to communicate via writing. She can move all extremities, although very weakly. Sensation to pinprick impaired UE and LE bilaterally. Propofol restarted at 75mcg/kg/min for pt comfort after EMG was completed. Pt. well sedated, easily aroused by verbal stim, yet comfortable. PEARL.\n\nGI: Abdomen soft and non tender with active bowel sounds throughout. Tube feeds of promote with fiber started at 10cc/hr, to be advanced q6hr. Colace and senna also given...has not yet stooled.\n\nID: Temp spike to 101.4 rectally. Urine, sputum and blood cultures x 2 sent. CXR ordered and tylenol 650mg given.\n\nRESP: Sats of 98% on A/C 60% (down from 70%) 350 x 24 with 5 of PEEP.\nLungs with very coarse breath sounds throughout...more diminished on the left. Suctioned q3hr for moderate amounts of thick, yellow-green, foul smelling secretions with NS lavage. (?new pneumonia fever source). Oral secretions are also purulent and foul smelling. Mouth care done q4hr.\n\nF and E: IVF dc'ed and urine output has decreased significantly over the past few hours. In light of this and temp, pt. is currently receiving 600cc NS fluid bolus and then maintenance fluid at 125cc/hr.\n\nSKIN: Intact.\n\nSOCIAL: Mother and step father in and were able to communicate with patient...updated by neuro team...very tearful at the bedside. Boyfriend also in to visit and was updated by nursing...also quite tearful.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314076, "text": "Addendum: Vanco, flagyl and levaquin also started.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314077, "text": "Addendum: Hemodynamically stable except for some tachycardia most likely r/t fever and dehydration. Pt. received bolus of 500cc NS and started on a gtt at 150cc/hr. UOP increased to 200cc over 2hr period.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 1314078, "text": "Respiratory Care Note:\nPt remains intubated and on the ventilator. Pt remains on AC, no vent changes made this shift. Fio2 weaned down to 50%. Suctioned for moderate amounts of thick yellow secretions. Plan: continue full ventilatory support. See careview for vent settings and additional info.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-12 00:00:00.000", "description": "Report", "row_id": 1314079, "text": "Resp Care\nPt remains on vent and intubated with # 8 @ 23 lip, patent and secure. Bs clear to course bilat. Suctioned mod amt of thick yellow secretions. Sating in the high 90s. No changes made. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-28 00:00:00.000", "description": "Report", "row_id": 1314141, "text": "NURSING PROGRESS NOTES 1900-0700\nEVENTS: HCT THIS AM 21.3 1 UNIT OF PRBC UP AT 0500 NO EVIDENCE OF ACUTE BLEEDING NOTED.\n\nNEURO:\n PT A&O X 3 MAE PERL 3MM BRISK. PT C/O FEELING PINS AND NEEDLES ON HER LEGS AND FEET. HAND GRASPS AND PEDAL PUSHES EQUAL. AFEBRILE. PT HAS BEEN VERY UPSET AND DEPRESSED ABOUT WHAT IS GOING ON W/ HER DURING THIS ADMISSION STATING \"WHY ME?\" EMOTIONAL SUPPORT GIVEN.\n\nRESP: PT ON 70% TRACH MASK SATS 100% SUCTIONED LAST EVENING FOR DARK OLD BLDY SECRETIONS. LS COARSE UPPER RIGHT LOBE DIMINISHED RIGHT BASE. DIMINISHED TO ABSENT BS HEARD LEFT LUNG. PCXR ORDERED FOR THIS AM.\n\nCV: TELE SR 90S BP WNL. HRT SOUNDS S1S2, PEDAL PULSES +4 NO EDEMA NOTED. PT/INR LAST EVENING 18.6/2.4 THIS AM 20.3/2.9. ARBACTRABAN ON HOLD FOR NOW. PICC LINE AND SALINE LOCK INTACT.\n\nGI: PT HAS TUBE FEEDING VIA PEDITUBE PROMOTE W/ FIBER AT 20CC/HR. BS + ABD SOFT. NO STOOL THIS SHIFT.\n\nGU: FOLEY DRAINING YELLOW URINE 30-60CC/HR.\n\nSKIN: INTACT\n\nCOMFORT: PT RECEIVES TYLENOL QID, NEURONTIN TID, AND MS 2-4MG Q 3HRS PRN FOR PAIN. SHE HAS RECEIVED MS 4MG ( IN 2MG DOSES X 2) AT FOR LEFT CHEST PAIN AND LEFT SHOULDER PAIN W/ GOOD RELIEF. AND AT 0340 2MG IV MORPHINE. FOR PAIN SCALE OF 7. PT ALSO ON ATIVAN .5MG PO QID FOR ANXIETY.\n\nCODE: FULL\n\nSOCIAL: FIANCE, MOTHER AND 3 CHILDREN. SHE CALLED ALL OF THEM LAST EVENING. SHE IS WORRIED ABOUT THEM AND FEELS LIKE SHE IS A BURDEN.\n\nPLAN:\n1. RECHECK HCT AFTER UNIT OF BLOOD.\n2. CONT TO GIVE EMOTIONAL SUPPORT, SHE NEED A ANTIDEPRESSANT, SOCIAL WORKER, AND -SHE HAS STATED THAT THE PSYCHIATRIST SHE HAS TALKED W/, HAS NOT HELPED HER AT ALL.\n3. F/U W/ AM LABS.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-28 00:00:00.000", "description": "Report", "row_id": 1314142, "text": "Nursing progress note:\n\nNeuro:Pt. alert,0X3,MAE. Pt. has had pain to L chest described as \"pinching\" and felt that pain wasn't under control. Pt. hesitant to take Morphine IV due to unpleasant sensation during administration so giving via IV gtt attempted with good tolerance and efffect. 4mg MOrphine in 50cc run in over 15 min worked well and lasted almost 3 hrs. Pt's mood has been good today.\n\nCV: HR 89-99,BP 120s/70s. Pt's Hct up to 27 after transfusion with 1 unit PRBCs this am. Last pt 19.4, INR 2.7. Pt. was to have pleurectomy tomorrow but poss. delay due to wanting INR to drop without administraion of blood products. Pt's type and screen good through tomorrow at midnight.\n\nResp: RR 17-29, R side clear,L side diminished, 02 sats >95%. Pt. has no c/o resp distress and required no suctioning.\n\nGI/GU: Pt. on Pro-fiber via peditube, rate increased by 20cc/hr during day, well tolerated.BSX4, no c/o nausea with increased rate. Urine output has been good for shift with no hematuria today.\n\nSkin: Intact\n\nSocial: Pt had visits from father,mother, sisters and daughter, animated and engaged in conversation during visits. Team aware of need for emotional support and poss depression.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-21 00:00:00.000", "description": "Report", "row_id": 1314122, "text": "Respiratory Therapy\n\nPt remains trached w/ #8.0 Portex trach tube on PSV. Currently +12PSV/+10PEEP w/ Vt ~530 RR ~12 maintaining Ve ~7L-9L. Pt very anxious at times and needs positive reassurance that she is doing well breathing on her own. SpO2 remained 90s, MDIs given as ordered. Just switched to A/C for dobhoff placement by MD. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: maintain support; wean back to PSV when sedation wears off; continue to reassure/encourage pt...\n" }, { "category": "Nursing/other", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 1314123, "text": "Resp: Pt trached #8 portex rec'd on a/c 20/400/10+/40%, Bs are clear bilaterally. Suctioned for small amount of tan secretions. MDI's administered Q4 combivent, no adverse reactions. Vent changes to decrease peep to 8, then 5 with 02 sats @ 98% and tolerating well. RSBI=61. Plan to wean to psv this am.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-22 00:00:00.000", "description": "Report", "row_id": 1314124, "text": "nursing note: 7p-7a\nneuro- pt alert and oriented x3. communicating by mouthing and writing. mae in bed, upper extremities stronger than lower. remains on morphine gtt currently at 4mg/h. states pain at rest is 2, with coughing and repositioning rates it a 7. c/o chest wall pain and r shoulder pain. ativan changed back to po doses now that ngt in place. pt with no c/o anxiety this shift. pt able to sleep in long naps.\n\nresp- trach in place, remains on vent on ac mode. peep decreased from 10 to 8 then to 5 without difficulty. sats 97-100%. suctioned for thick tan blood tinged sputum. ls clear.\n\ncv- hr 90-110's sr no ectopy noted. sbp 95-110's. remains on argatroban at 3.25mcg/kg/min. ptt 66 overnight.\n\ngi- abd soft flat + bs no stool. pedi-dobhoff ngt in place at 80cm at r nare. dr confirmed placement with cxr. resumed tf promote with fiber and resumed po meds, including bowel regimen. unable to check residuals but pt appears to be tolerating tf, no abd discomfort, no nausea, rate currently at 30cc/h.\n\ngu- foley patent for 25-30cc/h of amber urine.\n\naccess- double lumen picc in r arm,and #20g piv in left ac.\n\nid- afebrile overnight. no longer on abx treatment.\n\nsocial- fiance in to visit last evening.\n\ndispo- remains in icu, full code, continue to wean vent as tolerated. continue to monitor pain and anxiety, wean meds as tolerated. increase activity as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 1314068, "text": "MICU NPN 7P-7A\nPATIENT ARRIVED FROM THE FLOOR INTUBATED AND SLIGHTLY AGITATED @2200.\n\nNEURO: STARTED ON PROPOFOL @20MCG/HR. BOLUSED SEVERAL TIMES FOR CT SCAN AND LP. EASILY AROUSABLE AND OPENING EYES. WHEN AWAKE TRIES TO COMMUNICATE BY MOUTHING WORDS. PERL @2MM AND SLUGGISH INITIALLY. NOW 3MM AND BRISK. FOLLOWING COMMANDS CONSISTENTLY. MOVING ALL EXTREMITIES BUT WEAK, GRASPS EQUAL. C/O PAIN BUT UNABLE TO LOCALIZE. GIVEN 1MG MORPHINE IV AND INCREASED PPF TO 30MCG WITH GOOD EFFECT. RESTRAINED FOR SAFETY OF LINES/TUBES. CT SCAN HEAD PRELIM REPORT WAS NEGATIVE. LP DONE WITH OPENING PRESSURE OF 9 AND FLUID WAS CLEAR.SERUM TOX SCREEN WAS NEGATIVE.\n\nCARDIAC: HR 80-110 SR/ST WITH NO ECTOPY. INCREASED HR ?PAIN RELATED, DECREASED WITH MORPHINE. BP 129-168/51-106. PPP. HCT STABLE @38, INR 1.2, NO SIGNS OF BLEEDING. EKG DONE MILDLY PROLONGED QT, PARTIAL RBBB, DIFFUSE ST DEPRESSIONS. CK 203, MB 4, TROP 0.03.\n\nRESP: ON A/C 400X20 100->40% +5 PEEP. RR 20-25 WITH SATS 98-100%. LS COARSE TO CLEAR WITH COARSE BASES. SXTED FOR NOTHING. ABG ON ARRIVAL 7.29/46/424/23.\n\nGI/GU: ABD SOFT WITH +BS. OGT IN PLACE. UOP 30-40CC/HR YELLOW AND CLEAR TO SEDIMENT. URINE TOX SCREEN + FOR OPIATES WHICH IS EXPECTED.\n\nFEN: STARTED ON D5.45NS @75CC/HR. LYTES PER CAREVUE. NPO FOR NOW.\n\nID: INITIALLY HYPOTHERMIC 93.1, BAIRHUGGER ON AND TEMP UP TO 99. U/A SENT THIS AM. WAS ON ISOLATION PRECAUTIONS BRIEFLY UNTIL LP CAME BACK WITH NO WBC'S. NOW UNIVERSAL PRECAUTIONS. NO ABX UNTIL CX'S RETURN. WBC 24 ON ARRIVAL DOWN TO 20 NOW.\n\nSKIN: WARM AND DRY NOW. SEVERAL CHEST TUBE SITES ON LEFT CHEST. ONE STILL HAS SUTURES IN PLACE.\n\nACCESS: PIV X2.\n\nSOCIAL/DISPO: FULL CODE. MD SPOKE WITH HER MOM LAST TO UPDATE HER. PATIENT DOES HAVE A FIANCE, NO CONTACT FROM HIM.\n\nPLAN IS FOR CONTINUED W/U OF HER WEAKNESS/NUMBNESS AND ?WHY SHE BECAME HYPERCARBIC...SEVERAL CX'S ADDED TO CSF THIS MORNING TO R/O ANY VIRAL CAUSING NEUROMUSCULAR WEAKNESS (GULLIEN-, MG, LYME DISEASE)...? SEIZURE AND PATIENT WAS POST-ICTAL, POSSIBLE EEG/MRI...?BLEED BUT CT WAS NEGATIVE...?OPIATE OD (RECEIVED 16MG MORPHINE OVER DAY SHIFT AS WELL AS ATIVAN)...?PAIN RELATED, HYPOVENTILATION...MONITOR FOR SIGNS OF OPIATE WITHDRAWAL...NEURO CONSULT...?EXTUBATE MD TO CHECK ABG THIS AM...POSSIBLE TODAY TO CHECK FOR PERICARDITIS.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 1314069, "text": "Respiratory Therapy\nPt transfered from S/P resp arrest. Etiology unknown, Intubated W #8 ett. BS clear. Able to wean FiO2 to .4. Please see carevue and nsg note for specifics.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-29 00:00:00.000", "description": "Report", "row_id": 1314144, "text": "Nursing Progress Note 7a-7p\nNEURO: A&O x3, anxious and tearful at times. Pain in left shoulder/chest area. Inc. pain med frequency. Still in constant pain bu verbalizes acceptable pain control with new schedule. +4 strength all extremities. Evaluated per PT today. Receiving scheduled ativan.\n\nCV: BP stable. HR NSR. Warm extremities. Afebrile.\n\nRESP: O2 sat high 90s on 70% humidified O2 via trach mask. Thick, tan colored secretions. Pt has good cough. Diminished BS on left side, overall CTA. Inc. pain with coughing.\n\nGI/GU: TF at goal rate. Passed video swallow eval today. Okay to eat but NPO after MN for OR in AM. Foley with good UOP. Pt c/o pain with foley cath. Noted to be displaced. New foley inserted using sterile technique. No complaint afterwards.\n\nPLAN: Recheck INR tonight, if acceptable <1.8 to OR in AM for Pleurodesis/CT placement. NPO after MN. SS consult for support group. Pt has good family support. Cont. pain med on regular schedule.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-30 00:00:00.000", "description": "Report", "row_id": 1314145, "text": "FULL CODE Universal Precautions\nAllergies: Vicodin, Percocet, PCN\n\n\nNeuro: AAOx3, MAEx4 well, assists to turn self. Can be anxious w/ coughing jags - Ativan .5mg po ATC q6hr. Also anxious about pending OR procedures, but overall in good spirits.\n\nCV: HR=80s, NSR, no ectopy. BP=90-120/50-60s. +periph pulses, extrems warm, no edema.\n\nResp: #8 trach w/ trach collar - 02sat 99-100% and maintains this 02sat when trach collar off. Lungs essent clear. Good cough effort, using yankar to clear secretions. Sx occ via trach for thin bloody secretions. Using passe muir valve during the day and inner cannula replaced at night. When awake, she does have a continual cough w/ occ coughing jag which makes her very anxious and SOB.\n\nGI/GU: abd soft, +BS, no BM. Passed swallow study yesterday and was taking ice cream and Italian ice w/o a problem. NPO since midnight for OR - L pleuradesis and chest tube placement. INR ealier in the evening was 1.7 (team wants INR<1.8). Am labs pending.\n\nSkin: intact\n\nPain: Med w/ morphine 2-4mg q3hr for comfort. Fent patch also in place. C/O discomfort in L shoulder.\n\nAccess: PICC - double lumen; blue port clotted. #20 PIV\n\nID: T=99.3. No antibx.\n\nSocial: No updates given to family members by nurse, but pt spoke w/ family herself in the evening.\n\nPlan: To OR for pleuradesis and CT placement. Monitor resp status, med prn for discomfort/anxiety.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-25 00:00:00.000", "description": "Report", "row_id": 1314136, "text": "RESPIRATORY CARE NOTE\n\nPt remains trached with 8.0 Portex Perc. trach tube. Sxn for thick bloody secretions x2. Tolerating 35% TM very well. Coughs up most of secretions into trach. Inner cannula changed.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2132-09-25 00:00:00.000", "description": "Report", "row_id": 1314137, "text": "npn transfer note\n\nOOB to chair today for 6 hours before tiring. Visit from son and has improved her spirits greatly.\n\nneuro: Pt is axox3, follows commands. No neuro deficits noted.\nPt has baseline anxiety and gets ativan and haldol around the clock.\n\nresp: 100% on RA. Requests suctioning appropriately; approximately q4 hours.\n\ncv: St no ectopy. Tachy to 130 with activity. BP with MAP in the 80's.\nArgatroban gtt for PE last week. Today is day of coumadin.\n\naccess: Double lumen PICC.\n\ngi/gu: Belly is soft, distended. Does not tolerate TF well. Had been receiving 10cc/h from 7pm-7am. Will try bolusing as tolerated 60cc at a time.\n\nendo: No issues.\n\nSkin: Perineal area is reddened and raw. Lidocaine jelly applied with some relief. Aloe Vesta cream applied.\nNo other skin issues.\n\nPlan: Transfer to floor. Contiue transitioning from agatroban to coumadin.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-27 00:00:00.000", "description": "Report", "row_id": 1314138, "text": "Nursing Note (2100-0700hrs)\n\nMs. is a 39yr old female adm after approx a 2.5week stay at for pneumothorax-- pleurodesis/VATS and weakness; came to and admitted to where she received narcotics for pain management; resp failure requiring intubation and transfer to MICU B. Dx w/ Syndrome. Found to have HIT/PE--anticoagulated. Stabilized and transferred to 3; developed left sided chest pain. CXR negative. CT showed a significant pneumothorax of her left lung-70% collapse. Transferred to MICU a for close observation and FFP as well as insertion of CT by cardiothoracic once reveresed.\n\nReview of systems:\nNeuro; Mouthing words; slept most of night. Med w/ativan at HS w/good effect. Continues w/left sided chest pain however no increase. Ativan for anxiety and prevent nauseau. Morphine given prior to arrival for pleuritic pain w/good effect.\n\nCV: hemodynamically stable thru . Has PIV/PCC--red port to picc clotted; unable to give TPA w/hx HIT. AM labs pnd. Skin intact throughout. INR 4.4--scheduled to receive 4 bags FFP starting at 6am per cardiothoracic for placement of CT between 7-9am.\n\nResp: LS clear to right; left sign decreased. Cough weak. Maintained on 70% TM overnoc. Denied need for suctioning.\n\nGI/GU: TF on hold at 12m pnd CT placement. Abd flat, NTND. Oliguria --bolused w/500cc NS w/fair response of 80cc; foley irrigated w/ease. Pt reports malfunctioning catheter while on floor; presently functioning without difficulty; balloon checked. No BM\n\nSocial: No calls/visits. Has ; mom is HCP. young son and daughter; pt is primary caretaker for 15yr old niece.\n\nPlan: CT by CT service this am once 4 FFP given. Monitor for tension pneumothorax. Emotional support. Await labs. restart TF of promote w/fiber once CT in, goal of 50cc/hr.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314116, "text": "Pt placed on CPAP+PS x.50 with rr 8-11 and tv's 500-600. vbg sent and pending. hr 110's, bp 110/60, no c/o sob or resp distress. k repleted this afternoon and evening lytes sent. parents in to visit this evening and updated on status and plan of care.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314117, "text": "resp care\nremains trached/vent dependant on ac mode presently. fio2 weaned to 50% per sats. pt changed to psv for a trial, vbg acceptable, (slight chronic co2 retention)..pt subsequently c/o sob, appeared anxious but switched back to ac mode. sxned thick bld tinged sputum,weak cough effort. nif not measured d/t sedatives. mdi given q4h. c/w slow wean.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-21 00:00:00.000", "description": "Report", "row_id": 1314118, "text": "1900-0700 rn notes micu\n\nneuro: no changes in neuro status,A/Ox3, follows commands, opens eyes spont, communicates by writting, time to time became anxious, received Ativan with good response.c/o pain in left side,shoulder,\n cont morphine 5mcg gtt.\n\nresp: remains on vent CMV 50%/400/RR20/peep10. LS at 0400 wheezing received nebs. st 100%, sx small tan/bloody secretion.\n\ncv: HR 100's ST, no ectopy, SBP 100-118. cont Argatroban gtt, increased to 2.75mcg/kg/min per sliding scale d/t PTT 52.2. no signs of bleeding. morning labs pending.\n\nid: Tmax 99.3,cont ABX please check Vanco level at 0730 befoe morning dose.\n\nplan: cont monitoring neuro/resp/cardio status\n wean vent to PS\n monitoring HCT, PTT.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-21 00:00:00.000", "description": "Report", "row_id": 1314119, "text": "ADDENDUM TO NOTES ABOVE\n\nPTT 44.2, INCREASED ARGATROBAN 3MCG/KG/MIN, HCT 23.4.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-21 00:00:00.000", "description": "Report", "row_id": 1314120, "text": "neuro: a+ox3...using writing board and mouthing words. +mae noted. bilat upper extremities>lower extremities. cough impaired, gag intact. +perrla noted. remains anxious throughout shift...medicated with ativan atc and prn haldol. responds well to verbal reassurance.\ncv: monitor shows st with no ectopy noted. qt=.30. argatroban increased to 3.25 mcg/kg/min for subtherapeutic ptt (currently off for gi access placement this afternoon and then to be resumed...will need ptt in 6hrs).\nresp: ls coarse throughout. sxn for mod amts thick tan/blood-tinged secretions via trach. trach care done. pt placed on pressure support for a while then returned to previous settings low minute ventilation. will cont to reattempt ps as pt tolerates. fio2 weaned to .40.\ngi: abd soft and nontender. +bs noted. no stools this shift. all po meds held no gi access. dr to place dobhoff catheter at bedside this afternoon.\ngu: foley intact and patent draining yellow urine with no sedimentation noted.\nskin: l cw old ct site sutures c/d/i.\nendo: remains on fingersticks q6hr with no coverage required.\nheme: hct 24.\ni-d: abx d/c'd. afebrile. wbc flat.\npain: cont to c/o chest and throat discomfort. able to wean morphine sulfate to 4 mg/hr and currently rating pain .\npsy-soc: mother in to visit in afternoon and updated on status and plan of care. remains full code on micu service.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-21 00:00:00.000", "description": "Report", "row_id": 1314121, "text": "Pt retrialed on cpap +ps and tol well. cont to c/o chest cavity discomfort, throat and shoulder discomfort. cont to provide reassurance and emotional support. dr placed dobhoff in r nare...medicated with ativan 1 mg for procedure. awaiting cxr to confirm placement. will need to resume agatroban this evening once confirmation obtained. fiance in to visit this evening.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-24 00:00:00.000", "description": "Report", "row_id": 1314134, "text": "NPN 07:00-19:00 MICU\n*Please refer to Carevue for additional patient information\n*Full Code\n*Allergies: PCN,Percocet,Vicodin,(+)HIT\n\nShift Events: Patient c/o of feeling \"lowsy\" all day. N/V (small amounts of clear liquid) this am, given Anzimet with no relief, later given Compazine with good effect. Speech and Swallow in to assess patient, Cuff deflated and Passy Muir valve in place, tolerated well. Failed Swallow; to reassess tomorrow. OT in, per OT patient appears to be have increased muscular strength. Pain Service in to assess, MD note, \"stop PCA\"; control pain with po med's, prn. MICU team aware, will reassess. *Argatroban continues to infuse,necessary for overlap of Coumadin for Five Days per Pharmacy, in order to reach goal INR ~.*Next PTT due at 20:00. *Per Case Management, patient does not have insurance, ?when will go to rehab d/t this issue.\n\nNeuro:A/O, very pleasant. C/o N/V, please see above. OOB to chair for most of shift, tolerated transfer well with two assist. Please see carevue for full neuro assessment.\n\nCV: HR low 100's, ST. SBP 113/69-130/74. Low grade fever most of shift, tmax 99.5, given written dose of PO tylenol.\n\nResp: Trach mask all day, Fio2 35% from 50%, O2 sat's 100%, RR~18. LS slightly coarse upper (small amount of bld tinged secretions in upper airway, able to expectorate on own; however has receivied deep suctioning by respiratory x1.) clear lower.\n\nGI/GU: +bs, no bm, Senna and Docusate given, Lactulose refused by patient. TF's to be restarted at 19:00 and run throughout night until ~7:00am (please see order at front of medication book.) U/O wnl, pink, cloudy, with sediment, MD's aware.\n\nAccess: Double lumen PICC, wnl.\n\nSocial: Mother in this afternoon. Fiance to be in this evening, updated on patients progress by RN.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-25 00:00:00.000", "description": "Report", "row_id": 1314135, "text": "Neuro: Pt. is A&Ox3, following commands, MAE, intact gag/cough, able to talk with Muir valve. C/o generalized body aches , also c/o \"soar throat\" around trach site due to ETT suctioning and coughing.\nMorpheine PCA discontinued. Pt. continues on Tylenol, Neurontin, Ativan via dophoff tube.\nResp: On trach collar @35% FiO2, sats high 90s-100, rr 20s. LS coarse, diminished at bases. Pt. able to clear secretions, self-suctioning with yankaur, occasionally requesting to be suctioned via ETT with thich blood tinged secretions out. Inner cannula changed by RT.\nCV: HR 90s-110s, ST, no ectopy. BP 110s-120s/70s. Palpable pedal pulses. No edema noted. Adequate u.o.(see careview for I&O).\nCoags: Continues on Argatroban gtt, decreased to 4.0mcg/kg/min per scale, am PTT pending, next draw @ 1000. Pt. received Coumadin 3rd dose, needs to overlap with Argatroban for 5 days per orders. INR pending.\nGI/Gu: TF restarted at 1900, pt. c/o nausea x1, refused antiemetics, nausea resolved spontaneously. TF held for 1 hr, restarted at 2200. Abd. soft, nondistended. Pt. c/o abdominal cramps, received Colace and Senna per orders, refused Lactulose. Had soft brown BM x1. Foley patent with amber cloudy urine out.\nID: Tmax 99.8. Continues on PO Tylenol. WBC pending.\nSkin intact.\nSocial: Fiance visited in the evening, no calls from family recieved overnight.\nPlan: Continue pain management, possibly start Oxycontin PO per pain service recommendation. Speech and swallow reevaluation today.\nFULL CODE.\nALLG: PCN, PERCOCET, VICODIN.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-24 00:00:00.000", "description": "Report", "row_id": 1314132, "text": "RESPIRATORY CARE NOTE\n\nPt remained on 50% Trach mask all . Tolerated well. No desaturation, no distress. Coughing up moderate amount secretions into mouth where she sxn with yankauer. Encouraged to deep breath.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2132-09-24 00:00:00.000", "description": "Report", "row_id": 1314133, "text": "NURSING NOTE: 7P-7A\nUPDATE: 35 Y/O FEMALE WITH PMH OF SPONT PNEUMOTHORAX, S/P VATS AND PLEUREDSIS(), ADMITTED WITH DIFFUSE WEAKNESS AND PAIN. S/P RESP ARREST AFTER PROGRESSIVELY WORSENING MUSCLE WEAKNESS. INTUBATED AND TRANSFERRRED TO MICU. TREATED FOR WITH 4 SESSIONS OF PLASMAPHERESIS. ON 5TH AND FINAL PHERESIS CANCELLED DUE TO PT R/I FOR MULTIPLE PE'S AS WELL AS NEEDING BRONCH FOR RML RLL COLLAPSE. PT ALSO +HIT ALLERGY. STARTED ARGATROBAN FOR ANTICOAGULATION PT AT BEDSIDE.\n\n\nNEURO- SLEEPING IN NAPS. AROUSES EASILY. MAE IN BED. WRITING AND MOUTHING TO COMMUNICATE. RATES PAIN . REMAINS ON MORPHINE PCA. NO C/O ANXIETY. REMAINS ON ATC 0.5MG ATIVAN PO.\n\nRESP- REMAINS ON TRACH COLLAR AT 50%. NO C/O OF RESP DISTRESS. SATS 98-100%. RR 14-20'S. SELF ORAL SUCTIONING. C/O PAIN AROUND TRACH WITH SWALLOWING. LS CLEAR. SUCTIONED DOWN TRACH X1 FOR SMALL AMOUNT OF THICK BLOOD TINGED SPUTUM, OTHERWISE PT ABLE TO EXPECTORATE A SMALL AMOUNT HERSELF.\n\nCV- HR 90-100'S SR NO ECTOPY NOTED. BP STABLE 100-120'S. ARGATROBAN INCREASED TO 4MCG/KG/MIN AT FOR PTT 50. REPEAT PTT AT 0200 THERAPEUTIC AT 63. RECEIVED 5MG COUMADIN LAST EVENING.\n\nGI-ABD SOFT DISTENDED + BS. NO STOOL OVERNIGHT (BM ). C/O MILD NAUSEA, UNRESOVLED FROM ANZEMET GIVEN ON PREVIOUS SHIFT. TF HELD FOR COUPLE OF HOURS, NOW RESUMED BUT NOT ADVANCED.\n\nGU- FOLEY PATENT FOR PINK TO AMBER URINE WITH SEDIMENT IN ADEQUATE AMOUNTS.\n\nACCESS- DOUBLE LUMEN PICC IN R ARM.\n\nSOCIAL- FIANCE VISITED LAST EVENING. SUPPORTIVE FAMILY.\n\nDISPO/PLAN- REMAINS IN MICU. FULL CODE. PT AND OT CONSULTS ONGOING. SPEECH CONSULTED FOR POSSIBLE SWALLOW EXAM AND PASSE MUIR TRIAL TODAY. CONSULT CASE MANAGER FOR REHAB SCREENS AS PT COULD BE READY TOMORROW.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1314128, "text": "nursing note: 7p-7a\nneuro- pt alert and oriented x3. mouthing words and writing to communicate. mae, upper extremitied remain stronger than lower. morphine pca maintained. pt rates pain anywhere from 2 at rest to 7 with turning and coughing. encouraged to premedicate for activities. po ativan 0.5mg q6h maintained, pt's anxiety better managed overnight.\n\nresp- remains trach'd, site clean. on vent ps 5/5. rr 12-28 tv 250-500cc. suctioned for small amounts of thick blood tinged sputum. self oral suctioning. ls relatively clear.\n\ncv- hr st 100-110's sr no ectopy noted. bp stable 100-130's. argatroban increased to 3.25mcg/kg/min overnight for ptt 49. am ptt pending. started coumadin last night. t max 99.5 po though remains on atc tylenol for pain management.\n\ngi- abd soft distended + bs. incontinent of multiple small liquid stools. pt c/o bloated gassy feeling. lactulose and soap suds enema given this morning after digital exam revealed large amount of soft stool in rectal vault. tf put on hold this am due to abd discomfort.\n\ngu- foley patent for initially marginal amounts of amber urine. 500cc fluid bolus given with improvement to 30-60cc/h.\n\naccess- r arm double lumen picc intact\n\nsocial- fiance visited last evening.\n\ndispo/plan- remains in micu, full code. continue to monitor resp status, ? trach collar trial today. also ? speech and swallow and passe muir valve trial today. coordinate with case management for rehab screens.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1314129, "text": "RESPIRATORY CARE:\n\nPt remains trached, minimally vent supported. No changes overnight. Sxing small amts secretions. Administering Combivent prn. BS's ess clear. See flowsheet for further data. Will follow, consider trache mask today?\n" }, { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1314130, "text": "neuro: a+ox3. +mae noted. gag intact, cough impaired. +perrla noted. pt remains on ativan atc with decreased anxiety noted from previous shift.\ncv: monitor shows nsr-st with rare pac noted. agatroban gtt incrased to 3.75 mcg.kg.min for subtherapeutic ptt...will send next ptt @ 1900.\nresp: ls clear with occ coarse bs's throughout. sxn for mod amts thick blood tinged secretions. pt on trach collar for majority of day and tolerated well.\ngi: abd soft with +bs noted. mod sized loose brown stool. c/o abd crampy pain. tf's resumed and to be advanced as tolerated. awaiting speech and swallow eval.\ngu: foley intact and patent draining pink tinged urine with sm amt sedimentataion noted.\ni-d: temp max 99. off abx.\npain: fentanyl patch to l upper arm intact. remains on morphine pca and using appropriately.\nm-s: oob-c x4 hrs and tolerated well. oob with 2 person assist with slow steady gait. PT and OT consults in place.\nheme: k 3.7 and repleted with 40 po as ordered.\npsy-soc: fiance and father in to visit and updated on status and plan of care. remains full code on micu service.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-23 00:00:00.000", "description": "Report", "row_id": 1314131, "text": "patient removed from mechanical ventilation at 11 o'clock to time. Suctioned PRN for copious amount of bloody plug type secretion.Secretion appears to be diminished but still needs bronchial hygien Q3-4hrs.Combivent ambu to patient with spacer.Will keep patient on T-collar as tolerated. If she stays off vent over night will pull vent in AM. Plan to use Passy-Muir valve tomorrow as secretion diminished.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-15 00:00:00.000", "description": "Report", "row_id": 1314095, "text": "NPN 07:00-19:00 MICU\n*Please see Carevue for additional patient information\n*Full Code\n\nShift Events: Patient only has one PIV, with redness. IV nurse paged, unable to place line, Dr. and team aware. PICC line to be placed however has not gone down to IR at this time. MRI to be done of spine, per Neurology to assess \"tightening\", MRI checklist in room. *ABX's have not been given d/t access issues, Dr. made aware. *TF's restarted however d/t Nausea/vomitting tf's turned off, Dr. aware. *Pain management continues to be an issue. MD in to assess patient, will be followed when patient is extubated. *Plan for Plasmapheresis tomorrow, then extubation (NPO after mn.)\n\nROS:\nNeuro: Alert, writing on tablet. Overall uncomfortable, tx'd with Fentanyl boluses with some effect. Repositioned for comfort with little effect. Please see carevue for full assessment.\n\nCV: HR 100's, ST, no ectopy. BP 130-140's/80's.Low grad fever 99.1\n\nResp: PS 12/5/50%, O2 sat's high 90's, LS coarse througout. Sxn'd x2 thick yellow secretions.\n\nGI/GU: NPO, U/o wnl.\n\nAccess: See above\nSkin: Intact\nEndo: RISS, no coverage\nSocial: Mother called, spoke to RN, update on patient and plan of care.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-16 00:00:00.000", "description": "Report", "row_id": 1314096, "text": "PT. REMAINS A/A/O AND CONTINUES TO WRITE NOTES PRETAINING TO HER PLAN OF CARE, ALL QUESTIONS HAVE BEEN VERY APPROPRIATE, AND ANSWERED BY ALL MEMBERS OF THE TEAM. PT. HAD BEEN QUITE ANXIOUS AND AGITATION AT THE BEGINNING OF THE SHIFT, WITH PAIN CONTROL BEING THE ISSUE. PT. HAS BEEN LEFT ON CONSTANT FENTANYL GTT WITH FENTANYL PCA TO START IN THE MORNING ALONG WITH FENTANYL PATCH OF 100MCG. PT. HAS REMAINED AFEBRILE DURING THIS SHIFT WITH NO INTERVENTIONS. PT. IS TO BE PAN CULTURED IF SHE SPIKE HER TEMP. PT. EXHIBITS NO NEURO DEFICITS AT THIS TIME. PT. REMAINS ON BOTH FENTANYL AND VERSED GTT'S AT THIS TIME. PT. HAS BEEN NSR/ST 98-110 WITH NO NOTED ECTOPY AT THIS TIME. B/P HAS BEEN WNL RANGING 104-120/50-70'S. PT'S PULSES ARE ALL STRONG WITH NO NOTED EDEMA NOTED AT THIS TIME. PT. REMAINS INTUBATED, WITH PLANS TO POSSIBLE EXTUBATE. PT. HAS BEEN SUCTIONED FOR MEDIUM AMT'S OF LOOSE PALE YELLOW SECRETIONS. OVER THE PAST FEW DAYS PT. HAS IMPROVED MUCH FROM LARGE AMT'S OF THICK TENACIOUS TAN SECRETIONS. QUESTION IS WHETHER OR NOT THE PT. HAS THE STRENGTH TO MOBILIZE THESE SECRETIONS. PT. WAS ON PSV SETTINGS BUT WAS PLACED ON FULL SEPPORT ONCE PAIN AND SEDATION LEVELS FINALLY REACHED AFTER FIRST FEW HOURS. PT. WILL BE PLACED BACK ON PRESSURE SUPPORT AND SWITCH TO PCA ANALGESIC WITH PLANS TO EXTUBATE. PT. RESP RATE HAS BEEN CONTROLLED, O2 SATS RESD >98% AND 100% ON PSV. LUNG SOUNDS REMAIN COURSE THROUGHOUT, WHICH IS UNCHANGED. REFER TO CAREVUE FOR LATEST VENT SETTINGS. PT. REMAINS NPO AT THIS TIME. OGT REMAINS IN PLACE WITH THIS VERIFIED BY NURSE. PT. HAS NOT EXPERIENCE NOR C/O ANY N&V DURING THIS SHIFT. BLOOD SUGARS REMAIN WNL'S ABD. IS BENIGN IN ASSESSMENT, WITH BOWEL SOUNDS EASILY AUDIBLE IN ALL QUADRANTS. PT. REFUSED HER SENIKOT BY DID ACCEPT HER COLACE. PT. HAS HAD MULTIPLE STOOLS FOR THE PAST TWO DAYS AFTER MULTIPLE LAXACTIVES GIVEN. PT. HAS FOLEY CATHETER IN PLACE WHICH CONTINUES TO DRAIN >40-220CC OF CLEAR TO CLOUDY URINE PER HR. PT. WILL RECEIVED PLASMA PHORESIS PT'S SKIN REMAINS INTACT WITH TWO OLD INCISIONS FROM OLD CHEST TUBES PRIOR TO THIS ADMISSION. THESE HAVE BEEN LEFT OTA. THERE IS ONE SMALL AREA PROXIMAL TO LOWER CHEST TUBE INCISION WHICH REMAINS OTA AND SLIGHTLY REDDENED. PT. HAS BEEN TURNING, FREQUENTLY AND AT TIMES SMALL BOULS OF FENTANYL GIVEN PRIOR FOR COMFORT. PT. HAS 2 #20 PIV'S IN HER LEFT HAND AND AC SITE. PT. REMAINS A DIFFICLT STICK AND IS FOR PICC LINE PLACEMENT IN I.R. TODAY.\nPT. REMAINS A FULL CODE AND AT PRESENT IS RESTING AND DENIES ANY PAIN. PT. HAS BEEN BATHED AND TOLERATED THIS WELL. P.O.C. IS PICC LINE PLACEMENT, PLASMA PHORESIS, AND POSSIBLE EXTUBATION.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-16 00:00:00.000", "description": "Report", "row_id": 1314097, "text": "Respiratory Care\nVent was changed back to a/c overnight due to decreased resp rate but was turned back to psv this morning. RSBI =14 this morning. Suctioning thick yellow sputum but pt has a strong cough effort.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-16 00:00:00.000", "description": "Report", "row_id": 1314098, "text": "Respiratory Care Note\nPt received on AC as noted. NIF -16cmH2O; VC 933. Pt placed on PSV, but returned to AC secondary to inconsistent breathing pattern due to medication for pain. Pt anxious today. BS are clear bilaterally with good aeration. Pt had plasmapharesis today. Plan to go to IR for PICC line placement and to MRI for full spine series. Plan to remain intubated and on AC at this time. ? possible trach for pt comfort.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-16 00:00:00.000", "description": "Report", "row_id": 1314099, "text": "npn 7-7pm\n\nPt taken to IR for PICC placement. Angio nurse does not request that this Rn remain with the patient. Verbal report given and questions answered.\n\nneuro: Neurologically intact. MAE on the bed with normal strength, lifts and kicks legs. She is able to clearly write and communicate her needs, mouthes words. PERL.\n\nPain: Started on 100 mcg fentanyl patch at 0400; it was dc'd in rounds. It has not been removed and team is aware b/c pain was not well controlled until ~ 1500. Pt tachycardic and hypertensive with pain/anxiety. She does calm with verbal reassurance.\n\nresp:No vent changes made, remains on AC. Unable to wean due to high NIFs and unsuccessful SBT.\n\ncv: SR-St 90-130. No ectopy. BP 120-130 systolic.\n\naccess: At 1650 lost all peripheral access. Dr. is aware. Pt does have a dialysis catheter for phoresis in case of emergency.\n\ngi/gu: Belly soft with + BS. Patent foley with adequate u/o.UA sent this am.\nTF have not been resumed. Please restart after MRI at a slow rate as pt became nauseated yesterday.\n\nEndo: RISS.\n\nDispo: Full code.\n\nPlan: Pt will have MRI tonite. Monitor patient for anxiety and pain. Pt says she becomes violently sick from toradol.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 1314090, "text": "Respiratory Care\n\n Pt continues on PSV 10/5 C/O heavy chest and difficulty a breath this afternoon. B/S coarse sx'd for mod thick pale yellow. Pt with increased RR and decreased VT's PS increased to 15 she settled and within one hour she was placed back on current settings. Will continue to follow closely and wean as able. Plan\n" }, { "category": "Nursing/other", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 1314091, "text": "MICU B Nursing Progress Note (0700-1900)\n\nPt. had a difficulty day today due to problems with pheresis catheter and therefore prolonged treatment time. She is also complaining of constipation and nausea. Vomited x 1.\n\nCNS: Pt. awake and alert on versed 2mg/hr and fentanyl 50mcg/hr. Bolused with fentanyl 50 prior to turning with decent effect. Versed 3mg bolus also given when pt. c/o being unable to get comfortable with only marginal effect. (Pt states she is on ativan as an outpatient). Able to move all extremities...lifting them off the bed when asked. Hand grasps remain weak, but improving. PEARL. Pt. able to make her needs known via writing. She is aware of the plan of care.\n\nPHERESIS: Exchange completed after catheter was pulled back and re-sutured. Placement confirmed by CXR.\n\nRESP: Continues to have coarse breath sounds throughout, diminished on the left. Suctioned frequently for large amounts of thick, yellow secretions requiring NS lavage. Currently on CPAP/PSV 50% 10/5 with TV of 480, RR of 22. NIOF -16 with VC of .662 (to be checked qd). Pt. had one episode when pheresis was initiated of feeling SOB, RR elevated, TV down. PS increased to 15 at that time, yet able to wean quickly.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 1314106, "text": "nursing note: 7a-7p\nevents: at 1245 pt acutely desaturated to 86%. suctioned and lavaged for no results. pt c/o not getting enough air, increase in anxiety and increase in pain especially around torso R>L. vent mode changed, cxr obtained, abg sent and pt went to cat scan for cta of chest which revealed mulitple PE's, and rml/rll collapse. upon return to unit argatroban gtt started for anticoagulation and bronchoscopy was done for pulmonary toileting. please see flowsheet for further details.\n\nneuro- pt now sedated due to ativan iv given for studies mentioned above. prior to above event pt alert and oriented x3, communicating with writing tablet. mae in bed, upper extremities stronger than lower. self oral suctioning. perla. 5th and final plasma pheresis treatment cancelled for today due to above findings, per transefusion services to be reevaluated tomorrow. fentanyl gtt at 75mcg/h, patch d/c'd. po ativen prn and verbal reassurance has helped manage anxiety.\npain at r hip pt states is from recent fall, ct of pelvis obatined was negative.\n\nresp- remains intubated, now on ac mode 350x20 peep increased to 12 and fio2 100%. plans to wean fio2 as tolerated. ls coarse. sats now 100%. bronch'd for tenacious plugged secretions in rml/rll.\n\ncv- hr tachycardic today 110's-140's, ekgs done, echo done, enzymes cycled. partial fluid bolus given for hr with no improvement and was d/c'd due to hypoxic event mentioned above. bp stable 110's-150's. argatroban started at 1600 at 2mcg/kg/min. heparin antibodies sent today. plts 93 this am, repeat 111. heparin sc d/c'd and flushes as well. hct 26.9 today, hemolysis labs sent, guiac negative, trying to minimize blood draws and waste.\n\ngi- abd soft + bs, lactulose given, pt had small hard pellet-like stool. guiac negative. tolerating tf, advancing towards goal.\n\ngu- foley patent for adequate amounts of urine.\n\naccess- double lumen picc in r arm. #20g piv in lac inserted for ct contrast. phersis catheter intact.\n\nsocial- fiance in to visit, brought photos and drawings in from home to help with morale. mother updated over the phone by this rn. she plans to visit this pm.\n\ndispo/plan- remains in micu, full code. continue to monitor. follow ptt and hct, now on argatroban. continue to treat for pain and anxiety. continue to support.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 1314107, "text": "Respiratory Therapy\nPt remains orally intubated on full mechanical support. Had episode of desaturation this shift, stat chest CTA showed multiple PE(s) lung collapse d/t mucous plugging. Bronch performed at bedside for tenacious amounts of tan sputum. See resp flowsheet for specific vent data.\n\nPlan: maintain support\n" }, { "category": "Nursing/other", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 1314092, "text": "NPN (cont'd)\n\nGI: Tube feedings initially held due to pt's being flat during majority of pheresis treatment. Pt. has still not stooled despite lactulose, colace, senna and dulcolax supp. Abdomen is distended with active bowel sounds throughout. Pt. complaining of discomfort and did vomit a small amount of bile x 1...therefore, tube feeds continue to be on hold. ?fleets enema next.\n\nID: Low grade temp of 99po. Continues on levofloxacin and vanco. Will need to be cultured if she spikes.\n\nCVS: Continues to be tachycardic with HR 100-110 ST. B/P ranging 120-130./syst. Pt. c/o CP along with SOB when pheresis treatment initiated. EKG done, without any changes noted by housestaff. This symptom also resolved with increase in PSV briefly.\n\nSKIN: Intact.\n\nREHAB: PT/OT consults in. Passive ROM given with turning. Pt. encouraged to move legs, perform \"ankle circles\".\n\nSOCIAL: Boyfriend, and pt's father and his family in to visit briefly. Pt. requests that she not have any further visitors this . mother also upset that she had so much company.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-15 00:00:00.000", "description": "Report", "row_id": 1314093, "text": "PT. REMAINS A/A/O AND IS ABLE TO WRITE NOTES PERTAINING TO HER CARE AND COMFORT. PT. DENIES PAIN, BUT C/O FREQUENT GENERALIZED DISCOMFORT WITH TURNS AND REPOSITIONING. PT. REMAINS ON BOTH FENTANYL AND VERSED GTT'S. PT. HAS BEEN BOLUSED WITH 12.5MCGS OF FENTANYL PRIOR TO REPOSITIONING. PT. HAS BEEN RUNNING A LOW GRADE TEMP WITH TMAX 99.8, PRESENTLY PT. IS 97.8 AXILLARY AFTER RECEIVING 650MG TYLENOL LAST EVENING. PT. IS TO BE CULTURED IF SHE SPIKES. PT. HAS BEEN NST 100-110 WITH NO NOTED ECTOPY. B/P HAS BEEN VERY STABLE RANGING 120-130/70-80'S. PULSES ARE ALL STRONG WITH NO EDEMA NOTED. NO ELECTROLYTE REPLETION HAS BEEN REQUIRED DURING THIS SHIFT. PT. REMAINS INTUBATED, AND TOLERATING WEANING WELL OVER THE PAST TWO DAYS. PT. WILL OCCASIONALLY C/O SMALL TIGHTNESS ACROSS CHEAST WHEN A VENT CHANGE HAS BEEN MADE. TEAM IS AWARE OF THIS. TIGHTNESS IS BEEN RESOLVING ON IT'S OWN WITHIN 2MINS OF CHANGE. ONLY ONCE DID R/T INCREASE HER P.S. FROM FOR PT'S COMFORT LEVEL. THIS LASTED FOR 2HRS THAN WAS TURNED BACK DOWN. PT. AM RSBI IS 36, AND PULLING -20 THIS AM. PT. DOES STATE THAT SHE IS SCARED WHEN IT COMES TO THE VENTILATOR. PT. IS COMFORTED, AND REASSURANCE PROVIDED. PT. HAS BEEN SUCTIONED FOR MODERATE AMT'S OF THICK TAN SECRETIONS. PT. IS AWARE OF ISSUE REGARDING QUESTIONABLE STRENGHT ON HER PART TO MOBILIZE THESE SECRETIONS. PT. HAS IMPROVED OVER THE PAST TWO DAYS, REGARDING THESE SECRETIONS. RESP RATE REMAINS STABLE AND O2 SATS READ 99-100% PT. HAS FOLEY CATHETER DRAINING MODERATE AMT'S OF CLEAR YELLOW URINE. OUTPUT HAS BEEN >80CC/HR. PT. REMAINS NPO AT THIS TIME. PT. HAD BEEN AT GOAL OF PROMOTE WITH FIBER AT 80CC/HR. BUT OGT HAS BEEN CLAMPED FOR 24HRS NOW. PT. WAS A QUESTIONABLE EXTUBATION YESTERDAY, AND THAN PT. C/O N&V WITH FOUR SEPARATE EPISODES OF VOMITING SAMLL AMT'S OF BILE AROUND OGT YESTERDAY AND ONCE DURING THIS SHIFT. PT. HAS BEEN MUCH IMPROVED SINCE ANZEMET HAS BEEN ORDERED WITH ONE DOSE GIVEN. OGT IS CONNECTED TO LIS FOR SMALL AMT'S OF BILIOUS SECRETIONS. BLOOD SUGARS HAVE BEEN WNL RANGING 108-114. PT'S SKIN REMAINS INTACT AND BENIGN IN ASSESSMENT. PT. HAS TWO #20 PIV'S IN LEFT HAND AND WRIST. THESE WARRANT CLOSE MONITORING, BUT CONTINUE TO FLUSH WELL. PT. IS FOR PICC LINE PLACEMENT TODAY, IN I.R. DUE TO FAILURE TO OBTAIN IT AT BEDSIDE.\nPT. REMAINS A FULL CODE AT THIS TIME. PT. REMAINS A/A/O AND WITH POSSITIVE SPIRITS. PT. IS FOR PLASMAPHORESIS, PICC LINE PLACEMENT, AND POSSIBLE EXTUBATION. AM LABS ARE PENDING AT THIS TIME.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-15 00:00:00.000", "description": "Report", "row_id": 1314094, "text": "Resp Care,\nPt. remains intubated on IPS 12 overnoc. 600's RR 9. Suctioned for thick tan spuutm. IPS increased to 14 for short time due to pt. c/o difficulty breathing, although VT, RR, O2 Sat were WNL. IF -20 this am, VC 1 L RSBI 38. Appears anxious if any testing being done. Cont. to wean IPS as tol.\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-19 00:00:00.000", "description": "Report", "row_id": 1314108, "text": "resp care\nPt continues to be orally intubated/ventilated . Tube pushed back to 22cm s/p tube becoming displaced by pt. Currently on A/C 350/20/12/.70--poor oxygenation persists despite high FI02/PEEP secondary to multiple PE's. BS: decreased/coarse bilat. Suctioned for mod tan thick secretions. Combivent MDI's given x2. Plan for trach at bedside this morning. Will continue to follow.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-19 00:00:00.000", "description": "Report", "row_id": 1314109, "text": "MICU NPN 7P-7A\nNEURO: RECEIVED ON FENTANYL GTT, CHANGED OVER TO MORPHINE GTT @2MG/HR. STILL C/O GENERAL DISCOMFORT/PAIN IN BACK, HIP, SHOULDER. AAO X3 AND WRITING TO COMMUNICATE. SLEPT BRIEFLY DURING THE EVENING AND THEN AWOKE AND NEARLY SELF-EXTUBATED AND ALSO PULLED OUT OGT. WHEN ASKED WHAT HAPPENED SHE SAID SHE WAS DREAMING THAT THE MD WAS TALKING TO HER AND SAID IT WAS ALMOST OUT. SHE THEN WROTE SHE WANTED TO GO AHEAD WITH THE TRACH. MD WAS PRESENT AND PATIENT WAS GIVEN ADDITIONAL 3MG HALDOL AND 1MG ATIVAN WITH GOOD EFFECT @2345. PATIENT SLEPT FOR 3HOURS. PATIENT RECEIVED STANDING DOSE OF 2MG HALDOL @4AM AND THEN REQUESTED ATIVAN THIS MORNING AND WAS GIVEN 1MG @0600 WITH GOOD EFFECT. RESTRAINTS WERE ON FOR A FEW HRS WHILE ASLEEP SO PATIENT WOULD NOT ACCIDENTLY PULL AT ETT. WHEN AWAKE SHE IS FOLLOWING COMMANDS AND MOVING ALL EXTREMITIES. PATIENT C/O SOME NUMBNESS/TINGLING ON BOTTOM OF FEET. CONTINUES ON NEURONTIN. PERL.\n\nCARDIAC: HR 127-134 ST WITH NO ECTOPY. BP 97-132/52-86. PPP. HCT 26.6 DOWN FROM 28 YESTERDAY AFTERNOON. CONTINUES ON AGRATROBAN. RECEIVED ON 2MCG BUT HAS BEEN INCREASED TO 2.5MCG OVER THE SHIFT AS PTT X2 HAS BEEN 44. PLTS 129. NO SIGNS OF BLEEDING. NEXT PTT AT 0900.\n\nRESP: REMAINS ON A/C 350X20 70% +12PEEP. RR 20-32 WITH SATS 96-100%. LS RIGHT DIMINISHED TO COARSE, LEFT CLEAR. SXTED FOR THICK WHITE TO TAN SPUTUM. ?TRACH TODAY AS PEEP >10.\n\nGI/GU: ABD SOFT WITH +BS. OGT PULLED OUT. MD AWARE, NOT REPLACED WITH POSSIBILITY OF TRACH. NO STOOL, DID RECEIVE LACTULOSE PRIOR TO LOSING OGT. STILL ON SENNA AND COLACE. UOP 20-60CC/HR YELLOW AND CLEAR.\n\nFEN: LYTES PENDING. NO EDEMA +5L. TUBE FEEDS AT 60CC/HR WITH MINIMAL RESIDUALS. FS 136.\n\nID: TMAX 100.3 WITH WBC 8. NOT ON ANY ABX. NO SPEC WERE SENT FROM BRONCH. BLOOD CX'S HAVE BEEN NEGATIVE.\n\nSKIN: COOL/DRY/INTACT.\n\nACCESS: LSC DIALYSIS LINE, RIGHT BRACHAIL PICC.\n\nSOCIAL/DISPO: SEVERAL FAMILY MEMBERS VISITING LAST . UPDATED BY MD. POSSIBLE TRACH AT BEDSIDE. ?LAST PHERESIS SESSION TODAY.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-19 00:00:00.000", "description": "Report", "row_id": 1314110, "text": "Respiratory Therapy\nPt trached @ bedside this shift w/ #8.0 Portex trach w/out incident. Currently on A/C d/t sedation for the procedure. Will switch back to PSV when appropriate. BLBS slightly diminished. MDIs given as ordered. SpO2 remained 90s. See resp flowsheet for specific vent settings/data/changes.\n\nPlan: wean back to PSV\n" }, { "category": "Nursing/other", "chartdate": "2132-09-19 00:00:00.000", "description": "Report", "row_id": 1314111, "text": "MICU B Nursing Progress Note (0700-1900)\n\nPlease see carevue for all objective data. Significant events include tracheostomy being placed at the bedside by interventional pulmonology...visualized with fiberoptic bronchoscopy. Pt. now has definitive diagnosis of HIT, therefore, pheresis line pulled by resident.\n\nRESP: #8 portex tracheostomy placed at the bedside. Pt. tolerated procedure well and was medicated throughout with a total of 2mg ativan, 300mcg fentanyl and 400mg propofol. MSO4 gtt also increased from 2mg/hr to 5mg/hr. Suctioned for large amount of thick, tan secretions. Trach site is clean and dry...no bleeding noted. Pt. briefly on CPAP/PSV 18/10 today and tolerated it well. As she is now sedated, vent settings are at A/C 70% 400 x 20 with 10 of PEEP (down from 12). Lungs with coarse breath sounds throughout, clearing post bronch.\n\nCNS: Pt. alert, oriented, making her needs known by writing. Cooperative. Became very agitated during AM care with turning. Attempting to sit up, c/o being \"hot\". Pt did not desaturate at this time and responded well to 2mg ativan IVP. Ordered for RTC haldo and ativan.\n\nCVS:Hemodynamically stable, less tachycardic today with HR 115-125....briefly on neo gtt during procedure as SBP dropped down to the 90's/ transiently.\n\nGI: Pt. has not received tube feeds or po meds today, as she self dc'ed OGT overnight. This RN unable to pass NGT...small amount of bleeding from nares after attempts were made. HO made aware and will try again later this evening. No stool this shift, although pt. has been on and off bedpan several times.\n\nF and E: Tube feeds on hold and no IVF ordered. However, pt. received 800cc NS during procedure. UOP borderline at 30cc/hr.\n\nHEME: Argatroban dc'ed 4hr prior to trach being placed. Baseline PTT now pending at gtt is to be restarted. As mentioned, HIT+....pheresis catheter dc'ed as it is impregnated with heparin.\n\nID: Low grade temp of 99.2po.\n\nSKIN: Intact\n\nLINES: #20 peripheral left AC, functioning well. Aptelase to clear PICC line with success.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314112, "text": "MICU NPN 7P-7A\n35Y/O WITH PMH OF MUTIPLE PNEUMOTHORACIES, ANXIETY D/O. RECENTLY ADMITTED X2 TO FOR VATS AND SPONATNEOUS PNEUMOTHORAX. PRESENTED TO ON WITH SEVERE PAIN AND WEAKNESS. WAS MANAGED ON FLOOR, STARTED ON MORPHINE PCA. INCREASE WEAKNESS OVER WHOLE BODY AND NUMBNESS. INCREASE SOB. WAS BECOMING INCONTINENT. FOUND UNRESPONSIVE WITH SLOW SHALLOW BREATHING. INTUBATED FOR AIRWAY PROTECTION AND TRANSFERRED TO MICU.\n\nWHILE IN MICU PATIENT WITH + BY EMG AND STARTED ON PLASMAPHERSIS. HAS HAD FOUR SESSIONS. TACHYCARDIAC ISSUES WAS INITIALLY R/O FOR PE. VAP AND STARTED ON ABX. PAIN AND ANXIETY ISSUES. WAS ON FENTANYL GTT CHANGED TO MORPHINE. RECEIVING HALDOL AND ATIVAN FOR ANXIETY. HAD MRI OF SPINE WHICH WAS NEGATIVE. DROPPING HCT AND PLTS, +HIT. PHERESIS LINE D/C'D HEPARIN. RECEIVED PICC FOR POOR ACCESS. ACUTELY DESATTED, CTA SHOWED MULTIPLE PE'S. STARTED ON AGATROBAN. ALSO BRONCHED FOR RML/RLL COLLAPSE. MANY PLUGS. TRACHED AT BEDSIDE AS PATIENT HAS BEEN A DIFFICULT WEAN.\n\nNEURO: PATIENT SLEEPING MOST OF SHIFT. WILL SPONTANEOUSLY AWAKE. COMMUNICATING VIA WRITING BOARD. AAOX3. REMAINS ON MORPHINE GTT @5MG/HR WITH GOOD EFFECT. PATIENT C/O OF SOME DISCOMFORT IN LEFT SHOULDER. MOVING ALL EXTREMITIES AND FOLLOWING COMMANDS. REMAINS ON ATC HALDOL AND ATIVAN. UNABLE TO GIVE NEURONTIN NO GI ACCESS.\n\nCARDIAC: HR 119-95 ST/SR WITH NO ECTOPY. BP 97-115/57-67. RESTARTED ON AGATROBAN @2MCG WITH 2HR PTT 39 SO GTT INCREASED TO 2.5MCG. AM PTT PENDING. AM HCT AND PLTS ALSO PENDING. NO SIGNS OF BLEEDING. PPP.\n\nRESP: #8 PORTEX TRACH IN PLACE. SITE LOOKS GOOD, NO BLEEDING. REMAINS ON A/C 400X20 70% +10PEEP. RR 20-21. SATS 100%. LS CLEAR. SXTED FOR NOTHING.\n\nGI/GU: ABD SOFT WITH +BS. NO GI ACCESS. NO STOOL. UOP 40-130CC/HR YELLOW AND CLEAR.\n\nFEN: NO EDEMA. +5.4L. LYTES PENDING. NPO AS SHE HAS NO GI ACCESS. SPEECH AND SWALLOW STUDY TODAY.\n\nID: TMAX 98.8 WITH WBC PENDING. RESTARTED ON VANCO AND CEFTAZADIME AFTER BRONCH. CX'S PENDING.\n\nSKIN: W/D/I.\n\nACCESS: PIV X1, RIGHT BRACHIAL PICC.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. NEED CASE MANAGEMENT/MICU TEAM TO FOLLOW UP AS PATIENT HAS NO INSURANCE AND WONDERING IF SHE CAN GET STATE DISABILITY. IF FAILS SWALLOW STUDY NEEDS DOBHOFF PLACED.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314113, "text": "MICU NPN 7P-7A\nADDENDUM: AM HCT WAS 23.7 DOWN FROM 25.2, MD AWARE. MOST LIKELY FROM PROCEDURE. WILL TRANSFUSE IF <21. WILL ORDER A PM HCT. PLTS UP TO 155. PTT CAME BACK @46 SO AGATROBAN INCREASED TO 2.75MCG @0630. WILL NEED PTT DRAWN @1230.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314114, "text": "RESPIRATORY CARE:\n\nPt remains trached, vent supported. No changes made overnight. BS's ess clear. Few secretions. See flowsheet for pt data. Will follow.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-20 00:00:00.000", "description": "Report", "row_id": 1314115, "text": "please see above note for hx.\n\nneuro: a+ox3...able to communicate with writing board and mouthing to make needs known. +mae noted bilat upper extremites>lower extremites. cough weak/gag intact. +perrla noted. remains anxious at times and prn ativan given with +effect. remains on ativan and haldol atc.\ncv: monitor shows nsr-st with no ectopy noted. qt=.36. ptt sent @ 1230 and supertherapeutic...argatroban off x1hr and resumed @ 2.5 mcg/kg/min. will need repeat ptt @ 2100.\nresp: ls with coarse breath sounds bibasilar. sxn for mod amts thick tan/blood tinged secretions via trach. fio2 weaned from .70-.50. current vent settings a/c 400x20x50 +10.\ngi: abd soft and nontender. +bs noted. po meds held no gi access. dr aware and ? to place dobhoff this evening. awaiting speech and swallow eval.\ngu: foley intact and patent draining yellow urine with sm amt sedimentation noted...slight hematuria noted in afternoon in setting of ^ptt.\nendo: remains on fingersticks q6hr with riss.\ni-d: afebrile. remains on vanco and ceftaz for empiric coverage.\npain: c/o diffuse achiness over chest, abdomen, hip, throat and l shoulder. rating on pain scale.\nheme: hct trending down now 22.8...plan to transfuse for hct<21. no signs of bleeding.\npsy-soc/dispo: mother called x1 and updated on status and plan of care fiance in to visit throughout day. remains full code on micu service.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-12 00:00:00.000", "description": "Report", "row_id": 1314082, "text": "Respiratory Care Note:\nPt remains intubated and on the vent. Pt on AC with no vent changes made this shift. Suctioned for moderate amounts of thick yellow secretions. Plan: continue full support to rest pt until ready to attempt weaning. See careview for vent settings and additional info.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-13 00:00:00.000", "description": "Report", "row_id": 1314083, "text": "Resp. Care:\n Pt. remains intubated and on vent.support. No changes made. BS- coarse bilat. Sx'ng thick yel. secretions.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-13 00:00:00.000", "description": "Report", "row_id": 1314084, "text": "MICU NURSING NOTE 7P-7A:\n\nSEE CAREVUE FLOWSHEET FOR FULL ASSESSMENT DETAILS AND LABS.\n\nNEURO: PT REMAINS LIGHTLY SEDATED ON PROPOFOL GTT. OPENS EYES SPONTANEOUSLY, FOLLOWS COMMANDS. PUPILS EQUAL/SLUGGISHLY REACTIVE BILAT. PT ABLE TO COMMUNICATE NEEDS BY WRITING ON NOTE PAD OR USING ABC BOARD. PT MAE, VERY WEAK. DECREASED COUGH/GAG REFLEX. + CORNEALS, + EOMS. PT C/O GENERALIZED PAIN TREATED WITH MORPHNE 1 MG IV Q 6 HOURS AS ORDERED WITH SOME RELIEF. MD AWARE OF GENERALIZED PAIN. PT REPOSITIONED FOR COMFORT AND GIVEN EMOTIONAL SUPPORT.\n\nCV: TMAX 99.5 AX. PT GIVEN TYLENOL 650 MG. HR 90-120 SR-ST NO ECTOPY. BP STABLE + 1 GENERALIZED EDEMA + PULSES. PM K= 4.2 PT CONTINUES TO GET FREE WATER BOLUSES FOR HYPERNATREMIA. AM LABS PENDING. PT REMAINS ON IVF D5W 0.45NSS @ 100CC/HOUR.\n\nPULM: PT REMAINS INTUBATED ON AC-24 TV 350 FIO2 50% PEEP 5. RR 24-35 MV 10-12.5. SUCTIONING MOD THICK YELLOW SECRETIONS. CHEST PT DONE Q 4 HOURS. LUNGS COARSE THROUGHOUT.\n\nGI/GU: ABD SOFT, NON-TENDER + BS X 4. PT DENIES N/V. OGT PLACEMENT CONFIRMED WITH AIR BOLUS. PROMOTE WITH FIBER @ 70CC/HOUR (GOAL 80CC/HOUR) MINIMAL RESIDUAL NOTED. FOLEY DRAINING CLEAR/YELLOW URINE. EXCELLENT UO.\n\nPLAN: CONT IV ANTIBIOTICS, WEAN VENT AS TOLERATED, FOLLOW LABS AND REPLETE LYTES AS NEEDED, PICC PLACEMENT TODAY, CONT TO INCREASE TUBE FEEDS TO GOAL (80 CC/HOUR), CONT PHERESIS FOR , CONT TO MONITOR.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-13 00:00:00.000", "description": "Report", "row_id": 1314085, "text": "Respiratory Care\n\n Pt continues on full ventilatory support. B/S sl coarse Sx sm amount thick yellow. No changes today. Will continue to follow closely.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-13 00:00:00.000", "description": "Report", "row_id": 1314086, "text": "MICU B Nursing Progress Note (0700-1900)\nPt. is a 36 year old woman admitted to MICU B with respiratory failure, diagnosed with . +VAP.\n\nPt. stable today with some adjustments in sedation regime. Remains febrile with purulent secretions. Access is an issue...unable to place PICC at the bedside.\n\nCNS: Propofol increased to 85mcg/kg/min due to pt's being awake, gagging on the tube. She is complaining of generalized pain which has not been relieved with ibuprofen or MSO4 1mg. Therefore, propofol dc'ed and fentanyl and versed gtts initiated at 50mcg/hr and 2mg/hr respectively with good effect. 50mcg fentanyl bolus given prior to turning. Pt. is easily aroused, able to communicate via writing, MAE's. Able to briefly lift UE's and LE's off of the bed. Very appropriate, understands what is going on. She has reasonable questions regarding pheresis treatments, pneumonia.\n\nCVS: Remains tachycardic with HR 100-120 ST without VEA. B/P ranging 120-140/syst.\n\nRESP: Remains on CMV 50% 350 x 24 with 10 of PEEP. O2 sats of 93-96%. Lungs with coarse BS throughout. Suctioned very frequently for copious amounts of thick, yellow secretions. ABG 7.42 47 70 32. PO2 has deteriorated since last ABG a few days ago.\n\nGI: Tolerating tube feeds of promote with fiber at 80cc/hr. Receiving free water boluses of 400cc q6hr due to elevated Na. Abdomen soft with active bowel sounds throughout. No stool this shift despite senna and colace. Most likely will require dulcolax/fleet enema.\n\nF and E: D5.45NS dc'ed as pt. is at goal rate and blood glucose has been high (175 at 1200). Will continue to check q6hr...may need sliding scale.\n\nSKIN: Intact.\n\nID: T max of 101...ibuprofen given x 1, currently low grade at 99.2. Remains on vanco and levaquin.\n\nREHAB: Needs PT consult, OOB with . Multipodus boots on.\n\nLINES: IV team unable to place PICC at the bedside. Pt has 2 peripherals, which are only temporary...should go to IR for PICC placement ASAP.\n\nSOCIAL: Mother, father and boyfriend all in at different times. Pt. is able to communicate with them. Daughter spoke with pt. over the phone. has 3 children...5, 7 and 17.\n\nLINES: IV team una\n" }, { "category": "Nursing/other", "chartdate": "2132-09-13 00:00:00.000", "description": "Report", "row_id": 1314087, "text": "Addendum: Right arm noted to be edematous, hand to upper arm. IV's did not appear infiltrated, but removed. +radial pulse. Arm elevated and warm pack applied. HO notified. Very difficult to get access on this pt. 2 #20's placed left hand, but are very precarious.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 1314088, "text": "PT. REMAINS A/A/O AND COMPLAINS OF SLIGHT PAIN AND DISCOMFORT DURING REPOSITIONING. PT. WAS GIVEN A TOTAL OF 3 FENTANYL BOLUSES PRIOR, OR FOLLOWING THESE INTERVENTIONS. PT. REMAINS ON BOTH FENTANYL AND VERSED PT. HAS BEEN EXHIBITING A LOW GRADE TEMP WITH TMAX 99.4 AND PRESENTLY PT. IS 98.9. PT. HAS BEEN ABLE TO COMMUNICATE HER NEEDS BY WRITING NOTES, AND MOUTHING WORDS. PT. HAS BEEN NST 100-110 WITH NO NOTED ECTOPY. B/P HAS BEEN RANGING 120-140/50-70'S WITH MAP'S >60. PULSES REMAIN STRONG AND EASILY PALPABLE WITH ONLY EDEMA NOTED IN RIGHT UPPER EXTREMITY. HEAT PACKS HAVE BEEN APPLIED AND MOST OF THE SWELLING HAS SUBSIDED BY THIS TIME. PT. HAS DENIED AND PAIN AND PULSES HAVE ALWAYS REMAINED STRONG AND EASILY PALPABLE. PT. RECEIVED 40MEQ KCL DURING HS HRS. PT. REMAINS INTUBATED AND LAST EVENING WAS PLACED ON BREATHING TRIAL OF . PT. TOLERATED THIS WELL, MAINTAINING SATS >99% AND RESP RATE 14-20. PT. DENIED AND DIFFICULTY NOR SOB. PT. ABG WAS EXCELLENT DURING THIS WITH PO2 CLIMBING FROM A PREVIOUS 70 TO 151. PT. WAS LEFT FOR 3.5HRS. AND THEN PLACED BACK ON FULL SUPPORT. PT. WILL BE ATTEMPTED TO BE WEANED AND HOPEFULLY EXTUBATED TODAY. PT. IS AWARE OF PLAN DISCUSSED WITH M.D. PT. HAS REQUIRED SUCTIONING FOR MODERATE AMT'S OF THICK TAN/YELLOW SECRETIONS. PT. CONTINUES TO TUBE FEEDS WHICH ARE AT GOAL OF 80CC/HR. BLOOD SUGARS HAVE BEEN 130-140'S. ABD. REMAINS SOFT. BUT SLIGHTLY DISTENDED. PT. DENIES ANY DISCOMFORT, AND BOWEL SOUNDS REMAIN EASILY AUDIBLE IN ALL QUADRANTS. M.D. HAS NOW ORDERED LACTULOSE, SINCE NO BM NOTED FOR THREE DAYS AND AFTER SENOKOT AND COLACE HAVE NOT PRODUCED. NO STOOL NOTED AS OF YET. PT. HAS OGT IN PLACE WITH PLACEMENT VERIFIED AND RESIDUALS <20CC Q4HRS. PT. HAS ALSO TOLERATED HER FREE H2O BOLUSES. PT. HAS FOLEY CATHETER AND HAS DRAINED 40-220CC HR. OF CLEAR AMBER URINE. SKIN REMAIN BENIGN IN ASSESSMENT. WITH ALL LINES SECURE, PATENT AND FUNCTIONING WELL. PT. DOES HAVE POOR ACCESS WITH 2 #20 IN HER LEFT HAND. PT. IS SCHEDULED FOR I.R. FOR PICC PLACEMENT. OTHERWISE PT'S LEFT SUBCLAVIAN CATHETER REMAINS SECURE.\nPT. REMAINS A FULL CODE AT THIS TIME. WITH PLANS FOR PICC LINE PLACEMENT, PHYSICAL THERAPY CONSULT, AND A POSSIBLE WEAN AND EXTUBATION FROM VENTILATOR. PT. REMAINS AND HAS BEEN WRITING NOTES REGARDING P.O.C, COMFORT ISSUES AND HOPES TO GET OFF THE VENTILATOR.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 1314089, "text": "RESPIRATORY CARE NOTE\n\nPt remains intubated and ventilated on PS settings this AM. Trialed on PS at 8:30 pm, tolerated for 4 hours. Placed back on AC to rest for . ABG shows good ventilation and oxygenation. RSBI completed on PS 5 @ 0400=22. Will place on SBT this AM. BLBS are coarse. Sxn for thick pale yellow secretions.\n\n , RRT\n" }, { "category": "Nursing/other", "chartdate": "2132-09-17 00:00:00.000", "description": "Report", "row_id": 1314103, "text": "nursing note: 7a-7p\nneuro- pt alert, communicating with writing tablet. very anxious and c/o generalized back and hip pain. fentanyl gtt and patch for comfort. pain better controlled when anxiety controlled. mri of spine done today, pt required propofol for procedure due to length of study 2.5 hours. upon return to unit pt's room changed to increase visibility of staff and hopefully help with anxiety. pt mae. oob to chair with 2 assist and pivot only, legs weak.\n\nresp- remains intubated, on pressure support 50%. ls coarse and rhonchi. small amount of white secretions from ett, self suctioning oral secretions. nif and vital capacity improved today, please see flowsheet. trach discussed with pt during rounds. pt wants more time to attempt extubation and avoid trach, has discussed with mother.\n\ncv- hr 90-100 st no ectopy noted. bp stable 100-140's.\n\ngi- abd soft + bs no stool, tf resumed, off for some time today due to mri. rate now at 30cc/h, no nausea/vomiting, scant residuals, advance to goal 80cc/h as tolerated.\n\ngu- foley patent for adequate amounts of clear yellow urine.\n\naccess- double lumen picc intact.\n\nsocial- fiance updated over phone. mom and sister in to visit, updated by rn.\n\ndispo/plan- full code. continue to control pain and anxiety. continue to wean vent and follow resp mechanics as tolerated.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 1314104, "text": "Respiratory Care:\n\nPatient intubated on Psv. ETT retaped @ 22cm/lip. Bs equal/clear bilaterally. Sx'd for sm amount of thick white secretions. Pt. weaned to Psv yesterday. Tolerated well overnoc. Psv 12, Peep 5, Fio2 50%. Spont vols 400-500, RR 11-19. RSBI 25. No further changes made. Plan: Continue to wean Psv as tolerated. Repeat V/C and NIF later today.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 1314105, "text": "MICU NPN 7P-7A\nNEURO: AAOX3, COMMUNICATING VIA WRITING. EXPRESSING HER FRUSTRATIONS, TEARFUL WHEN TALKING ABOUT HER CHILDREN WITH WHOM SHE HAS NOT TALKED TO IN A FEW WEEKS. C/O BEING ANXIOUS, EMOTIONAL SUPPORT AND REASSURANCE, AS WELL AS 1-2MG ATIVAN PO GIVEN. PERL @3MM AND BRISK. MOVING ALL EXTREMITIES WITH IMPROVED STRENGTH. DID NOT SLEEP MUCH. PATIENT SXTING HER MOUTH CONSTANTLY THROUGHOUT THE . C/O PAIN IN BACK, RIGHT HIP AND LEFT SHOULDER, 1MG MORPHINE IV AND FENTANYL BOLUSES WITH LITTLE EFFECT. HAS FENTANYL PATCH ON LEFT ARM. ALSO RECEIVING NEURONTIN. FENTANYL GTT REMAINS @75MCG, 1GM TYLENOL Q6HRS. MRI OF SPINE WAS NEGATIVE.\n\nCARDIAC: HR 92-120 SR/ST WITH OCCASIONAL SELF LIMITING BURSTS TO 130-140. NO ECTOPY. NO C/O CHEST PAIN. BP 103-141/47-76. PPP. HCT 27.7 DOWN FROM 37.6, PLTS 93 DOWN FROM 124. MD AWARE. CLOT SENT TO BLOOD BANK. NO DECISION AS OF YET WHETHER TO TRANSFUSE. NO SIGNS OF BLEEDING.\n\nRESP: REMAINS ON CPAP 12/+5 50% WITH RR 8-30 AND SATS 95-100%. TV'S 400-500CC AND AM RSBI 25. LS COARSE AND DIMINISHED WITH INSP WHEEZES ON RIGHT, COARSE TO CLEAR ON LEFT. SXTED FOR SMALL AMOUNT OF WHITE THICK SPUTUM.\n\nGI/GU: ABD SOFT WITH +BS. NO STOOL. ON COLACE AND SENNA. OGT IN PLACE. UOP 25-65CC/HR YELLOW AND CLEAR.\n\nFEN: LYTES PER CAREVUE. +5L LOS. NO EDEMA. TUBE FEEDS @40CC/HR, GOAL 80CC/HR. FS 135/126. NA 134, ?NEED FOR FLUID BOLUSES @400CC/Q6HRS. UNABLE TO TOLERATE, MAKES HER NAUSEATED.\n\nID: TMAX 98.6, FINISHED ABX COURSE LAST NIGHT. WBC 10.4 FROM 14.4. BLOOD CX'S PENDING.\n\nSKIN: COOL, DRY, AND INTACT.\n\nACCESS: RIGHT BRACHIAL PICC, LSC DIALYSIS LINE.\n\nSOCIAL/DISPO: FULL CODE. NO CONTACT FROM FAMILY. PLAN FOR FINAL PHERESIS SESSION TODAY AND POSSIBLE EXTUBATION.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-30 00:00:00.000", "description": "Report", "row_id": 1314146, "text": "Nursing Progress Note 7a-7p\n\n35yo female admitted back from OR s/p left VATS, wedge resection, and mechanical pleurodesis due to recurring spont. pneumothorax. EBL 100cc.\n\nNEURO: Sedated on propofol gtt. PRN morphine for pain control. Arousable to touch, follows commands and mouth words. MAE. PERL. Pt is being followed by neurology for management of - syndrome. Pt has been improving in strength.\n\nCV: BP stable. HR 100s SR-ST. Afebrile. Warm extremities, palpable pulses.\n\nRESP: A/C 50% 14/450/5. spont. breaths. Good ABG. Coarse lung sounds on left, diminished on base. CT & drain to -20cm suction, draining serosang. drainage. Air leak noted.\n\nGI/GU: TF restarted @ 50cc/h. Pt passed video swallow eval, eligible to eat once back on trach mask. Soft abd, hypoactive BS. UOP adequate.\n\nSOCIAL: Family called to check. Updated.\n\nPLAN: Cont. pain management with sedation. Rest pt tonight on vent. Cont. CT to suction. Watch UOP, notify MD if <20cc/h. Keep fluid bal. equal or slightly negative. Resume Argatroban on POD #2.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-01 00:00:00.000", "description": "Report", "row_id": 1314147, "text": "Respiratory Care Note\nPt received on AC as noted. No vent changes during the night. BS clear bilaterally with good aeration. Pt suctioned for moderate amt thick, bloody secretions. RSBI done. Plan to possibly place on trach mask this morning.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-01 00:00:00.000", "description": "Report", "row_id": 1314148, "text": "MICU A NPN 7p-7a\nNeuro: Pt lightly sedated on propofol for most of shift as it was goal made by CT surgery for pt to rest overnight. Pt appears to be oriented x3, able to follow commands and MAE. Pt does have anxiety at times, rec'd ativan x2 with good effect. Pt also has pain in L chest at incision site and is requiring Morphine 2-4mg q2hrs. HCT stable.\n\nPulm: On AC settings overnight per CT surgery, pt did tolerate well. Sxned for large amt of thick blood tinged plugs and secretions, requiring lavaging at times. LS coarse t/o. CT and drain to Left ant. chest at -20cm CWS. CT drained ~80cc this shift, drain with only 5cc. +airleak, no crepitus. Trach site with some old blood around stoma.\n\nCV: HR 100-110s SR, BP stable. Aline d/c'd as it lost its waveform and unable to draw back on it. Tmax 100.2, pt gets tylenol atc, and MD aware of temps.\n\nGI/GU: TF residual was >200 last pm, TF shut off x4hrs, then restarted at 20cc/hr and pt tolerating well. No residual this am, and pt also given reglan iv x1. No BM overnight. U/O 20-100cc/hr.\n\nSkin: INtact\n\nPlan: Pt to go back to TM today and has been cleared to eat 2 days ago. Cont to medicate for pain as needed, monitor temps.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-01 00:00:00.000", "description": "Report", "row_id": 1314149, "text": "Nursing Progress note:\n\nPt. is a 35 yo female who underwent VATS/pluerodesis last pm. Pt. has recent hx of PE and spontaneous pneumothoraces. Pt. received with trach, on vent with Profofol d/c'd and awake with chief complaint of pain to L side.\n\nNeuro: PT. weaned off Propofol in am, found awake,following commands and communicating by mouthing words and writing. Pt. MAE well.Pt. receiving Morphine for pain and finding pain management inefffective. Pt. especially in pain when moving and coughing. Pain management discussed with team, pt. placed on PCA pump of Morphine 1:1, with continuous rate of 2mg hr and PCA doses of 2mg with an hourly total of 8 mg. Pt. has found this to be effective but is anxious about her resp effort being stopped. Pt. educated about being monitored closely and that her total doses of Morphine were not siginificantly higher than what she had been getting via . PT. now calm and pain is reduced from to which she finds acceptable.\n\nCV: HR 90-113 not ectopy, NBP 100s/50s.Arterial line d/c'd during night. Pt. has PICC in RAC with blue port clotted off and other port with PCA pump running well. PIV 18g in R forearm patent. Both sites WNL.\n\nResp: Pt. initially vented but placed on 70% trach mask with RR 15-24 and 02 sats 98-100%. LS initially course to all lobes, now inspitation is much clearer with exp. wheezes bilat. Pt. has good cough but was afraid to cough due to pain and required suctioning of thick,tan, blood-tinged secretions. Since pain is managed pt. is more able to bring secretions into oropharynx and requires only shallow suctioning.\nPt. has chest tube and drain to L chest. CT is draining small amounts of serosanguinous fluid and tube is draining scant amounts. Both tubes are connected to the same Pleurevac and on 20mmgh of wall suction. Pt. unable to tolerate Passe/Muir valve yet (led to coughing and pain) but is motivated to try again.\n\nGI/GU: Pt.on Profiber @ 20/hr, now advanced to 40/hr and well tolerated. Pt. has BSX4. Diet has been advanced to clears and advance as tolerated but pt. must be able to tolerate Passe-Muir valve first.\nUO 20-80cc hr (mostly around 40cc/hr).\n\nSkin: CT dressing dry and intact,trach site with small amount of blood,chest tube visible as lump to back.\n\nSocial: Fiance, father,and mother all visited pt. today. Pt.happy to socialize and indicates that she misses talking.\n\nPlan: Pt. has been called out to floor. Monitor PCA use for effective parameters, monitor resp status and chest drainage, suction as needed, advance TF to goal of 50cc/hr, try Passe-Muir valve again.\n" }, { "category": "Nursing/other", "chartdate": "2132-10-01 00:00:00.000", "description": "Report", "row_id": 1314150, "text": "ADDEDDUM...BED FACILITATAOR AWARE OF PCA/PCA DOSE FOR TRANSFER TO FLOOR...NO DECISION AS OF YET TO RE-COMMENCEC ACTROBAN, AWAIT..TOLLERTED PASSE MUIR VALVE VERY WELL THIS PM, ALTHOUGFH REFUSED DIET AS THIS TIME\n" }, { "category": "Nursing/other", "chartdate": "2132-10-01 00:00:00.000", "description": "Report", "row_id": 1314151, "text": "Transfer Note\nReport faxed and called to 2. RN aware of PCA gtt. Pt to start on argatroban on 2 tonite. Pt stable at time of transfer, given ativan 0.5mg for anxiety.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-16 00:00:00.000", "description": "Report", "row_id": 1314100, "text": "update\n\n had a PICC placed in IR and was there for approximately 55 minutes. Double lumen PICC placed in R brachial.\n\nPt will have MRI tonite. Checklist has been faxed.\n\nFentanyl gtt to be restarted.\n\nLevolflox will be given as she lost access during initial infusion at 1600.\n\nPt has done well this afternoon when she received 1mg ativan iv. She was able to rest peacefully (? sleep) for about 1 hour.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-17 00:00:00.000", "description": "Report", "row_id": 1314101, "text": "Respiratory Care\nPt remains intubated and ventilated on a/c with no remarkable changes overnight. Suctioning thick yellow sputum,2 episodes of ?plugging. Tidal volume on vent would decrease/increase after lavage and suctioning. RSBI = 86. Pt is going for mri later this morning.\n" }, { "category": "Nursing/other", "chartdate": "2132-09-17 00:00:00.000", "description": "Report", "row_id": 1314102, "text": "1900-0700 NPN:\n\nPLEASE SEE CAREVUE FLOWSHEET FOR OBJECTIVE DATA AND FURTHER SHIFT DOCUMENTATION. RIGHT DOUBLE LUMEN PICC PLACED BY IR YESTERDAY. MRI STILL HAS NOT BEEN COMPLETED R/T EQUIPMENT FAILURE. PER MRI DEPT, SPECIAL PART ON ORDER FOR SPINAL COIL MACHINE. DR. OF MICU TEAM MADE AWARE. PT ALERT AND ORIENTED. FENTANYL GTT @ 100MCG/HR, VERSED GTT OFF. ATIVAN IV GIVEN Q 4HRS PRN. PMH OF ANXIETY, AND PT APPEARS TO GET AGITATED EASLIY R/T TUBES/LINES AND LONG HOSPITAL STAY. PT WRITES WORDS AND SENTENCES ON BOARD TO COMMUNICATE. C/O GENERALIZED BODY DISCOMFORT. FENTANYL PATCH Q72HR APPLIED . MAE WELL- NORMAL STRENGTH. PERLA- 2MM/BRISK. NSR TO ST @ 95-132, NO ECTOPY NOTED. TACHYCARDIC W/ ANXIETY AND AGITATION. NBP= 95-127/44-92. NO C/O CP. AFEBRILE. PALPABLE PEDAL PULSES. LS= COARSE. 02 SAT 97-100%. CONTINUES ON AC 350/20/50%/PEEP=5. DEEP ETT SXN Q 4HRS FOR MODERATE AMTS OF THICK TAN SECRETIONS. PT ORAL SXN INDEP FOR CLEAR THIN SECRETIONS. ABD SOFT, PRESENT BS. NO BM THIS SHIFT. TUBE FEEDING RESUMED- PROMOTE W/ FIBER VIA OGT AT 20CC/HR. INCREASE SLOWLY TO GOAL RATE OF 80CC/HR. PT REPORTS N/V FROM OGT AND TF. ANZEMET IV GIVEN PRN W/ GOOD EFFECTS. FOLEY CATH D/S/P DRAINING CLEAR YELLOW URINE 30-140CC/HR. SKIN INTACT, LEFT ARM W/ FEW ECCYMOTIC AREAS AND SWELLING NOTED TO LEFT HAND FROM IV INFILTRATE. RIGHT ANTECUB DUAL- LUMEN PICC AND LEFT SUBCLAV PHERESIS CATH INTACT. S/P PHERESIS . FULL CODE. FAMILY CALLED THIS SHIFT TO INQUIRE ON PT'S STATUS/CONDITION. EMOTIONAL SUPPORT PROVIDED TO PT AND FAMILY.\nPLAN- FOLLOW UP W/ MRI DEPT THIS AM FOR TIME OF SPINAL SCAN. REPLETE AM LYTES AS ORDERED. EVAL AM RSBI AND NIF, DETERMINE RESP POC. ASSESS PAIN CONTROL. CONTINUE ICU SUPPORTIVE CARE.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-16 00:00:00.000", "description": "FLUOR GUID PLCT/REPLCT/REMOVE", "row_id": 879227, "text": " 7:38 AM\n PICC LINE PLACMENT SCH Clip # \n Reason: Patient requires IV access for antibiotics and continued int\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ********************************* CPT Codes ********************************\n * PICC W/O FLUOR GUID PLCT/REPLCT/REMOVE *\n * US GUID FOR VAS. ACCESS C1751 CATH ,/CENT/MID(NOT D *\n ****************************************************************************\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with Syndrome now with ventilator associated\n pneumonia who requires a PICCL for IV antibiotics and continued invasive\n monitoring.\n REASON FOR THIS EXAMINATION:\n Patient requires IV access for antibiotics and continued intense monitoring.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Pneumonia, Guillain- syndrome, needs IV antibiotics.\n\n PROCEDURE: The procedure was performed by doctors and with Dr.\n , the Attending Radiologist, supervising. The right upper arm was\n prepped in a sterile fashion. Since no suitable superficial veins were\n visible, ultrasound was used for localization of a suitable vein. The\n brachial vein was patent and compressive. After local anesthesia with 2 mL of\n 1% lidocaine, the brachial vein was entered under ultrasonographic guidance\n with 21-gauge needle. Hard copy ultrasound images were obtained. A 0.018\n guidewire was advanced under fluoroscopy into the superior vena cava. Based\n on the markers on the guidewire, it was determined that a length of 45 cm\n would be suitable. The PICC line was trimmed to length and advanced over a 4-\n French introducer sheath under fluoroscopic guidance into the superior vena\n cava. The sheath was removed. The catheter was flushed. A final spot chest\n radiographic image demonstrates the tip in the high SVC. The line is ready\n for use. StatLock was applied and the line was hep-locked.\n\n IMPRESSION: Successful placement of a 45-cm total length PICC line with tip\n in the high superior vena cava, and ready for use.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-10 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 878573, "text": " 7:26 PM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: line placement\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, decreased mental status s/p line placement lsc\n\n REASON FOR THIS EXAMINATION:\n line placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Hypoxia and decreased mental status. Status post line placement.\n\n COMPARISON: .\n\n UPRIGHT AP CHEST: The endotracheal tube has been repositioned, such that the\n tip is now located approximately 9 cm from the carina. There has been\n interval placement of a left subclavian pheresis catheter with the tip\n overlying the mid to distal SVC. No pneumothorax is identified. The heart\n and mediastinal contours are normal. The lungs are grossly clear.\n\n IMPRESSION: The endotracheal tube is positioned above the thoracic inlet. The\n finding was discussed with Dr. at the time of interpretation.\n Satisfactorily positioned pheresis catheter.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-21 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879926, "text": " 6:42 PM\n CHEST (PORTABLE AP) Clip # \n Reason: placement of Dobhuff tube\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX being treated for \n intubated s/p trach and placement of Dobhuff tube\n REASON FOR THIS EXAMINATION:\n placement of Dobhuff tube\n ______________________________________________________________________________\n FINAL REPORT\n STUDY: Chest radiograph.\n\n INDICATION: Patient with - syndrome and spontaneous\n pneumothorax, who has had a Dobhoff feeding tube placed.\n\n TECHNIQUE: Single AP portable chest radiograph was received.\n\n COMPARISON: .\n\n REPORT: A right-sided PICC line is seen with it's tip unchanged in the distal\n SVC. The patient has now had a tracheostomy tube placed- and it's tip lies\n 4.7cm above the carina.. An NG tube is seen coursing beyond the range of the\n film through the distal stomach. There is a midline catheter present, in\n unchanged position of undetermined significance.\n\n Background mild hyperinflation changes are present. Cardiomediastinal\n silhouette appears normal. Some atelectatic changes are identified in the\n right lower lobe.Bilateral breast implants are seen.\n\n The lungs otherwise appear within normal limits.\n\n CONCLUSION:\n 1. Right-sided atelectasis.\n 2. Tracheostomy tube appears in satisfactory position.\n\n\n\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-08 00:00:00.000", "description": "CT CHEST W/O CONTRAST", "row_id": 878165, "text": " 12:55 AM\n CT CHEST W/O CONTRAST Clip # \n Reason: ?pneumo\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 36\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o recurrent pneumothoraces\n REASON FOR THIS EXAMINATION:\n ?pneumo\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: DFDkq MON 1:45 AM\n no pneumothorax; right pleural thickening\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: 35-year-old woman discharged from on\n after pleurodesis for bleb removal, complicated by readmission for\n pneumothorax. Now, the patient presents with diffuse weakness and diffuse\n body pain. Evaluate for recurrent pneumothorax.\n\n COMPARISON: No previous chest CT at this hospital. Chest radiographs\n performed on are available for correlation.\n\n TECHNIQUE: Non-contrast chest CT.\n\n FINDINGS: There is no pneumothorax. There is scarring around a previous\n chest tube tract at the left lung apex. Linear scarring is also present in\n the right and left lower lobes. There is pleural thickening or small amount\n of pleural fluid at the right lung base. Scattered blebs are present in both\n lungs. The airways are patent to the level of segmental bronchi. There is no\n mediastinal or axillary lymphadenopathy. There is no evidence of hilar\n lymphadenopathy on noncontrast evaluation. The heart and great vessels appear\n unremarkable. There is no pericardial effusion.\n\n The visualized portions of the liver and spleen appear unremarkable. There\n are no suspicious lytic or sclerotic lesions in the visualized osseous\n structures.\n\n IMPRESSION: No pneumothorax. Right basilar pleural thickening versus a small\n pleural effusion.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2132-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879554, "text": " 1:21 PM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for PTX\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX being treated for \n intubated, now with acute hypoxia\n REASON FOR THIS EXAMINATION:\n eval for PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old female with history of spontaneous pneumothorax being\n treated for -, presents with acute hypoxia.\n\n COMPARISONS: Comparison is made to serial chest radiographs from to the most recent of .\n\n TECHNIQUE/FINDINGS: A single AP chest radiograph was reviewed. An\n endotracheal tube is located 6 cm above the level of the carina. The tip of a\n right subclavian venous catheter overlies the mid SVC. There is no\n pneumothorax. The heart size is normal. Mediastinal and hilar contours are\n stable. The nasogastric tube has its tip within the distal portion of the\n stomach. The right hemidiaphragm is elevated. There is\n significant atelectasis/collapse of the right middle lobe. Mild linear\n atelectasis is noted at the left base. Pulmonary vasculature is within normal\n limits.\n\n IMPRESSION:\n 1. Right middle lobe atelectasis/collapse.\n 2. No pneumothorax.\n 3. Stable left lower lobe linear atelectasis.\n\n These findings were discussed with Dr. on the date of study.\n\n" }, { "category": "Echo", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 105222, "text": "PATIENT/TEST INFORMATION:\nIndication: Left ventricular function.\nHeight: (in) 67\nWeight (lb): 120\nBSA (m2): 1.63 m2\nBP (mm Hg): 132/70\nHR (bpm): 118\nStatus: Inpatient\nDate/Time: at 11:54\nTest: Portable TTE (Complete)\nDoppler: Full Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\n\nLEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size. Overall\nnormal LVEF (>55%). No resting LVOT gradient. No LV mass/thrombus.\n\nRIGHT VENTRICLE: Normal RV chamber size and free wall motion.\n\nAORTA: Normal aortic root diameter. Normal ascending aorta diameter.\n\nAORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.\n\nMITRAL VALVE: Normal mitral valve leaflets with trivial MR. No MVP. Normal\nmitral valve supporting structures.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR. Normal main PA. No Doppler evidence for PDA\n\nPERICARDIUM: No pericardial effusion.\n\nConclusions:\nThe left atrium is normal in size. Left ventricular wall thicknesses are\nnormal. The left ventricular cavity size is normal. Overall left ventricular\nsystolic function is normal (LVEF 60-70%). No masses or thrombi are seen in\nthe left ventricle. Right ventricular chamber size and free wall motion are\nnormal. The aortic valve leaflets (3) appear structurally normal with good\nleaflet excursion and no aortic regurgitation. The mitral valve appears\nstructurally normal with trivial mitral regurgitation. There is no mitral\nvalve prolapse. There is no pericardial effusion.\n\nCompared with the findings of the prior study (tape reviewed) of , the left ventricular ejection fraction is increased.\n\n\n" }, { "category": "Echo", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 105054, "text": "PATIENT/TEST INFORMATION:\nIndication: Spontanous pneumothorax. EKG changes.\nHeight: (in) 67\nWeight (lb): 120\nBSA (m2): 1.63 m2\nBP (mm Hg): 141/86\nHR (bpm): 76\nStatus: Inpatient\nDate/Time: at 12:44\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. Dilated IVC (>2.5 cm).\n\nLEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild regional LV\nsystolic dysfunction. [Intrinsic LV systolic function depressed given the\nseverity of valvular regurgitation.] No resting LVOT gradient.\n\nLV WALL MOTION: Regional LV wall motion abnormalities include: mid anterior -\nhypo; mid anteroseptal - akinetic; remaining LV segments contract normally.\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. No MVP. Moderate to severe (3+)\nMR.\n\nTRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild PA\nsystolic hypertension.\n\nPULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with\nphysiologic PR.\n\nGENERAL COMMENTS: Based on AHA endocarditis prophylaxis recommendations,\nthe echo findings indicate a moderate risk (prophylaxis recommended). Clinical\ndecisions regarding the need for prophylaxis should be based on clinical and\nechocardiographic data. Echocardiographic results were reviewed by telephone\nwith the houseofficer caring for the patient.\n\nConclusions:\nThe left atrium is normal in size. The inferior vena cava is dilated (>2.5\ncm). Left ventricular wall thicknesses and cavity size are normal. There is\nmild regional left ventricular systolic dysfunction with focal near akinesis\nof the mid-portion of the anterior septum and anterior wall. The remaining\nsegments contract well. [Intrinsic left ventricular systolic function may be\nmore depressed given the severity of valvular regurgitation.] Right\nventricular chamber size and free wall motion are normal. The aortic valve\nleaflets (3) appear structurally normal with good leaflet excursion and no\naortic regurgitation. The mitral valve leaflets are structurally normal. There\nis no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is\nseen. There is mild pulmonary artery systolic hypertension. There is no\npericardial effusion.\n\nIMPRESSION: Regional left ventricular systolic dysfunction in atypical\ndistribution ?myocarditis. At least moderate to severe mitral regurgitation.\nIf clinically indicated, a TEE would be better able to define a possible\nstructural abnormality of the mitral valve.\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": "Echo", "chartdate": "2132-09-26 00:00:00.000", "description": "Report", "row_id": 105175, "text": "PATIENT/TEST INFORMATION:\nIndication: Chest pain. Evaluate for new RWMA or effusion\nHeight: (in) 67\nWeight (lb): 120\nBSA (m2): 1.63 m2\nBP (mm Hg): 112/78\nHR (bpm): 105\nStatus: Inpatient\nDate/Time: at 13:30\nTest: Portable TTE (Focused views)\nDoppler: Limited Doppler and color Doppler\nContrast: None\nTechnical Quality: Adequate\n\n\nINTERPRETATION:\n\nFindings:\n\nLEFT ATRIUM: Normal LA size.\n\nRIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.\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 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. The left ventricular cavity size is normal. Due to suboptimal technical\nquality, a focal wall motion abnormality cannot be fully excluded. Overall\nleft ventricular systolic function is normal (LVEF>55%).\n2. There is no pericardial effusion.\n3. Compared with the findings of the prior report (tape unavailable for\nreview) of , there has been no significant change.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-17 00:00:00.000", "description": "MR L-SPINE W & W/O CONTRAST", "row_id": 879418, "text": " 10:27 AM\n MR W & W/O CONTRAST Clip # \n Reason: please eval for inflammation or cord compression\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with gullian- syndrome now with increased reflexes and\n band like pain across chest\n REASON FOR THIS EXAMINATION:\n please eval for inflammation or cord compression\n ______________________________________________________________________________\n FINAL REPORT\n PROCEDURE: MRI of the lumbar spine pre- and post-contrast administration.\n\n INDICATION: syndrome with increased reflexes and band like\n pain.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the lumbar spine pre- and\n post-gadolinium contrast administration was performed.\n\n MRI OF THE LUMBAR SPINE WITHOUT AND WITH CONTRAST: Vertebral body height and\n alignment is normal. The intervertebral disks are normal in appearance and\n height. There is an increased T1, T2 focus within the mid L4 vertebral body,\n present on STIR images and consistent with a hemangioma.\n\n There is no spinal canal or neural foraminal stenosis throughout the lumbar\n spine. The cauda equina is normal in signal intensity and appearance. No\n prevertebral or paraspinal soft tissue enhancing masses, or epidural enhancing\n mass lesions.\n\n IMPRESSION: No spinal stenosis or neural impingement. Normal appearance of\n the conus medullaris and cauda equina. No paraspinal or epidural enhancing\n mass lesions.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 878725, "text": " 5:01 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for consolidation\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with intubated now with fever.\n REASON FOR THIS EXAMINATION:\n please eval for consolidation\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: , dyspnea, intubated, now with fever.\n\n COMPARISON: , 1:23 a.m. CT scan, .\n\n SINGLE CHEST: There is linear atelectasis at the right medial lung base, and\n opacity in the left medial lung base, new since the chest radiograph of 1:23\n a.m. Endotracheal tube, nasogastric tube, left-sided central venous line are\n in good position. Cardiac, mediastinal, and hilar contours are unchanged.\n There is suture material seen in the left lung apex and in the left lower lung\n zone.\n\n IMPRESSION:\n 1. Left retrocardiac opacity, which may represent pneumonia or aspiration in\n the correct clinical setting.\n 2. Residual right lower lung zone atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-17 00:00:00.000", "description": "MR C-SPINE W& W/O CONTRAST", "row_id": 879417, "text": " 10:26 AM\n MR W& W/O CONTRAST; MR W &W/O CONTRAST Clip # \n MR CONTRAST GADOLIN\n Reason: please eval for cord compression or inflammation\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Contrast: MAGNEVIST Amt: 10\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with gullian- syndrome now with increased reflexes and\n band like pain across chest\n REASON FOR THIS EXAMINATION:\n please eval for cord compression or inflammation\n ______________________________________________________________________________\n FINAL REPORT\n MRI OF THE CERVICAL AND THORACIC SPINES\n\n INDICATION: Guillain- syndrome with increased reflexes and band-like\n pain across the chest.\n\n TECHNIQUE: Multiplanar T1- and T2-weighted MRI of the cervical and thoracic\n spines pre- and post-gadolinium administration were performed.\n\n MRI OF THE CERVICAL SPINE WITHOUT AND WITH CONTRAST: Vertebral body height,\n alignment, and signal intensity are normal. No prevertebral or paraspinal\n soft tissue enhancing mass is seen. No epidural mass lesions seen. There is\n no spinal canal or neural foraminal stenosis. The intervertebral discs are\n normal in appearance. The spinal cord is normal in signal intensity and\n caliber.\n\n MRI OF THE THORACIC SPINE WITHOUT AND WITH CONTRAST: Vertebral body height,\n alignment, and signal intensity are normal. The intervertebral discs are\n normal. The thoracic cord is normal in signal intensity and caliber. No\n prevertebral or paraspinal soft tissue enhancing masses are seen. No epidural\n mass lesions identified.\n\n IMPRESSION: Normal MRI of the cervical and thoracic spines.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 878149, "text": " 10:14 PM\n CHEST (PA & LAT) Clip # \n Reason: \\\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB\n REASON FOR THIS EXAMINATION:\n ?infiltrate?pneumo\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath. History of recent pleurodesis at \n Hospital, complicated by recurrent pneumothoraces.\n\n COMPARISON: No previous studies.\n\n FINDINGS: PA and lateral views of the chest. The heart, mediastinum and\n pulmonary vessels appear normal. There is mild blunting of the right\n costophrenic angle. The lungs appear clear. There is no pneumothorax. The\n visualized osseous structures appear unremarkable.\n\n IMPRESSION: No pneumothorax. Blunting of the right costophrenic angle,\n likely related to previous pleurodesis.\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2132-09-09 00:00:00.000", "description": "CT HEAD W/O CONTRAST", "row_id": 878448, "text": " 10:52 PM\n CT HEAD W/O CONTRAST Clip # \n Reason: please evaluate for head bleed\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman s/p VATS became unresponsive with hypercapnic respiratory\n distress now intubated.\n REASON FOR THIS EXAMINATION:\n please evaluate for head bleed\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post VATS, became unresponsive with hypercarbic and\n respiratory distress.\n\n There are no prior studies available for comparison.\n\n TECHNIQUE: Noncontrast head CT.\n\n FINDINGS: There is no intraparenchymal or extra-axial hemorrhage. There is\n no shift of normally midline structures, mass effect or hydrocephalus. The\n -white differentiation is preserved. The ventricles, sulci and cisterns\n are within normal limits. The visualized paranasal sinuses and osseous\n structures are normal in appearance.\n\n IMPRESSION: No intracranial hemorrhage or mass effect.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-18 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 879558, "text": " 1:46 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 100CC NON IONIC CONTRAST\n Reason: eval for PE\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o recurrent pneumothoraces s/p VATS now with\n respiratory distress/intubated in MICU now with increasing FiO2 requirements.\n\n REASON FOR THIS EXAMINATION:\n eval for PE\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with history of recurrent pneumothoraces status\n post VATS now with respiratory distress, intubated in the ICU with increasing\n FIO2 requirements and falling hematocrit. Please evaluate for pulmonary\n embolus as well as intraperitoneal or retroperitoneal hemorrhage.\n\n COMPARISON: Chest x-ray dated , CTA of the chest with and\n without contrast dated .\n\n TECHNIQUE: MDCT continuously acquired axial images of the chest were obtained\n after the administration of a fast bolus of 150 mL of Optiray IV contrast per\n the CTA pulmonary embolism protocol. 60-second-delayed images of the abdomen\n and pelvis as well as coronal and sagittal reformations of the thorax were\n performed.\n\n CTA OF THE CHEST: Examination of the pulmonary arterial tree demonstrates\n filling defects within the 3 segmental branches of the right upper lobe\n pulmonary artery consistent with pulmonary emboli. The pulmonary arterial\n tree of the left lung is patent without evidence of pulmonary embolus. The\n patient is intubated and there is an endotracheal tube in the trachea slightly\n above the level of the clavicles. There is a central venous catheter with its\n tip in the SVC. There is a nasogastric tube extending into the stomach.\n\n There are secretions within the airways of the right lower lobe causing near\n complete atelectasis of the right lower lobe. There is nonspecific ground-\n glass opacity at the base of the left lung, which may be caused by infection,\n aspiration, or atelectasis. Again noted are blebs at the bilateral apices.\n There is stable appearance of bilateral breast implants.\n\n CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen, pancreas,\n kidneys, adrenal glands, duodenum, and intraabdominal loops of large and small\n bowel are unremarkable. There is a nasogastric tube coiled in the stomach,\n which is otherwise unremarkable. There is no free air or free fluid within\n the abdomen. There is no pathologic mesenteric or retroperitoneal\n lymphadenopathy. No intraperitoneal or retroperitoneal hemorrhage is\n identified.\n\n CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter and associated\n (Over)\n\n 1:46 PM\n CTA CHEST W&W/O C &RECONS; CT ABDOMEN W/CONTRAST Clip # \n CT PELVIS W/CONTRAST; CT 100CC NON IONIC CONTRAST\n Reason: eval for PE\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 36 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n air within the urinary bladder. The rectum, sigmoid colon, and intrapelvic\n loops of bowel are unremarkable. There is no inguinal or pelvic\n lymphadenopathy. There is no free fluid within the pelvis. No\n retroperitoneal or intrapelvic hemorrhage identified.\n\n BONE WINDOWS: The visualized osseous structures are unremarkable.\n\n IMPRESSION:\n\n 1. Pulmonary emboli found within all 3 segmental branches of the right upper\n lobe pulmonary artery.\n\n 2. The right lower lobe airways are filled with secretions causing near\n complete atelectasis of the right lower lobe.\n\n 3. No retroperitoneal hematoma or intraperitoneal hemorrhage identified.\n\n The results of this study were discussed with the ICU physician . \n .\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-14 00:00:00.000", "description": "CHEST PORT. LINE PLACEMENT", "row_id": 879019, "text": " 11:50 AM\n CHEST PORT. LINE PLACEMENT Clip # \n Reason: Evaluate catheter position. Also, please evaluate for PNA.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with intubated, now with fever. Plasmapheresis\n catheter repositioned today.\n REASON FOR THIS EXAMINATION:\n Evaluate catheter position. Also, please evaluate for PNA.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Plasmapheresis catheter repositioning.\n\n COMPARISON: .\n\n SINGLE SUPINE CHEST: A left-sided central venous line is seen terminating in\n the distal SVC. Endotracheal tube is in place. Nasogastric tube is seen\n coursing below the diaphragm. In the interval, there is increased opacity in\n the left retrocardiac space, and continued atelectasis in the right medial\n lower lung zone. Left upper lobe and left lower lobe sutures are again\n identified. Cardiac, mediastinal, and hilar contours are unchanged.\n Surrounding osseous structures are stable.\n\n IMPRESSION:\n 1. Satisfactory placement of plasmapheresis catheter. This was discussed\n with Dr. by telephone at approximately 12:30 p.m., .\n\n 2. Slight increase in left retrocardiac opacity and persistence of right\n medial lower lung zone atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-18 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 879587, "text": " 6:09 PM\n CHEST (PORTABLE AP); -76 BY SAME PHYSICIAN # \n Reason: please eval ET tube placement\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX being treated for \n intubated, pt tried to self extubate/ ET tube replaced\n REASON FOR THIS EXAMINATION:\n please eval ET tube placement\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: History of spontaneous pneumothorax with patient manipulating\n endotracheal tube. Please evaluate endotracheal tube placement.\n\n Portable AP view of the chest dated at 18:11 is compared with the\n same examination from 5 hours prior. The endotracheal tube is 6.5 cm above\n the carina. A right subclavian PICC line is in unchanged position terminating\n in the mid superior vena cava. The heart, hilar, and mediastinal contours are\n unchanged. The lung fields show some opacity at the right middle lung zone,\n which is unchanged. The surrounding osseous and soft tissue structures are\n unremarkable.\n\n IMPRESSION:\n 1. Endotracheal tube terminating 6.5 cm above the carina. Otherwise\n unchanged chest x-ray from 5 hours earlier.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-11 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 878607, "text": " 1:15 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for pneumothorax.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, decreased mental status s/p line placement\n now hypoxic.\n REASON FOR THIS EXAMINATION:\n Please evaluate for pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old female with hypoxia, decreased mental status, status\n post line placement. Evaluate for pneumothorax.\n\n COMPARISONS: Comparison is made to serial chest radiographs from to the most recent of .\n\n TECHNIQUE/FINDINGS: Single AP upright chest radiograph. The endotracheal\n tube is located in a standard position. The tip of a left subclavian catheter\n projects over the mid SVC. There is a small left pleural effusion with likely\n subpulmonic component. There is no pneumothorax. The mediastinal and hilar\n contours are unremarkable. The heart size is normal. The lungs are otherwise\n clear.\n\n IMPRESSION: Standard position of endotracheal tube. No evidence of\n pneumothorax. Small stable left pleural effusion.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-10 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 878594, "text": " 10:35 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: reeval repositioning of ETT\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, decreased mental status s/p line placement\n lsc\n REASON FOR THIS EXAMINATION:\n reeval repositioning of ETT\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with hypoxia and decreased mental status for\n line placement.\n\n X-RAY CHEST, AP PORTABLE VIEW.\n\n COMPARISON: .\n\n FINDINGS: The tip of the ET tube is 6 cm from the carina and can be pushed in\n about 2 cm for optimal positioning. The tip of the left subclavian catheter\n projects over the mid SVC. There is a small left pleural effusion with likely\n a subpulmonic component. There is right basilar atelectasis. The left lung\n field is clear. The heart size is normal. The mediastinal and hilar contours\n are normal. There is no pneumothorax.\n\n IMPRESSION: 1. Tip of the left subclavian catheter projects over the mid\n SVC.\n\n 2. ET tube 6 cm from the carina and can be pushed in about 2 cm for optimal\n positioning.\n\n 3. Small right pleural effusion with likely a subpulmonic component with\n right basilar atelectasis.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-26 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 880552, "text": " 11:03 AM\n CHEST (PORTABLE AP) Clip # \n Reason: ? pneumothorax.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX being treated for ,\n now with increasing left sided CP.\n REASON FOR THIS EXAMINATION:\n ? pneumothorax.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old female with history of spontaneous pneumothorax being\n treated for - presents with increasing left-sided chest pain.\n Evaluate for pneumothorax.\n\n COMPARISONS: Comparison is made to serial chest radiographs from to the most recent of .\n\n TECHNIQUE/FINDINGS: A single AP upright chest radiograph was reviewed.\n Tracheostomy tube is seen with its tip located 4 mm above the level of the\n carina. A right-sided PICC has its tip projecting over the mid SVC. The\n nasogastric tube is seen coursing towards the stomach, then out of view.\n Cardiomediastinal silhouette is unchanged. No pneumothorax is identified.\n Right lower lobe atelectasis has slightly improved, although the lung base\n remains elevated. A small right pleural effusion is stable. The pulmonary\n vasculature is within normal limits. No new infiltrates are identified.\n Visualized osseous structures are unremarkable.\n\n IMPRESSION:\n 1. No pneumothorax.\n 2. Slight improvement in right basilar atelectasis.\n 3. Small right pleural effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-09 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 878446, "text": " 9:17 PM\n CHEST (PORTABLE AP) Clip # \n Reason: evaluate for infiltrate, CHF\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with hypoxia, decreased mental status CODE\n REASON FOR THIS EXAMINATION:\n evaluate for infiltrate, CHF\n ______________________________________________________________________________\n FINAL REPORT\n INDICATIONS: Mental status changes.\n\n PORTABLE AP CHEST AT 2127: Comparison is made to . The\n endotracheal tube is approximately 2 cm above the carina. This could be\n retracted 2 cm for optimal positioning. Cardiac size is within normal limits.\n Postural changes are seen within the pulmonary vessels. There is linear\n atelectasis in both lower lobes and a blunting of the right CP angle, which\n likely reflects a small effusion.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-11 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 878611, "text": " 3:38 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please evaluate for PE.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 33.1 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o recurrent pneumothoraces s/p VATS now with\n respiratory distress/intubated in MICU now with increasing FiO2 requirements.\n\n REASON FOR THIS EXAMINATION:\n Please evaluate for PE.\n No contraindications for IV contrast\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n HISTORY: Status post pleurodesis with history of recurrent pneumothoraces.\n Recently, intubated for respiratory distress.\n\n COMPARISON: Non-contrast chest CT of .\n\n TECHNIQUE: Axial multidetector CT images of the chest were obtained without\n contrast utilizing low-dose expiratory technique and then with intravenous\n Optiray per pulmonary CT angiogram protocol. Multiplanar reconstructions were\n performed.\n\n CHEST CT ANGIOGRAM: There are no filling defects in the pulmonary vasculature\n to suggest pulmonary embolism. The aorta and the heart appear unremarkable.\n There is new increased density in the left supraclavicular region, superior\n mediastinum, and portions of the pericardium, consistent with a hematoma which\n is likely venous. There is no evidence of contrast extravasation. This finding\n may be related to recent cardiopulmonary resuscitation. Unchanged mild pleural\n thickening is noted at both lung bases, as well as at the left lung apex.\n There is no pneumothorax or pleural effusion.\n\n There are no new pulmonary opacities. Linear atelectasis is again noted in\n both lower lobes. Surgical material is again noted at the left lung apex.\n There is a piece of tubing in the left lower lobe adjacent to the heart,\n possibly representing a retained pigtail catheter tip. Blebs are noted at both\n lung apices.\n\n The patient is intubated, with the endotracheal tube tip in good position\n between the carina and the thoracic inlet. There is a nasogastric tube\n extending into the stomach.The visualized portions of the liver, spleen,\n pancreas, adrenal glands, and the left kidney appear unremarkable. The\n visualized osseous structures appear unremarkable. Bilateral breast implants\n are again noted.\n\n CT RECONSTRUCTIONS: Multiplanar reconstructions confirm the findings\n demonstrated on the axial images. They were essential for delineating the\n pulmonary vascular anatomy, particularly in the right upper lobe. Overall\n value grade is IV.\n\n IMPRESSION:\n (Over)\n\n 3:38 AM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please evaluate for PE.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 33.1 Contrast: OPTIRAY Amt: 150\n ______________________________________________________________________________\n FINAL REPORT (REVISED)\n (Cont)\n\n 1. No evidence of pulmonary embolism.\n 2. New small hematoma in the left supraclavicular region, superior\n mediastinum, and portions of the pericardium, which is likely venous as there\n is no active extravasation. It may be related to recent cardiopulmonary\n resuscitation\n 3. No pneumothorax. Stable appearance of the lungs.\n\n DFDkq\n\n" }, { "category": "Radiology", "chartdate": "2132-09-23 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 880034, "text": " 3:37 AM\n CHEST (PORTABLE AP) Clip # \n Reason: assess for interval change\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX being treated for \n intubated s/p trach and placement of Dobhuff tube\n REASON FOR THIS EXAMINATION:\n assess for interval change\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST, 4:13 A.M. .\n\n HISTORY: Spontaneous pneumothorax. Guillain- syndrome. Intubated.\n Assess Dobbhoff placement.\n\n IMPRESSION: AP chest compared to :\n\n Feeding tube passes to the region of the proximal duodenum. Tracheostomy tube\n in standard placement. Right lower lobe atelectasis has improved, though the\n lung base remains elevated. There may be a tiny right pleural effusion,\n probably of no clinical significance. Lungs are otherwise clear. Heart is\n normal size and the mediastinum is midline. Right subclavian line projects\n over the expected course of the SVC. No pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-10 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 882453, "text": " 12:08 PM\n CHEST (PA & LAT) Clip # \n Reason: please eval for interval change\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now\n s/p L chest tube removal vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n please eval for interval change\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left chest tube removal.\n\n COMPARISON: Chest x-ray dated .\n\n PA AND LATERAL CHEST RADIOGRAPHS: There is a right-sided PICC line with its\n tip terminating in the superior vena cava. There is a left chest tube with\n its tip overlying the upper lung. The feeding tube tip is not visualized but\n is below the diaphragm. A tracheostomy tube is in standard position. There\n is atelectasis at the right lung base. The heart is normal in size. The\n slight opacity overlying the lower lung zones likely relates to the breast\n implants. There is no pneumothorax. There may be tiny bilateral pleural\n effusions.\n\n IMPRESSION: Atelectasis at the right lung base. No evidence of pneumonia or\n congestive heart failure.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-10 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 882454, "text": " 12:09 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Please assess for potential obstruction.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with abdominal distention. Please do abd films while down\n for her CXR if possible. Thanks.\n REASON FOR THIS EXAMINATION:\n Please assess for potential obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with abdominal distention. Please assess for\n bowel obstruction.\n\n COMPARISON: Abdominal radiograph dated .\n\n TECHNIQUE: AP supine and upright abdominal radiographs were obtained.\n\n FINDINGS: There is an NG tube which on had shape\n consistent with post pyloric position but now is coiled over the left abdomen\n presumably within the non-distended stomach. Small and large bowel are of\n normal caliber. Air is seen throughout loops of small bowel and within the\n proximal colon. There is no definite free air identified. There are two 5 cm\n metallic linear objects overlying the right abdomen with shape consistent with\n pins and are likely external to the patient. There is stable appearance\n of bilateral breast implants. Bony structures are unremarkable.\n\n IMPRESSION: No evidence of obstruction. NG tube with tip previously in post-\n pyloric position has now migrated back into the stomach.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881112, "text": " 4:19 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: please assess s/p L mechanical pleurodesis, chest tube plac\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, admitted w/\n \n REASON FOR THIS EXAMINATION:\n please assess s/p L mechanical pleurodesis, chest tube placement x2\n ______________________________________________________________________________\n FINAL REPORT\n TYPE OF EXAMINATION: Chest AP portable single view.\n\n INDICATION: History of spontaneous pneumothorax. Admitted with\n -? syndrome, assess status post left-sided mechanical pleurodesis.\n Two chest tubes placed.\n\n FINDINGS: AP single view of the chest obtained with patient in semi-upright\n position is analyzed in direct comparison with a preceding similar study\n obtained the same day with approximately two hours interval. Tracheostomy\n cannula unchanged in trachea. NG tube reaches far below diaphragm.\n Right-sided PICC line terminating in SVC. The left-sided chest tubes remain\n in unchanged position and no residual pneumothorax can be identified.\n Right-sided atelectasis in lower lung field beginning to resolve. Densities\n on left base remain. Lower lung fields partially obscured by breast implants.\n No conclusive evidence for new abnormalities.\n\n IMPRESSION: No significant interval change with two hours examination\n interval.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 883208, "text": " 2:59 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: eval for interval change, ptx s/p tube d/c\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p\n L chest tube to heimlick valve d/c now.\n\n REASON FOR THIS EXAMINATION:\n eval for interval change, ptx s/p tube d/c\n ______________________________________________________________________________\n FINAL REPORT\n TWO VIEW CHEST, AT 14:51\n\n COMPARISON: Previous study of earlier the same date at 8:24.\n\n INDICATION: Status post removal of left-sided chest tube.\n\n Since the recent chest radiograph, a left-sided chest tube has been removed.\n A small left apical pneumothorax is present, best visualized on the lateral\n view. In retrospect, this is also present on the pre-chest tube removal\n radiograph and is without interval change. On the PA view, the pneumothorax\n was partially obscured by the overlying chest tube on the previous film,\n rendering it more difficult to visualize prospectively. The remainder of the\n chest radiograph is without change since the recent radiograph.\n\n IMPRESSION: Small left apical pneumothorax, stable in retrospect compared to\n pre-chest tube removal radiograph of earlier the same date.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-16 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 883126, "text": " 8:36 AM\n CHEST (PA & LAT) Clip # \n Reason: interval chnage x 24hrs\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p\n L chest tube to heimlick valve now clamped x 24hrs\n\n REASON FOR THIS EXAMINATION:\n interval chnage x 24hrs\n ______________________________________________________________________________\n FINAL REPORT\n PA AND LATERAL CHEST FROM \n\n HISTORY: Guillain- syndrome. Multiple pneumothorax. Chest tube to\n Heimlich valve.\n\n IMPRESSION: PA and lateral chest compared to and 28:\n\n There is no discernable left pneumothorax, apical pleural tube still in place.\n Mild left-sided pleural thickening is present, but there is no appreciable\n pleural effusion. Bands of atelectasis are seen in both lower lungs. Heart\n is normal size. Right PIC catheter tip projects over the SVC.\n\n\n" }, { "category": "ECG", "chartdate": "2132-09-26 00:00:00.000", "description": "Report", "row_id": 309723, "text": "Sinus tachycardia. Short P-R interval. Poor R wave progression - probable\nnormal variant. Lateral ST segment elevation - possible early repolarization.\nThese ST segment elevations are new compared to the previous tracing of .\nClinical correlation is advised.\n\n" }, { "category": "ECG", "chartdate": "2132-09-18 00:00:00.000", "description": "Report", "row_id": 309724, "text": "Sinus tachycardia\nPoor R wave progression - probable normal variant\nInferior T wave changes\nSince previous tracing, no significant change\n\n" }, { "category": "ECG", "chartdate": "2132-09-14 00:00:00.000", "description": "Report", "row_id": 309725, "text": "Sinus tachycardia.\nModest diffuse nonspecific ST-T wave changes\nSince previous tracing of , ST-T wave changes less prominent\n\n" }, { "category": "ECG", "chartdate": "2132-09-11 00:00:00.000", "description": "Report", "row_id": 309726, "text": "Sinus tachycardia. Right atrial abnormality. Delayed anterior precordial\nR wave progression. Compared to the previous tracing of heart rate now\nfaster. Otherwise, no diagnostic change.\n\n" }, { "category": "ECG", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 309727, "text": "Sinus rhythm without diagnostic abnormality. No previous tracing available for\ncomparison.\nTRACING #3\n\n" }, { "category": "ECG", "chartdate": "2132-09-10 00:00:00.000", "description": "Report", "row_id": 309728, "text": "Sinus rhythm. Borderline left atrial abnormality. Compared to the previous\ntracing of no definite change.\nTRACING #2\n\n" }, { "category": "ECG", "chartdate": "2132-09-09 00:00:00.000", "description": "Report", "row_id": 309729, "text": "Normal sinus rhythm, without diagnostic abnormality. No previous tracing\navailable for comparison.\nTRACING #1\n\n" }, { "category": "Radiology", "chartdate": "2132-10-05 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 881715, "text": " 8:38 AM\n CHEST (PA & LAT) Clip # \n Reason: assess for pneumothorax\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n vats/wedgeresection , CT to waterseal now.\n\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CHEST SINGLE VIEW ON .\n\n HISTORY: Chest tube to water-seal, check pneumothorax.\n\n FINDINGS: There is no significant change in the tracheostomy, feeding tube\n with tip off film, right subclavian line with tip in superior vena cava, and\n two left chest tubes. Left apical pneumothorax is again visualized and is\n possibly slightly smaller than on the prior study. Left lateral chain sutures\n are again seen. There is patchy subsegmental atelectasis and volume loss in\n the left lower lobe. Linear atelectasis is again seen in the right lower\n lobe. Overall, there has been no significant interval change.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-06 00:00:00.000", "description": "L ABDOMEN (LAT DECUB ONLY) LEFT", "row_id": 881872, "text": " 2:33 PM\n ABDOMEN (LAT DECUB ONLY) LEFT; ABD (SINGLE VIEW ONLY) Clip # \n Reason: Please assess right lucency seen on CXR this AM for ? new PT\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX on left, s/p Chest tube placement\n with new lucency on R hemidiaphragm noticed on CXR this AM.\n REASON FOR THIS EXAMINATION:\n Please assess right lucency seen on CXR this AM for ? new PTX or\n intraperitoneal free air. (recommended by radiology)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with history of recent pneumothorax status post\n chest tube placement, found to have question of new pneumothorax or\n intraperitoneal free air on recent chest x-ray. Please assess for free air.\n\n TECHNIQUE: AP upright and left lateral decubitus abdominal radiographs were\n obtained.\n\n FINDINGS: No free air within the abdomen is identified. No pneumothorax is\n found within the visualized portions of the lung bases. There is stool mixed\n with air throughout the colon and rectum. There is a nasogastric tube with\n morphology consistent with post-pyloric placement. There are bilateral breast\n implants. Bony structures are unremarkable.\n\n IMPRESSION: No intra-abdominal free air or pneumothorax within the visualized\n lung bases identified. NG tube with shape consistent with post-pyloric\n position.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-07 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 881995, "text": " 12:40 PM\n CHEST (PA & LAT) Clip # \n Reason: interval change on bulb sxn-please obtain cxr at noon\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p\n L chest tube removal vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n interval change on bulb sxn-please obtain cxr at noon\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Shortness of breath. Left chest tube removal.\n\n IMPRESSION: PA and lateral chest compared to .\n\n Small left apical pneumothorax, unchanged, level of the fourth posterior\n interspace. Apical pleural tube unchanged in position. No layering left\n pleural effusion, but there is posterior pleural thickening on the left. Tiny\n right pneumothorax, predominantly basal, has nearly resolved. Right basal\n atelectasis is stable. The heart size is top normal, unchanged. Upper lungs\n clear. Tracheostomy tube in standard placement. Right PIC catheter projects\n over the SVC and a nasogastric feeding tube passes into the stomach and out of\n view.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-26 00:00:00.000", "description": "CTA CHEST W&W/O C &RECONS", "row_id": 880627, "text": " 6:18 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please assess for new PEs or pneumothorax.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 34 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o recurrent pneumothoraces, GBS, PEs, now with\n increasing left sided chest pain.\n REASON FOR THIS EXAMINATION:\n Please assess for new PEs or pneumothorax.\n No contraindications for IV contrast\n ______________________________________________________________________________\n WET READ: JHjc FRI 8:10 PM\n large left pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n CT CHEST\n\n INDICATION: History of recurrent pneumothoraces, - syndrome,\n pulmonary embolism with increasing left-sided chest pain.\n\n Comparison is made to the prior chest CT dated and prior\n chest x-ray on the same day.\n\n TECHNIQUE: Multidetector CT scanning of the chest was performed following\n intravenous administration of 150 cc of Optiray contrast. Multiplanar\n reconstructions were also obtained.\n\n FINDINGS: Compared to the prior CT scan, there has been interval development\n of a large left-sided pneumothorax. This also appears to have progressed\n significantly compared to the chest x-ray performed on the same day. There\n are associated atelectatic changes in the left lung. There is again evidence\n of left upper lobe wedge resection. Multiple peripheral blebs are noted along\n the right upper lobe. Linear atelectatic changes are demonstrated in the\n right lower lobe with marked interval reexpansion of the right lower lobe.\n There has been development of an oval shaped roughly 3.8 x 2.1 cm\n low-attenuation lesion in the right lower lobe with a few foci of gas most\n consistent with loculated fluid. The pulmonary arteries demonstrate no\n evidence of pulmonary embolism. The heart, pericardium, and great vessels are\n within normal limits. Note is made of a tracheostomy tube. An NG tube is\n also noted. No pathologically enlarged axillary, mediastinal, or hilar lymph\n nodes are demonstrated.\n\n BONE WINDOWS: There are no suspicious lytic or sclerotic lesions.\n\n CT RECONSTRUCTIONS: The above findings were confirmed with multiplanar\n reconstructions.\n\n IMPRESSION:\n 1. Interval development of very large left-sided pneumothorax.\n 2. Marked interval reexpansion of the right lower lobe compared to the prior\n CT scan with residual small loculated fluid collection in the right lower\n (Over)\n\n 6:18 PM\n CTA CHEST W&W/O C &RECONS; CT 100CC NON IONIC CONTRAST Clip # \n Reason: Please assess for new PEs or pneumothorax.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n Field of view: 34 Contrast: OPTIRAY Amt: 100\n ______________________________________________________________________________\n FINAL REPORT\n (Cont)\n lobe.\n 3. No evidence of pulmonary embolism.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-04 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 881620, "text": " 9:29 AM\n CHEST (PA & LAT) Clip # \n Reason: eval interval change\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n vats/wedgeresection , CT to waterseal now.\n\n REASON FOR THIS EXAMINATION:\n eval interval change\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: Guillain-? syndrome, chest tube to waterseal.\n\n FINDINGS: Two left chest tubes are again visualized. There is a moderate\n left pneumothorax that is not significantly changed compared to the study from\n the prior day. Chain sutures are again seen in the left mid lung. The\n tracheostomy tube and right subclavian line are unchanged. There continues to\n be basilar plate-like atelectasis and left lower lobe patchy\n consolidation/volume loss.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-30 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881081, "text": " 1:40 PM\n CHEST (PORTABLE AP) Clip # \n Reason: L vats, PTX\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, admitted w/\n , last pm developed new large left pneumothorax\n REASON FOR THIS EXAMINATION:\n L vats, PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP PORTABLE CHEST\n\n INDICATION: Followup of pneumothorax.\n\n Comparison is made to the previous examination of .\n\n The cardiomediastinal borders are unchanged. There is resolution to medial\n and lateral components of pneumothorax at the left lower lung zone, but\n increased size to left apical pneumothorax. There are two newly inserted\n left-sided chest tubes. There is new increased consolidation seen in the left\n mid and lower lung zones, as well as in the right lower lung zone. The\n pulmonary vasculature is normal. NG tube is seen coursing through the stomach\n and exits the field of view. Tracheostomy tube is seen in good position.\n\n IMPRESSION:\n 1. Interval increase in size to apical pneumothorax (now small to moderate),\n with resolution of previously seen medial and lateral lower lungs zone\n components.\n 2. Increased opacity seen in the left mid and lower lung zones, and right\n lower lung zone. These could reflect aspiration and/or infection. The left-\n sided opacity could in part relate to re-expansion edema.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-13 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 882747, "text": " 9:16 AM\n CHEST (PA & LAT) Clip # \n Reason: Please assess for residual PTX\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n chest tube removal vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n Please assess for residual PTX\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Assess residual pneumothorax.\n\n COMPARISON: Chest x-ray dated .\n\n PA AND LATERAL CHEST RADIOGRAPHS: Surgical sutures are again seen in the mid\n and upper left lung zones. There is a left chest tube in unchanged position\n as well as a right-sided PICC line tip in the upper superior vena cava. The\n tracheostomy and feeding tubes are in unchanged positions. There has been\n improvement in bibasilar atelectasis, though some residual discoid atelectasis\n remains bilaterally, along with small bilateral pleural effusions. There is a\n persistent tiny left apical pneumothorax, which in retrospect was seen on the\n prior and is unchanged since that time. The osseous structures appear\n unremarkable.\n\n IMPRESSION: Unchanged tiny left apical pneumothorax. Improvement in basilar\n atelectasis.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-06 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 881870, "text": " 2:33 PM\n CHEST (PA & LAT) Clip # \n Reason: ptx s/p left chest tube removal? plaese obtain cxr at 2pm\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p\n L chest tube removal vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n ptx s/p left chest tube removal? plaese obtain cxr at 1pm\n ______________________________________________________________________________\n FINAL REPORT\n CHEST TWO VIEWS, PA AND LATERAL\n\n History of VATS wedge resection and chest tube placement.\n\n Tracheostomy tube is 4 cm above the carina. Chest tube is present in the left\n upper hemithorax. There is a persistent small left apical pneumothorax.\n Surgical staples are present at the left apex and left upper lobe. Linear and\n discoid atelectasis are present at the right lung base. Line is in proximal\n SVC.\n\n IMPRESSION: Persistent small left apical pneumothorax. Linear and discoid\n atelectasis, right lung base. No new lung lesions.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 883012, "text": " 11:19 AM\n CHEST (PA & LAT) Clip # \n Reason: eval interval changePLEASE OBTAIN AT 11AM TODAY--THANKS\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n chest tube to heimlick valve now clamped vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n eval interval changePLEASE OBTAIN AT 11AM TODAY--THANKS\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: Status post left chest tube clamping.\n\n COMPARISON: Chest x-ray from .\n\n PA AND LATERAL CHEST RADIOGRAPHS: There has been interval removal of the\n tracheostomy tube. There has been removal of a feeding tube. The left-sided\n chest tube is in unchanged position. There is an improving small left apical\n pneumothorax. A right-sided PICC line tip is in the superior vena cava.\n There is no evidence of a right-sided pneumothorax. There is no evidence of\n congestive heart failure. There is no consolidation. There is no\n cardiomegaly. There is right basilar atelectasis. Surgical sutures are seen\n overlying the left lung.\n\n IMPRESSION:\n 1. Interval removal of tracheostomy tube and feeding tube.\n 2. Improving small left-sided apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881524, "text": " 12:59 PM\n CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN # \n Reason: Just watersealed chest tube - please assess for PTX - prefer\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n vats/wedgeresection , CT to waterseal now.\n\n REASON FOR THIS EXAMINATION:\n Just watersealed chest tube - please assess for PTX - prefer to have test\n around 11am if possible.\n ______________________________________________________________________________\n FINAL REPORT\n HX: SOB. syndrome, status post multiple pneumothoraces, now\n status post VATS and left wedge resection. Chest tube to waterseal.\n\n COMPARISON: Chest x-ray from 6:15 a.m. this morning. SINGLE AP PORTABLE\n UPRIGHT CHEST RADIOGRAPH: There has been no increase in size in the left-\n sided pneumothorax. There is no definite right-sided pneumothorax. Again\n seen is a right basilar atelectasis and presumed left lung contusion\n\n IMPRESSION: No short interval change.\n\n" }, { "category": "Radiology", "chartdate": "2132-09-28 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 880745, "text": " 3:57 AM\n CHEST (PORTABLE AP) Clip # \n Reason: eval for interval change in pneumothorax\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, admitted w/ ,\n last night developed new large left pneumothorax\n REASON FOR THIS EXAMINATION:\n eval for interval change in pneumothorax\n ______________________________________________________________________________\n FINAL REPORT\n HISTORY: History of spontaneous pneumothorax. New large left pneumothorax.\n -.\n\n chest, 1 vw\n\n Tracheostomy tube is in place. An NG tube is present, extending beneath the\n diaphragm off the film. The right subclavian central line is present, tip\n over proximal SVC. The heart is not enlarged. There is no CHF. There is\n small amount of right costophrenic angle pleural fluid or thickening, with\n atelectasis at the right base. There is increased retrocardiac density,\n consistent with left lower lobe collapse and/or consolidation. Question\n slight blunting of the left costophrenic angle.\n\n There is a large left pneumothorax. It is difficult to proceed, but is seen\n as an absence of markings in the left half of the left lower lung and along\n the medial aspect of the left lower lung. A tiny left apical component may\n also be present. Sutures are seen in the left upper lobe.\n\n IMPRESSION: Large left base pneumothorax which appears larger than on the\n chest x-ray from 11:20:38, but is probably not larger than that demonstrated\n on the CT from last night.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-01 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881141, "text": " 9:54 PM\n CHEST (PORTABLE AP) Clip # \n Reason: L vats, PTX\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, admitted w/\n , last pm developed new large left pneumothorax\n REASON FOR THIS EXAMINATION:\n L vats, PTX\n ______________________________________________________________________________\n FINAL REPORT\n AP CHEST 5:30 A.M.:\n\n HISTORY: 35-year-old woman with spontaneous pneumothorax. New large\n pneumothorax after LVATS.\n\n IMPRESSION: AP chest compared to a series of chest radiographs since\n , most recently at 4:41 p.m.\n\n Small volume of left apical pneumothorax persists despite 2 left apical chest\n tubes. A large region of consolidation in the left lower lung could represent\n contusion, hemorrhage or pneumonia. Consolidation also persists at the right\n lung base, with a similar differential diagnosis, although downward\n displacement of the right main and bronchus intermedius volume loss is the\n major finding.\n\n Tracheostomy tube is in standard placement. Feeding tube passes below the\n distal stomach and out of view. Right subclavian line tip projects over the\n SVC. The heart is normal in size. Mediastinum is shifted slightly to the\n left.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-02 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881358, "text": " 10:48 AM\n CHEST (PORTABLE AP) Clip # \n Reason: Please evaluate for residual PTX, ? pneumonia.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, GBS, s/p thoracic surgery;\n ct to sx; cont to have air leak\n REASON FOR THIS EXAMINATION:\n Please evaluate for residual PTX, ? pneumonia.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with spontaneous pneumothorax; to evaluate\n pneumothorax.\n\n CHEST X-RAY, AP PORTABLE VIEW:\n\n COMPARISON: .\n\n FINDINGS: A tracheostomy tube is at the thoracic inlet. The right PICC line\n is over the mid superior vena cava. Two chest tubes are seen in the left\n upper hemithorax. There is probably a small left apical pneumothorax, which\n could be confirmed by expiratory film. There is resolution of the right lower\n lobe consolidation. Left basilar atelectasis is noted. The patient has a\n left breast implant.\n\n IMPRESSION:\n 1. Probable left apical pneumothorax, which could be confirmed by expiratory\n film.\n 2. Right-sided PICC line and tracheostomy tube and left-sided chest tubes and\n the NG tube are in good position.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-11 00:00:00.000", "description": "ABDOMEN (SUPINE & ERECT)", "row_id": 882585, "text": " 2:17 PM\n ABDOMEN (SUPINE & ERECT) Clip # \n Reason: Please assess for obstruction.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with abdominal distention, vomiting, increasing pain.\n REASON FOR THIS EXAMINATION:\n Please assess for obstruction.\n ______________________________________________________________________________\n FINAL REPORT\n ABDOMEN TWO VIEWS\n\n History of abdominal pain, vomiting and distention.\n\n Feeding tube is coiled in body of stomach. Gas and fecal residue are present\n throughout the colon. No evidence for intestinal obstruction and no free\n intraperitoneal gas. Linear atelectasis is present at the right lung base.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-03 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881463, "text": " 6:27 AM\n CHEST (PORTABLE AP) Clip # \n Reason: F/up!!PLEASE TAKE CXR on EARLY AM!!! (6 AM)\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with h/o spontaneous PTX, HIT/PE, GBS, s/p thoracic surgery;\n ct to sx; cont to have air leak\n REASON FOR THIS EXAMINATION:\n F/up!!PLEASE TAKE CXR on EARLY AM!!! (6 AM)\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 38-year-old woman with history of HIT, PE, history of spontaneous\n pneumothorax.\n\n COMPARISON: Chest x-ray of .\n\n SINGLE PORTABLE AP SEMI-UPRIGHT RADIOGRAPH: Again seen is a tracheostomy tube\n in place. The right-sided PICC line tip is in the mid superior vena cava. One\n left-sided chest tube tip projects over the lung apex. The second left-sided\n chest tube tip projects over the left upper lung. The feeding tube tip is\n below the diaphragm. There is a persistent small apical left-sided\n pneumothorax, that is unchanged since the prior study. There are linear\n opacities in the right lower lobe in the area of the clearing pneumonia,\n suggesting persistent atelectasis. There is a persistent opacity involving\n the left lower lobe as well as the lingula, which appears to be improving\n since the prior exam, likely represents evolving hemorrhage versus post-\n expansion edema, but could also represent an improving pneumonia in this area.\n Again seen is a linear opacity of the left mid lung, which could represent\n atelectasis. The osseous structures appear unremarkable.\n\n IMPRESSION:\n 1. Persistent small apical left-sided pneumothorax.\n 2. Resolving left lower lobe and lingular hemorrhage or post-reexpansion\n edema.\n 3. Improving right lower lobe pneumonia, with recurrent atelectasis in this\n area.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-15 00:00:00.000", "description": "CHEST (PA & LAT)", "row_id": 883066, "text": " 4:31 PM\n CHEST (PA & LAT); -77 BY DIFFERENT PHYSICIAN # \n Reason: please eval for interval change 6 hours post clamp.PLEASE OB\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n chest tube to heimlick valve now clamped. vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n please eval for interval change 6 hours post clamp.PLEASE OBTAIN AT 4PM\n TODAY-THANKS\n ______________________________________________________________________________\n FINAL REPORT\n CHEST:\n\n INDICATION: Follow up pneumothorax.\n\n There is no significant change in the appearance of the chest since the\n earlier chest x-ray at at 11 a.m. The small left apical\n hydropneumothorax is again noted as are the left chest tube, the right PICC\n line, and the subsegmental atelectasis at the right lung base.\n\n IMPRESSION: No change in the chest over the past 6 hours.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-10-06 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 881823, "text": " 9:28 AM\n CHEST (PORTABLE AP); -59 DISTINCT PROCEDURAL SERVICE Clip # \n Reason: assess for pneumothorax/ effusion\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p L\n vats/wedgeresection\n REASON FOR THIS EXAMINATION:\n assess for pneumothorax s/p chest tube removal-plaese obtain CXR around noon\n time\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with -, status post left-sided\n wedge resection, status post multiple pneumothoraces.\n\n COMPARISON: Chest x-ray dated .\n\n SINGLE PORTABLE AP SEMI-ERECT CHEST RADIOGRAPH: Tip of the feeding tube is\n not seen, but is below the diaphragm. The tracheostomy tube is in appropriate\n position. The right-sided PICC line terminates in the superior vena cava,\n although its course is now more redundant than on prior exams. The two\n left-sided chest tubes are in unchanged position since the prior exam. There\n is a small apical left pneumothorax with the pleura at the level of the fourth\n posterior rib. There is a small left-sided pleural effusion and a left lower\n lobe opacity, which likely represents resolving atelectasis. On the right,\n there is a new lucency paralleling the right hemidiaphragm, which likely\n represents discoid atelectasis, but intraperitoneal free air cannot be fully\n ruled out and neither can a small right basilar pneumothorax, although this is\n less likely.\n\n IMPRESSION:\n 1. Small crescentic lucency paralleling the right hemidiaphragm. This is\n likely secondary to a focal area of discoid atelectasis adjacent to the\n diaphragm, although it is difficult to exclude free intraperitoneal air or a\n small right basilar pneumothorax. A left lateral decubitus abdominal plain\n film is recommended to exclude the latter two entities.\n 2. Persistent small apical left pneumothorax.\n 3. Redundant right-sided PICC line with its tip terminating in the superior\n vena cava.\n\n These findings were communicated to at the time of\n interpretation.\n\n" }, { "category": "Radiology", "chartdate": "2132-10-08 00:00:00.000", "description": "CHEST (PORTABLE AP)", "row_id": 882145, "text": " 12:24 PM\n CHEST (PORTABLE AP) Clip # \n Reason: s/p placement of Heimlech valve on Left chest tube\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with SOB - syndrome, s/p mult ptx, now s/p\n L chest tube removal vats/wedgeresection\n\n REASON FOR THIS EXAMINATION:\n s/p placement of Heimlech valve on Left chest tube\n ______________________________________________________________________________\n FINAL REPORT\n CHEST, SINGLE AP FILM\n\n History of wedge resection and chest tube placement.\n\n The ostomy tube is 3 cm above carina. Chest tube is present in left upper\n hemithorax. PICC line is in proximal SVC. Feeding tube is in stomach with\n distal end not included on the film. There is a probable a residual tiny left\n apical pneumothorax. Linear atelectasis/scar at right lung base with blunting\n of right costophrenic angle unchanged since prior study.\n\n IMPRESSION: Probable residual tiny left apical pneumothorax.\n\n\n" }, { "category": "Radiology", "chartdate": "2132-09-29 00:00:00.000", "description": "VIDEO OROPHARYNGEAL SWALLOW", "row_id": 880927, "text": " 3:11 PM\n VIDEO OROPHARYNGEAL SWALLOW Clip # \n Reason: please assess ability to swallow.\n Admitting Diagnosis: PAIN CONTROL,S/P VIDEO ASSISTED THORACOSCOPY\n ______________________________________________________________________________\n MEDICAL CONDITION:\n 35 year old woman with GBS, trach in place, would like to assess ability to\n swallow.\n REASON FOR THIS EXAMINATION:\n please assess ability to swallow.\n ______________________________________________________________________________\n FINAL REPORT\n INDICATION: 35-year-old woman with GBS, tracheostomy in place, presents for\n assessment of swallow function.\n\n COMPARISON: No prior studies available for comparison.\n\n TECHNIQUE: In conjunction with the speech and swallow therapy division oral\n and pharyngeal swallowing videofluoroscopy was performed utilizing thin\n liquids, nectar-thickened liquids, pureed consistency, a mixture of solid and\n liquid, and one-half of a barium pill.\n\n FINDINGS: The oral phase was within normal limits with adequate bolus\n formation and control. The pharyngeal phase was also within normal limits.\n There was mildly reduced laryngeal valve/airway closure. There was trace\n penetration during the swallow with both nectar-thick liquids and purees due\n to decreased laryngeal valve/vestibule closure. This penetration was trace,\n however, and spontaneously cleared during the course of the swallow. There\n was no aspiration during the exam.\n\n IMPRESSION: No evidence of aspiration. Normal oral phase. Normal pharyngeal\n phase with only mildly decreased laryngeal valve/airway closure. Please see\n the speech and swallow division's full report for more details.\n\n\n\n" } ]

[ { "category": "Radiology", "chartdate": "2140-04-02 00:00:00.000", "description": "BABYGRAM (CHEST ONLY)", "row_id": 818835, "text": " 12:18 AM\n BABYGRAM (CHEST ONLY) Clip # \n Reason: evaluate heart and lungs\n Admitting Diagnosis: NEWBORN\n ______________________________________________________________________________\n MEDICAL CONDITION:\n Infant with respiratory distress\n REASON FOR THIS EXAMINATION:\n evaluate heart and lungs\n ______________________________________________________________________________\n FINAL REPORT\n BABYGRAM CHEST:\n\n HISTORY: Infant with respiratory distress. Evaluate heart and lungs.\n\n FINDINGS: An ETT tip is just past the thoracic inlet. The lung volumes are\n normal to slightly hyperaerated. There are a few streaky and hazy opacities\n seen best in the left lower lobe and right upper lobe. These findings are\n associated with very mild hazy opacification in both lungs. The findings may\n represent very mild hyaline membrane disease. Clinical correlation is\n recommended. The heart size appears to be at least upper limits of normal.\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-02 00:00:00.000", "description": "Report", "row_id": 1853296, "text": "NPN 0700-\n\n\n1. Received infant in 250cc NC and weaned to RA by noon.\nAt 1600 infant having many desats to 85-89% and placed back\nin 25cc NC O2. Sats currently 95-99%. Lungs clear, RR\n30-60's with mild SC retractions at times. No A&B's thus\nfar. Cont to monitor resp status and wean NC O2 as\ntolerated.\n\n3. Infant ad lib demand feeds. Infant is breast feeding\nonly and waking Q 2-3.5hr for feeds. Infant able to breast\nfeed well with intermittent suckling for 10-20mins a feed.\nVoided and 2 meconium stools thus far. Dsticks stable 58\nand 71. Abd benign. Petechiae and bruising noted on face.\nInfant had one small spit and one large spit thus far. Cont\nto monitor dsticks and ability to breast feed.\n\n4. in to visit. Mother in throughout day to\nprovide infant cares. Mother updated by Dr. .\nMother eyed this afternoon. Invested . Cont\nto support, update, and educate .\n\n5. Maintaining temps swaddled in OC. Waking for feeds as\nnoted above, alert and very active. Rest well inbetween\ncares. MAE, brings hands to face. AGA. Cont to promote\ndevelopment.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-01 00:00:00.000", "description": "Report", "row_id": 1853291, "text": "NICU Attending Admission Note\n\nID: 4 hour old term male admitted from NN with persistent mild respiratory distress.\n\nPre/perinatal Hx: Mother is 40 y.o. G6 P now 2. PNS: A+, Ab-, HepBSAg-, PRPNR, RI, GBS -. Benign antepartum course with EDC . NSVD< 12 hours post AROM. No maternal fever, no intrapartum antibiotic prophylaxis. Required only routine care in DR, apgars 9 and 9. Transferred to NN. Since then, persistent mild respiratory sxs, though feeding well. O2 sat in high 80's therefor given BBO2 and admitted to NICU for further observation and management of mild persistent respiratory distress.\n\nAdmission PEx: Weight 4495 gm, RR 64, O2 sat 85% in RA, 93% in BBO2, up to 1L NCO2 with feeding to keep sat > 95%. Large, nondysmorphic well appearing term male, AFSOF, mild intercostal retractions, no grunting or flaring. BS slightly crackly but good air entry, RRR without\nmurmur, abd benign without HSM, no masses, normal male genitalia with testes descended bilaterally. Normal back and ext, tone and strength, skin pink and well perfused.\n\nD stick 52.\n\nA/P: 5 hour old term infant with mild respriatory sxs and O2 req't. Most likely transitional physiology, no perinatal risk factors for sepsis, no evidence of CHD. Will provide supplemental O2 as needed, if sxs not normalizing in next few hours, will pursue eval with CBC, blood cx, CXR. I updated mother.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-02 00:00:00.000", "description": "Report", "row_id": 1853292, "text": "1 Term Respiratory Distress\n2 Infant with Potential Sepsis\n3 3: fen\n4 Parents\n5 development\n\nREVISIONS TO PATHWAY:\n\n 1 Term Respiratory Distress; added\n Etiologies:\n Transient Tachypnea of the Newborn\n Meconium Aspiration\n Start date: \n 2 Infant with Potential Sepsis; added\n Start date: \n 3 3: fen; added\n Start date: \n 4 Parents; added\n Start date: \n 5 development; added\n Start date: \n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1853310, "text": "NPN Discharge note\n\n\nInfants VSS- see flowsheet for details. In RA without\ndesats, A&B's. Bili today 11.5/0.7/10.8. Color remains\nslightly jaundiced with facial petechia. Abd benign.\nVoiding and stooling. Waking Q 2hr and taking 41-62cc well.\nContinues with a hoarse cry- team aware. Reveiwed all D/C\nmaterial with ; see NICU D/C instruction form.\nInfant D/C home in car seat with belonging and .\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853305, "text": "Nursing NICU Note\n\n\n1. Resp. A/No evidence of resp distress noted at this time.\nP/Cont. to monitor.\n\n3. F/N. O/Adlib demand feeding E20/BM approx. Q2-3 hours.\nPlease refer to flowsheet for volumes consumed by pt this\nshift. Please refer to examinations from this shift. Voiding\nPassing stool. SKin slightly jaundice. A/Appears to be\ntolerating present feeding regimen. P/Cont. to monitor for\ns/s of feeding intolerance.\n\n4. . O/Mother and father in to visit today. Mother\nand father updated on pt's status and plan of care. Mother\n and attempted to nurse infant. Mother stated that she\nwould work on breastfeeding more at home. Mother was not\ninterested in this nurse's help. Lactation support number\ngiven to mother. Father also held infant. A/ are\nactively involved in pt's care. P/Cont. to support and\neducate . Cont. to prepare for pt's discharge from\nhospital to home.\n\n5. Dev. O/Waking approx 2-3 hours eager to feed. Awake and\nvery alert with cares. Temp stable thus far in an open air\ncrib. Rooting during care times eagerly and aggressive\nsucking on pacifier prior to being fed. A/Alt. in G/D.\nP/Cont. to support pt's growth and dev. needs.\n\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853306, "text": "Nursing NICU NOte Addendum.\nWhen offered bottle pt seems eager to feed. Pt does latch on to NUK nipple, but is noted to have a weaker suck while bottle feeding. Pt requiring encouragement to feed, and occasional chin and cheek support.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1853307, "text": "NICU NPN 1900-0700\nResp O: No desats during the night, o2 sats 95-100%, in room air, rr 30-50's, lungs are clear. Color is slightly jaundiced.\n\nFEN O: gained weight tonight, voiding and stooling, abdominal exma benign. Waking every 3 hrs, bottling 40-70cc's of bm/e20.\n\nParenting O: Mom in to visit, and updated. Plan to d/c today.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1853308, "text": "PCA Progress Note, 7p-7a\n\n\nRESP:\n INfant remains in RA. o2 sats are stable. RR: stable. LS:\ncl/=. No retrax or other signs of resp distress. No spells\nor destats so far this shift. Please refer to PT's chart for\nadditional RESP status. COntinue to monitor and support RESP\nstatus.\n\nFEN:\n Infant is adlib-demand feeder, waking Q3-4 hours. Infant is\nbottling full volumes with the NUK nipple, and tolerating\nthem well with one small spit. Infant is voiding appropriate\namounts, small stoolx1. Abd is benign with active BS. Please\nrefer to Pt's chart for additional FEN data. Continue to\nencourage and support all PO feeds.\n\nDEV:\n Infant's temp remains stable while swaddled in OAC.\nInfantis alert and active with cares. Waking hungry for\nfeeds, and sleeps well in between cares. Infant loves to be\nheld and cuddled. Infants has a weak, almost faint cry at\ntimes. Probable D/C for later on today (tuesday). Continue\nto encourage and support developmental milestones.\n\n\nPAR:\n Mom was in for evening care, minimal contact by this PCA.\nStopped in early morning to drop off BM and have a quick\nvisit. Aware of infant's probable discharge. Continue to\nupdate and support.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-05 00:00:00.000", "description": "Report", "row_id": 1853309, "text": "Neonatology note\n4 d.o\nin RA, no spells.\nAFOF.\nbruising on face fading\nRR with no murmur\nclear lungs\nabdomen soft\njaundice.\nwt= 4230 gm +85, tolerated feeding and breast- feeding\nA: FT infant with resolved mild desaturation, jaundice\nP: check bili, and may consider d/c home today if no high bilirubin.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853300, "text": "NPN 7p7a\n\n\nResp\nInfant began trial off of NC at 1800 hrs Sunday and has\ntolerated it well. Sats above 95%. Did have x 1 short desat\nto the high 70s with a crying spell. No desats with\nbottling. LSC. Infant hoarse, mild squeeky stridor audable\nas well. RR 30-60s. Infant tolerating RA. Monitor and\nsupport resp status.\nSepsis\nInfant is not on abx presently. Had CBC and clt sent shortly\nafter birth. CBC without shift and clt has not grown\nanything. Infant's resp status improved. No S&S presently of\ninfection. Cont to monitor.\nFEN\nInfant on adlib, demand BM or E20. Reported that he bottled\n65 cc during days. Overnight woke q 3 hrs but poor bottling.\nTaking only 20-30 cc with much encouragement. Infant wakes\ncrying demanding food, roots, wide open mouth. Does not\nclose mouth around nipple or suck, will cont to cry and\nsearch. Tried reg and nuk nipple without difference. Mom\nbrought [ed BM that was given to infant in bottle. Mom\n to sleep this shift, so no attemps at BF. Lactation\nconsult on Monday. Infant abd soft, round. Active BS. No\nspits. DS this shift was 82. Voided x 1 this shift.\nTransitional stool as well. Infant acting hungry unable to\nsuck on nipple. Cont to encourage bottling/BF. Monitor\nweight and exam.\n\nMom came up x 2 to deliver sm amts of milk. Stated she was\nfeeling better although she still felt very emotional.\nPlanned to stay in FR overnight and SLEEP. Mom and\ninvested. Overtired. Encourage Mom to rest. Lactation\nconsult. Support and educate.\nG/D\nInfant in OAC. Wakes frequently, irritable and crying.\nSettles if held. Some success in calming him, with tight\nswaddle and head boundries placed. Unable to use pacifier.\nPKU done. Family declined HepB shot. Infant MAEs. Shakes at\ntimes, especially with crying. FS&F. AGA. Monitor and\nsupport G/D.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853301, "text": "Neonatology note\nAFOF, bruise on face with presence of petechia.\nhoarse , muffled cry\nsucking good, normal tone\nextremities with full range of motion.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853302, "text": "Neonatology note\n3 d.o\nin RA, 1 mild desaturation\nRR with no murmur\nwt= -75 gm, 4145 gm\ntolerated feeding, trying breast-feeding\nAbdomen soft\nclear lungs\noff O2 since yesterday evening.\nA: full term infant probably resolved transitional respiratory distress.\nP: continue to observe for saturation off O2\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853303, "text": "Neonatology-NNP Physical Exam\n\n remains in RA. Active, alert in an open crib, AFOF, sutures opposed, good tone. BBS clear and equal with good air entry. No murmur, pulses +2, pink, RRR. Abdomen soft, non-distended with active bowel sounds, no HSM, tolerating feeds. Please refer to attending progress note for detailed plan.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-04 00:00:00.000", "description": "Report", "row_id": 1853304, "text": "Nursing NICU Note\nUrine crystals noted this afternoon in diaper and pt's mouth noted to be dry. NNP is aware. NNP also aware of TF consumed by this pt thus far today and thus far for this shift. Will cont. to monitor intake closely.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-03 00:00:00.000", "description": "Report", "row_id": 1853297, "text": "NPN\n\n\n#1\nInfant was in N/C until ~2300 last evening, at which point\nhe was placed in RA. Infant has maintained sats >92% thus\nfar. Infant did have to be placed in N/C 100%; 25cc x1\nduring a bottle feed for desats to low 80s. Infant waa able\nto nurse while in RA and keep sats >90%. BS clear=. Murmer\nnot audible. BP is stable. Color is pink and slightly\njaundiced. Face remains bruised with petecchiae noted.\n\n#3\nInfant remains on an ad lib schedule breastfeeding/bottle\nfeeding. Infant has been waking ~2-4 hours tonight. Infant\nlatched on eagerly at beginning of shift and nursed ~10\nminutes. Infant offered a bottle of E20 x2 during the night\nand infant took ~20cc each time with encouragement. Mom up\nto nurse this am, but infant latched on briefly and quickly\nwent back to sleep. Abd is soft and round. Infant has not\nvoided yet tonight. He did have a mod transitional stool\nx1. DS=74. Wt is down 275gms-4220 (checked x2).\n\n#4\nMom has been up on/off all night. Attempting to nurse\ninfant each time. Very loving toward infant. Plans to be\nD/C'ed today, but staying over for an extra night\ndownstairs.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-03 00:00:00.000", "description": "Report", "row_id": 1853298, "text": "Neo attending\nDOL 2 for this term infant male with resolving RFLF following precipitous delivery. In RA x 12 hours but saturations in the last few hours noted to decrease to 80's with rapid recovery with crying. Remains intermittently tachypneic. Weight is down 275 gms to 4220 gms. Remains on Breastfeeding and E20.\n\n\nRRR no m\nClear BS\nSoft abdomen + BS\n+ 2 pulses\n\nA: Well appearing term infant with slow transition and resolving TTN.\n\nP: Continue to monitor sats and consider O2 for sats consistently less than 93%. D-sticks are stable.\n\nWill encourage mother's participation and follow clinically.\n\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-03 00:00:00.000", "description": "Report", "row_id": 1853299, "text": "NICU nursing progress note\n\n\nPLease refer to flowsheet for specific info.\nResp\nO: was placed in 02 today for drifting sat to low\n80's while sleeping, (lowest sat was 79% briefly). RR\n80-90's prior to 02. NC 02 at 50cc 100%. RR during 02 tx\n40-70's. Currently trialing out of 02 since 1800, plan is\nto keep sat's >93%. BSCE bilat. No REtractions. A: Stable.\nAppears comfortable while out of 02. P: cont to follow.\nFEN\nO: On an ad lib demand schedule for bf, currently being\nsupplemented with E20 taking 60-65cc q 4 hours. Mom's milk\nhas not come in yet and was not latching today.\nLactation appt scheduled for 1300 on Monday. Bottling well\nwith good pacing. Abd pink, no loops, active bs. Voiding has\nimproved voiding q 6 hours. STooling (transitional) q diaper\nchange. DS 63. Jitteriness noted during this time. NNP\n updated and examed, and wnl. A: sTable. P: TErm\ninfant learning to bf, currently being supplemented until MM\ncomes in.\nGD\nO: TEmp stable in oac, active, irritable, and waking prior\nto bottling q 1 hour. After bottling begun waking q 4\nhours. MAE, Fonts, soft, flat. Calms with difficulty, though\nmuch improved post bottling. Petechiae, and bruising noted\non face. Eyes bilat with broken blood vessels noted from\nprecipitous delivery. A: AGA p: cont to support dev.\nmilestones.\nParenting\no: Mom and dad in and updated at bedside/ informal family\nmeeting with NNP and RN present. Questions encouraged\nand emotional support given. Mom verbalizing and tears well\nin eyes at thought of not being d/c to care\ntoday as well as infant being in NICU and not being at her\nbedside. Verbalizing stress at home due to 3 year asking for\nher as well not having much sleep due to bf q 1 hour, and\nnot eating well/ or drinking enough fluids. Teaching done\nreinforcing need to care for self, mom open to suggestions.\nA: Involved and . P: Social services notified\nby RN caring for mom. Cont to update, support, educate.\nHusband is and supportive of mom.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-02 00:00:00.000", "description": "Report", "row_id": 1853293, "text": "npn 2300-0700\n\n\n1: resp\nreceived infant on 750cc of o2 via nasal cannula. able to\nwean infant to 250 cc's. infant color dusky with crying. no\napnea. infant also having some drifts in o2 with\nbreastfeeding to high 80% requiring an increase in o2. no\nspells. Rr 30-60's. Lung sounds clear and equal. mild\nsubcostal retractions. weaning o2 as tolerated.\n\n2: sepsis:\ncbc and blood culture drawn this shift. infant not started\non antibiotics. no s.s of infection noted. continue to\nmonitor for changes.\n\n3: fen\nbw 4495gms. infant is on an ad lib demand. breastfeeding\nonly at this time . infant has breastfed at 0100 and 0300.\ndsticks 57 and 53.abd soft with no loops. one medium spit.\nno void and no stool thus far this shift. continue to\nmonitor for changes.\n\n4: \nmom in to breastfeed infant. very loving and involved.\nasking appropriate questions. updated by this rn.\n\n5: dev\ntemps stable on an off warmer. alert and active with cares.\nsleeps well inbetween. wakes for feedings. sucks vigorously\non pacifer. brings hands to face. aga. continue to monitor\nfor developmental milestones.\n\n\n" }, { "category": "Nursing/other", "chartdate": "2140-04-02 00:00:00.000", "description": "Report", "row_id": 1853294, "text": "npn 2300-0700\nDEV: INFANT WITH BRUISING ON FACE AND EXTREMETIES.\n" }, { "category": "Nursing/other", "chartdate": "2140-04-02 00:00:00.000", "description": "Report", "row_id": 1853295, "text": "Newborn Med Attending\n\nDOL#1. Cont in low flow O2 per NC, AF flat, clear BS, no murmur, abd soft, MAE. CXR c/w retained fetal lung fluid. Breast feeding.\nA/P: Infant with resloving TTN. Wean O2 as tolerated.\n" } ]